STONECREEK OF LITTLETON

A relicensure survey with complaint #CO39487, and #CO38745, was completed on 3/18/25. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure a resident's right to be free from physical abuse, intimidation, or punishment, affecting one current resident (#53). (Cross-reference S3078)Specifically, Former Staff #66 documented that on 3/2/25, she observed Staff #54 covering Resident #53's mouth with her hand. Former Staff #66 said Staff #65 lifted her hand in a gesture like she would hit Resident #53. Former Staff #66 wrote that she showed signs of intimidation when she flinched. Additionally, Former Staff #66 stated that both Staff #54 and #65 had forcefully placed the resident into bed. Staff #66 said Resident #50 did not want to be in bed. Local law enforcement stated Staff #54 and #65 had abused Resident #53. Findings include:1. Residence Policy The residents' undated Resident Rights policy read in part that residents have the right to be free from physical abuse. 2. Resident #53 was admitted to the residence on 11/30/22, with diagnosis including dementia and depression. On 3/17/25 at approximately 6:30 p.m., Resident #53's family member stated that he had received a call from the administrator on 3/2/25 at 8:00 a.m. to inform him that staff had allegedly physically abused Resident #53. He said that when he arrived at the residence, local law enforcement, an external service provider registered nurse (ESP-RN) and the external service provider's caregiver (ESP-C) assessed the resident for injuries. He stated he was shown a bruise on Resident #53's right hand by the knuckle and informed that Resident #53 had her hands clenched in fists close to her face, in a defensive manner and had shown signs of anxiety, fear, and confusion due to the alleged abuse by the staff. He stated she was visibly shaken and fearful of anyone who approached her. On 3/18/25 at 9:20 a.m., the administrator stated that she had received a text from Former Staff #66 regarding allegations of Resident #53 being physically abused by staff members. She said that she was informed that Staff #54 put her hand over Resident #53's mouth, and Staff #65 had made a physical gesture to hit Resident #53. She added she called and reported the abuse allegations and immediately suspended Staff #54 and #65 pending investigation. The administrator said she was informed by local law enforcement that one staff member was charged with three misdemeanors, and the other staff member was charged with three misdemeanors and a felony. On 3/18/25 at 10:53 a.m., local law enforcement confirmed that they found Staff #54 and Staff #65 had abused Resident #53 on 3/2/25, and charges were pressed on both staff members.

Based on interview, observation, and record review, the residence failed to ensure residents received the maximum degree of benefit from those services made available by the assisted living residence, affecting three of three sample residents (#47, #56, #57). Specifically, Resident #57 had pressed her call light pendant on 12/11/24 at 10:53 p.m. The request for assistance had not been responded to until 12/12/24 at 6:43 a.m. On 12/12/24, Resident #57 was found on the ground by Staff #63 at approximately 6:43 a.m. Former Staff #64 had not checked on Resident #57 overnight resulting in neglect of Resident #57. Specifically, on 3/18/25 at approximately 10:44 a.m., Resident #47, spouse of Resident #56, started crying when she discussed how long it took for staff to assist Resident #56 when he needed assistance in the bathroom or to bed. She said as she was crying, "I could only imagine if that were me, having to wait to go to the toilet ... I get panicky when he is not in bed by 9:00 p.m." Pull cord response time on 3/18/25 revealed Resident #56 waited 37 minutes for assistance to get up and ready for the day. Findings include:1. Residence PolicyThe residence's undated Resident Agreement, read in part: Emergency Call Pendant. The residence would provide the resident with an emergency call pendant to make it easier to alert staff of an emergency. 2. Resident #57 was admitted to the residence on 2/6/20 with diagnoses that consisted of osteoarthritis, tremors, syncope, vascular dementia with anxiety, reduced mobility, history of falling, and dependence on wheelchair. The residence's internal investigation dated 12/12/24 read in part, Resident #57's call pendant had been pressed on 12/11/24 at 10:58 p.m., and had not been answered until 12/12/24 at 6:47 a.m., seven hours and 38 minutes later. Staff #63 and Staff #67 had gone into Resident #57's room at approximately 6:40 a.m., on 12/12/24 and saw Resident #57 on the floor between the bathroom and her room, in her undergarments with a blanket on top of her. Staff #67 called the administrator, law enforcement and adult protective services (APS). All staff had an inservice re-education on abuse and neglect on 12/12/24. Call pendant times from 12/1/24 to 3/17/25 revealed response times over 15 minutes, as follows:12/8/24 at 5:34 p.m., 21 minutes12/11/24 at 7:31 p.m., 17 minutes12/11/24 10:58 p.m., seven hours and 38 minutes2/3/25 at 8:31 p.m., 58 minutes2/22/25 at 11:32 a.m., 27 minutes 3/4/25 at 7:38 a.m., 21 minutes3/11/25 at 2:42 p.m., 17 minutes3/14/25 at 10:28 a.m., 21 minutes On 3/17/25 at approximately 11:25 a.m., Resident #57 stated she had gotten out of bed on 12/11/24 to use the bathroom and had fallen in the bathroom when she pressed her call pendant for help. She stated two staff members came to her room, placed a blanket over her, and forced her to sleep on the floor. She also stated she pressed her call light pendant when she needed assistance with toileting and moving around; she had waited for long periods of time. On 3/17/25 at approximately 11:25 a.m., Resident #57's family member stated staff had contacted her to inform her that Resident #57 had fallen on 12/11/24 and pressed her call pendant at 10:58 p.m. However, staff had not responded to the call pendant until after their shift change at 6:30 a.m., on 12/12/24. She stated there had been many occasions when Resident #57 had long wait times after she had pressed her call pendant. On 3/18/25 at approximately 10:15 a.m., Staff #63 stated on 12/12/24 at 6:45 a.m., she noticed Resident #57 had pushed her call pendant at 10:58 p.m., and had not been responded to. She state when she entered Resident #57's room, she had seen her on the bathroom floor covered in a blanket. She stated Resident #57 said she was told to sleep on the ground for the night. 3. Resident #56 was admitted to the residence on 12/10/21 with diagnoses including glaucoma and neurogenic bladder. Requests for assistance via Resident #56 wrist pendant for March 2025 revealed wait times over 15 minutes, as follows:3/1/25 at 8:30 a.m. 26 minutes3/4/25 at 4:57 p.m. 21 minutes3/6/25 at 8:32 p.m. 19 minutes3/7/25 at 2:37 p.m. 27 minutes3/9/25 at 7:23 a.m., 28 minutes3/9/25 at 8:46 p.m., 32 minutes3/11/25 at 7:00 a.m., 32 minutes3/11/25 at 2:49 p.m., 26 minutes 3/12/25 at 7:48 p.m., 24 minutes3/16/25 at 7:27 a.m., 27 minutes3/18/25 at 7:38 a.m., 37 minutesOn 3/18/25 at 11:11 a.m., Staff #53 and #63 confirmed Resident #56 had to occasionally wait longer than 30 minutes for assistance after he pressed his wrist pendant, as he required a two person staff assist. 4. Evidence obtained during the onsite visits on 3/17 and 3/18/25 revealed that the residence failed to provide the maximum degree of benefit for Resident #45 who experienced longer than expected wait times over 30 minutes. 5. InterviewOn 3/18/25 at 12:00 p.m., the administrator stated response times between 15-29 minutes required improvement by staff to correct and any response time over 30 minutes was unacceptable. On 3/18/25 at 12:30 p.m., the administrator stated that they failed to correct the deficiency that had been cited previously due to oversight with a change in management.

Based on observation, 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 five of eight sample residents (#45 and #55-#58). Findings include:1. Resident #56 was admitted to the residence on 12/10/21 with diagnosis including essential hypertension. A progress note, dated 1/4/25, read in part: Resident #56 had a change of condition due to increased weakness after he was observed "sleeping most of the day, not eating much, wheezing, on antibiotics for UTI, not independent of his medications anymore we administer them and not able to transfer himself or empty out his catheter". A written practitioner's order dated 2/4/25, directed the residence to administer lisinopril 40 mg once daily, vitamin B12 100 mcg once daily, and vitamin D3 50 mcg once daily. However, the February and March 2025 medication administration records (MAR) revealed blank spaces for 2/5-3/14/25.2. ObservationOn 3/18/25, a medication cart audit revealed three bottles of Resident #56's medications; lisinopril 40 mg, vitamin B-12 100 mcg and vitamin D3 2,000 IU.3. InterviewsOn 3/17/25 at 7:15 a.m., Staff #68 said Resident #56 had recently switched from self-administering his medications to the residence administering his medications. On 3/18/25 at 9:10 a.m., Staff #68 said Resident #56 lisinopril, vitamin D, and vitamin B were not administered by her and had never been administered since the residence recently took over administering his medications approximately two months ago. On 3/18/25 at 10:44 a.m., Resident #56 confirmed the residence was responsible for administering all his medications. On 3/18/25 at approximately 12:00 p.m., the administrator said she was not aware that the residence was not administering some of Resident #56 medications, as ordered. Additionally, she stated that she expected the residence to administer medications to residents, as ordered. On 3/18/25 at approximately 12:00 p.m., the administrator said she expected the residence to administer medications to residents, as ordered. On 3/18/25 at 12:30 p.m., the administrator stated that they failed to correct the deficiency that had been cited previously due to oversight with a change in management. Evidence obtained during the onsite visits on 3/17 and 3/18/25 revealed that the residence failed to comply with authorized practitioner's orders for Residents #45, #55, #57 and #58.

Based on record review and interview, the residence failed to provide each staff member with a minimum of six hours of general training and education on providing care and services for residents with dementia/cognitive impairment for two of five sample staff (#54, #65) affecting 18 current residents in the secure environment. (Cross-reference S1322)Findings include:1. Record review Personnel files for Staff #54 revealed no evidence that she had completed a minimum of six hours of general training and education providing care and services for residents with dementia/cognitive impairment. Personnel files for Staff #65 revealed no evidence that she had completed a minimum of six hours of general training and education providing care and services for residents with dementia/cognitive impairment. An investigation folder dated 3/2/25 contained written statements. A statement written by Former Staff #66 on 3/2/25 stated that she had worked with Staff #54 and #65, and they had abused Resident #50 when they were working in a secure environment. On 3/17/25 at 1:40 p.m., the administrator stated that Staff #54 and #65 had not completed their online dementia training. On 3/17/25 at 2:13 p.m., Staff #65 stated that she had not completed online dementia training and had not attended any in-person "in-service training" for dementia.

9999 INFORMATIONALTHIS 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. 15.4 If providing laundry service for residents, the assisted living residence shall ensure the following: (D) Personal clothing is returned to the appropriate resident in a presentable, ready-to-wear manner in order to promote resident respect and dignity.

A complaint revisit was completed on 3/18/25 for all previous deficiencies cited on 8/21/24. Deficiencies were cited.

Based on interview, observation, and record review, the residence failed to ensure residents received the maximum degree of benefit from those services made available by the assisted living residence, affecting three of three sample residents (#47, #56, #57). Specifically, Resident #57 had pressed her call light pendant on 12/11/24 at 10:53 p.m. The request for assistance had not been responded to until 12/12/24 at 6:43 a.m. On 12/12/24, Resident #57 was found on the ground by Staff #63 at approximately 6:43 a.m. Former Staff #64 had not checked on Resident #57 overnight resulting in neglect of Resident #57. Specifically, on 3/18/25 at approximately 10:44 a.m., Resident #47, spouse of Resident #56, started crying when she discussed how long it took for staff to assist Resident #56 when he needed assistance in the bathroom or to bed. She said as she was crying, "I could only imagine if that were me, having to wait to go to the toilet ... I get panicky when he is not in bed by 9:00 p.m." Pull cord response time on 3/18/25 revealed Resident #56 waited 37 minutes for assistance to get up and ready for the day. This deficiency was cited previously during a complaint on 8/21/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's undated Resident Agreement, read in part: Emergency Call Pendant. The residence would provide the resident with an emergency call pendant to make it easier to alert staff of an emergency. 2. Resident #57 was admitted to the residence on 2/6/20 with diagnoses that consisted of osteoarthritis, tremors, syncope, vascular dementia with anxiety, reduced mobility, history of falling, and dependence on wheelchair. The residence ' s internal investigation dated 12/12/24 read in part, Resident #57's call pendant had been pressed on 12/11/24 at 10:58 p.m., and had not been answered until 12/12/24 at 6:47 a.m., seven hours and 38 minutes later. Staff #63 and Staff #67 had gone into Resident #57 ' s room at approximately 6:40 a.m., on 12/12/24 and saw Resident #57 on the floor between the bathroom and her room, in her undergarments with a blanket on top of her. Staff #67 called the administrator, law enforcement and adult protective services (APS). All staff had an inservice re-education on abuse and neglect on 12/12/24. Call pendant times from 12/1/24 to 3/17/25 revealed response times over 15 minutes, as follows:12/8/24 at 5:34 p.m., 21 minutes12/11/24 at 7:31 p.m., 17 minutes12/11/24 10:58 p.m., seven hours and 38 minutes2/3/25 at 8:31 p.m., 58 minutes2/22/25 at 11:32 a.m., 27 minutes 3/4/25 at 7:38 a.m., 21 minutes3/11/25 at 2:42 p.m., 17 minutes3/14/25 at 10:28 a.m., 21 minutes On 3/17/25 at approximately 11:25 a.m., Resident #57 stated she had gotten out of bed on 12/11/24 to use the bathroom and had fallen in the bathroom when she pressed her call pendant for help. She stated two staff members came to her room, placed a blanket over her, and forced her to sleep on the floor. She also stated she pressed her call light pendant when she needed assistance with toileting and moving around; she had waited for long periods of time. On 3/17/25 at approximately 11:25 a.m., Resident #57's family member stated staff had contacted her to inform her that Resident #57 had fallen on 12/11/24 and pressed her call pendant at 10:58 p.m. However, staff had not responded to the call pendant until after their shift change at 6:30 a.m., on 12/12/24. She stated there had been many occasions when Resident #57 had long wait times after she had pressed her call pendant. On 3/18/25 at approximately 10:15 a.m., Staff #63 stated on 12/12/24 at 6:45 a.m., she noticed Resident #57 had pushed her call pendant at 10:58 p.m., and had not been responded to. She state when she entered Resident #57's room, she had seen her on the bathroom floor covered in a blanket. She stated Resident #57 said she was told to sleep on the ground for the night. 3. Resident #56 was admitted to the residence on 12/10/21 with diagnoses including glaucoma and neurogenic bladder. Requests for assistance via Resident #56 wrist pendant for March 2025 revealed wait times over 15 minutes, as follows:3/1/25 at 8:30 a.m. 26 minutes3/4/25 at 4:57 p.m. 21 minutes3/6/25 at 8:32 p.m. 19 minutes3/7/25 at 2:37 p.m. 27 minutes3/9/25 at 7:23 a.m., 28 minutes3/9/25 at 8:46 p.m., 32 minutes3/11/25 at 7:00 a.m. 32 minutes3/11/25 at 2:49 p.m., 26 minutes 3/12/25 at 7:48 p.m., 24 minutes3/16/25 at 7:27 a.m., 27 minutes3/18/25 at 7:38 a.m., 37 minutesOn 3/18/25 at 11:11 a.m., Staff #53 and #63 confirmed Resident #56 had to occasionally wait longer than 30 minutes for assistance after he pressed his wrist pendant, as he required a two person staff assist. 4. Evidence obtained during the onsite visits on 3/17 and 3/18/25 revealed that the residence failed to provide the maximum degree of benefit for Resident #45 who experienced longer than expected wait times over 30 minutes. 5. InterviewOn 3/18/25 at 12:00 p.m., the administrator stated response times between 15-29 minutes required improvement by staff to correct and any response time over 30 minutes was unacceptable. On 3/18/25 at 12:30 p.m., the administrator stated that they failed to correct the deficiency that had been cited previously due to oversight with a change in management.

Based on observation, 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 five of eight sample residents (#45 and #55-#58). This deficiency was cited previously during a complaint investigation on 8/21/24. 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 #56 was admitted to the residence on 12/10/21 with diagnosis including essential hypertension. A progress note, dated 1/4/25, read in part: Resident #56 had a change of condition due to increased weakness after he was observed "sleeping most of the day, not eating much, wheezing, on antibiotics for UTI, not independent of his medications anymore we administer them and not able to transfer himself or empty out his catheter". A written practitioner's order dated 2/4/25, directed the residence to administer lisinopril 40 mg once daily, vitamin B12 100 mcg once daily, and vitamin D3 50 mcg once daily. However, the February and March 2025 medication administration records (MAR) revealed blank spaces for 2/5-3/14/25.2. ObservationOn 3/18/25, a medication cart audit revealed three bottles of Resident #56's medications; lisinopril 40 mg, vitamin B-12 100 mcg and vitamin D3 2,000 IU.3. InterviewsOn 3/17/25 at 7:15 a.m., Staff #68 said Resident #56 had recently switched from self-administering his medications to the residence administering his medications. On 3/18/25 at 9:10 a.m., Staff #68 said Resident #56 lisinopril, vitamin D, and vitamin B were not administered by her and had never been administered since the residence recently took over administering his medications approximately two months ago. On 3/18/25 at 10:44 a.m., Resident #56 confirmed the residence was responsible for administering all his medications. On 3/18/25 at approximately 12:00 p.m., the administrator said she was not aware that the residence was not administering some of Resident #56 medications, as ordered. Additionally, she stated that she expected the residence to administer medications to residents, as ordered. On 3/18/25 at approximately 12:00 p.m., the administrator said she expected the residence to administer medications to residents, as ordered. On 3/18/25 at 12:30 p.m., the administrator stated that they failed to correct the deficiency that had been cited previously due to oversight with a change in management. Evidence obtained during the onsite visits on 3/17 and 3/18/25 revealed that the residence failed to comply with authorized practitioner's orders for Residents #45, #55, #57 and #58.

Based on interview and record review, the residence failed to ensure resident's medication administration record (MAR) contained accurate information, affecting one of eight residents (#45). This deficiency was cited previously during a complaint revisit on 8/21/24. 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 #45 was admitted to the residence on 7/8/24.a. TizanidineA written practitioner's order, dated 1/25/25, directed the residence to administer tizanidine 2 mg once daily. However, the February and March 2025 medication administration record (MAR) for Resident #45 had blank spaces from 2/27-3/5/25, for a total of seven blank spaces.b. LevothyroxineA written practitioner's order, dated 2/21/25, directed the residence to administer levothyroxine 137 mcg one daily. However, the March 2025 MAR for Resident #45 had blank spaces on 3/1-3/4/25, for a total of four blank spaces. c. Melatonin A written practitioner's order, dated 1/25/25, directed the residence to administer melatonin 5 mg once daily. However, the March 2025 MAR had a blank space on 3/16/25.2. InterviewsOn 3/18/25 at 7:35 a.m., the compliance specialist said she did not have an answer for why there were blank spaces on Resident #45's MAR for the medications listed above. On 3/18/25 at approximately 12:00 p.m., the administrator said she expected the residence to accurately complete MARs for residents. On 3/18/25 at 12:30 p.m., the administrator stated that they failed to correct the deficiency that had been cited previously due to oversight with a change in management.

A complaint revisit was completed on 3/18/25 for all previous deficiencies/the previous deficiency cited on 8/21/24. Deficiencies were cited.

Based on interview, observation, and record review, the residence failed to ensure residents received the maximum degree of benefit from those services made available by the assisted living residence, affecting three of three sample residents (#47, #56, #57). Specifically, Resident #57 had pressed her call light pendant on 12/11/24 at 10:53 p.m. The request for assistance had not been responded to until 12/12/24 at 6:43 a.m. On 12/12/24, Resident #57 was found on the ground by Staff #63 at approximately 6:43 a.m. Former Staff #64 had not checked on Resident #57 overnight resulting in neglect of Resident #57. Specifically, on 3/18/25 at approximately 10:44 a.m., Resident #47, spouse of Resident #56, started crying when she discussed how long it took for staff to assist Resident #56 when he needed assistance in the bathroom or to bed. She said as she was crying, "I could only imagine if that were me, having to wait to go to the toilet ... I get panicky when he is not in bed by 9:00 p.m." Pull cord response time on 3/18/25 revealed Resident #56 waited 37 minutes for assistance to get up and ready for the day. This deficiency was cited previously during a complaint on 8/21/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's undated Resident Agreement, read in part: Emergency Call Pendant. The residence would provide the resident with an emergency call pendant to make it easier to alert staff of an emergency. 2. Resident #57 was admitted to the residence on 2/6/20 with diagnoses that consisted of osteoarthritis, tremors, syncope, vascular dementia with anxiety, reduced mobility, history of falling, and dependence on wheelchair. The residence's internal investigation dated 12/12/24 read in part, Resident #57's call pendant had been pressed on 12/11/24 at 10:58 p.m., and had not been answered until 12/12/24 at 6:47 a.m., seven hours and 38 minutes later. Staff #63 and Staff #67 had gone into Resident #57's room at approximately 6:40 a.m., on 12/12/24 and saw Resident #57 on the floor between the bathroom and her room, in her undergarments with a blanket on top of her. Staff #67 called the administrator, law enforcement and adult protective services (APS). All staff had an inservice re-education on abuse and neglect on 12/12/24. Call pendant times from 12/1/24 to 3/17/25 revealed response times over 15 minutes, as follows:12/8/24 at 5:34 p.m., 21 minutes12/11/24 at 7:31 p.m., 17 minutes12/11/24 10:58 p.m., seven hours and 38 minutes2/3/25 at 8:31 p.m., 58 minutes2/22/25 at 11:32 a.m., 27 minutes 3/4/25 at 7:38 a.m., 21 minutes3/11/25 at 2:42 p.m., 17 minutes3/14/25 at 10:28 a.m., 21 minutes On 3/17/25 at approximately 11:25 a.m., Resident #57 stated she had gotten out of bed on 12/11/24 to use the bathroom and had fallen in the bathroom when she pressed her call pendant for help. She stated two staff members came to her room, placed a blanket over her, and forced her to sleep on the floor. She also stated she pressed her call light pendant when she needed assistance with toileting and moving around; she had waited for long periods of time. On 3/17/25 at approximately 11:25 a.m., Resident #57's family member stated staff had contacted her to inform her that Resident #57 had fallen on 12/11/24 and pressed her call pendant at 10:58 p.m. However, staff had not responded to the call pendant until after their shift change at 6:30 a.m., on 12/12/24. She stated there had been many occasions when Resident #57 had long wait times after she had pressed her call pendant. On 3/18/25 at approximately 10:15 a.m., Staff #63 stated on 12/12/24 at 6:45 a.m., she noticed Resident #57 had pushed her call pendant at 10:58 p.m., and had not been responded to. She state when she entered Resident #57's room, she had seen her on the bathroom floor covered in a blanket. She stated Resident #57 saidshe was told to sleep on the ground for the night. 3. Resident #56 was admitted to the residence on 12/10/21 with diagnoses including glaucoma and neurogenic bladder. Requests for assistance via Resident #56 wrist pendant for March 2025 revealed wait times over 15 minutes, as follows:3/1/25 at 8:30 a.m. 26 minutes3/4/25 at 4:57 p.m. 21 minutes3/6/25 at 8:32 p.m. 19 minutes3/7/25 at 2:37 p.m. 27 minutes3/9/25 at 7:23 a.m., 28 minutes3/9/25 at 8:46 p.m., 32 minutes3/11/25 at 7:00 a.m. 32 minutes3/11/25 at 2:49 p.m., 26 minutes 3/12/25 at 7:48 p.m., 24 minutes3/16/25 at 7:27 a.m., 27 minutes3/18/25 at 7:38 a.m., 37 minutesOn 3/18/25 at 11:11 a.m., Staff #53 and #63 confirmed Resident #56 had to occasionally wait longer than 30 minutes for assistance after he pressed his wrist pendant, as he required a two person staff assist. 4. Evidence obtained during the onsite visits on 3/17 and 3/18/25 revealed that the residence failed to provide the maximum degree of benefit for Resident #45 who experienced longer than expected wait times over 30 minutes. 5. InterviewOn 3/18/25 at 12:00 p.m., the administrator stated response times between 15-29 minutes required improvement by staff to correct and any response time over 30 minutes was unacceptable. On 3/18/25 at 12:30 p.m., the administrator stated that they failed to correct the deficiency that had been cited previously due to oversight with a change in management.

Based on observation, 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 five of eight sample residents (#45 and #55-#58). This deficiency was cited previously during a complaint investigation on 8/21/24. 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 #56 was admitted to the residence on 12/10/21 with diagnosis including essential hypertension. A progress note, dated 1/4/25, read in part: Resident #56 had a change of condition due to increased weakness after he was observed "sleeping most of the day, not eating much, wheezing, on antibiotics for UTI, not independent of his medications anymore we administer them and not able to transfer himself or empty out his catheter". A written practitioner's order dated 2/4/25, directed the residence to administer lisinopril 40 mg once daily, vitamin B12 100 mcg once daily, and vitamin D3 50 mcg once daily. However, the February and March 2025 medication administration records (MAR) revealed blank spaces for 2/5-3/14/25.2. ObservationOn 3/18/25, a medication cart audit revealed three bottles of Resident #56's medications; lisinopril 40 mg, vitamin B-12 100 mcg and vitamin D3 2,000 IU.3. InterviewsOn 3/17/25 at 7:15 a.m., Staff #68 said Resident #56 had recently switched from self-administering his medications to the residence administering his medications. On 3/18/25 at 9:10 a.m., Staff #68 said Resident #56 lisinopril, vitamin D, and vitamin B were not administered by her and had never been administered since the residence recently took over administering his medications approximately two months ago. On 3/18/25 at 10:44 a.m., Resident #56 confirmed the residence was responsible for administering all his medications. On 3/18/25 at approximately 12:00 p.m., the administrator said she was not aware that the residence was not administering some of Resident #56 medications, as ordered. Additionally, she stated that she expected the residence to administer medications to residents, as ordered. On 3/18/25 at approximately 12:00 p.m., the administrator said she expected the residence to administer medications to residents, as ordered. On 3/18/25 at 12:30 p.m., the administrator stated that they failed to correct the deficiency that had been cited previously due to oversight with a change in management. Evidence obtained during the onsite visits on 3/17 and 3/18/25 revealed that the residence failed to comply with authorized practitioner's orders for Residents #45, #55, #57 and #58.

A complaint revisit was completed on 3/18/25 for all previous deficiencies cited on 8/21/24. A deficiency was cited.

Based on interview and record review, the residence failed to ensure resident's medication administration record (MAR) contained accurate information, affecting one of eight residents (#45). This deficiency was cited previously during a complaint revisit on 8/21/24. 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 #45 was admitted to the residence on 7/8/24.a. TizanidineA written practitioner's order, dated 1/25/25, directed the residence to administer tizanidine 2 mg once daily. However, the February and March 2025 medication administration record (MAR) for Resident #45 had blank spaces from 2/27-3/5/25, for a total of seven blank spaces.b. LevothyroxineA written practitioner's order, dated 2/21/25, directed the residence to administer levothyroxine 137 mcg one daily. However, the March 2025 MAR for Resident #45 had blank spaces on 3/1-3/4/25, for a total of four blank spaces. c. Melatonin A written practitioner's order, dated 1/25/25, directed the residence to administer melatonin 5 mg once daily. However, the March 2025 MAR had a blank space on 3/16/25.2. InterviewsOn 3/18/25 at 7:35 a.m., the compliance specialist said she did not have an answer for why there were blank spaces on Resident #45's MAR for the medications listed above. On 3/18/25 at approximately 12:00 p.m., the administrator said she expected the residence to accurately complete MARs for residents. On 3/18/25 at 12:30 p.m., the administrator stated that they failed to correct the deficiency that had been cited previously due to oversight with a change in management.

A licensure complaint, prompted by #CO37768 was completed on 10/15/24. A deficiency was cited.

Based on interview and record review, the residence failed to investigate all allegations of abuse of residents in accordance with its written policy, affecting one sample resident (#49) and one former resident (#51). Specifically, Resident #48 physically pushed Resident #51, and the resident experienced pain. The residence failed to investigate the allegation of abuse, and Resident #48 was aggressive with another unidentified resident. The residence failed to investigate the allegation of abuse, and subsequently, Resident #48 was verbally aggressive with Resident #49. Resident #49 reported and demonstrated that she was fearful of Resident #48. Findings include:1. Residence PolicyThe residence's undated Abuse and Neglect Allegation Reporting Checklist read in part that the residence was required to investigate all allegations of abuse, conduct documented interviews with staff and residents, write a narrative of summary of the events, report the incident to the Department and law enforcement (LE), and document all actions taken to ensure the safety of residents to prevent additional incidents from happening. 2. Record Reviewa. On 10/15/24, the residence provided one investigation of abuse allegations reported within 90 days prior to the onsite investigation; however, this investigation did not involve the secure environment (SE) nor Residents #51 and #48.b. Resident #51 was admitted to the residence on 11/28/23 with a diagnosis of dementia. A progress note, dated 8/31/24, read that Resident #51 reported another resident hurt her, and she experienced pain. The staff observed Resident #48 grip Resident #15's upper arms and push her. Staff told Resident #48 not to hit other residents. c. Resident #48 was admitted to the residence on 10/7/21 with a diagnosis of Alzheimer's Disease. Progress notes read in part:On 8/31/24, Resident #48 told Resident #51 to get out of her way. Resident #48 grabbed the arms of Resident #51 in a firm way and pushed her back. The residence staff asked Resident #48 not to hit other residents. On 9/2/24, Resident #48 was aggressive toward another unidentified resident without injury. A care plan, dated 6/28/24, read that Resident #48 was verbally aggressive with other residents and staff with a history of physical aggression toward staff. Further, it read that the resident was challenging to redirect; however, the behavioral management intervention was to redirect the resident with an activity, food, or fluid. 3. InterviewsA family member who wished to remain anonymous stated that Resident #48 had physically abused another unidentified resident in their presence, routinely called Resident #49 derogatory names, told her to get out of the way, and used aggressive language toward her. The family member stated that Resident #49 reported fear to the staff and was visibly afraid of Resident #48Staff #54, #55, and #58 stated that Resident #48 was frequently verbally aggressive and physically threatening toward staff and verbally aggressive toward residents; staff often were unable to redirect the resident. They affirmed that Resident #48 had a history of calling other residents derogatory names. Specifically, Resident #48 called Resident #49 derogatory names and spoke to her in an aggressive manner, and Resident #49 was fearful of the resident. They added that Resident #48 demonstrated aggression with other residents; however, they were unable to provide other details regarding the behavioral expressions. They stated that they were unaware of the incident of alleged physical abuse that occurred on 8/31/24 between Resident #48 and #51 but that it was possible as Resident #48 frequently became agitated and aggressive. They added that the approach to the aggression and to protect other residents from Resident #48 was redirecting the resident; however, this approach did not work for Staff #55 nor #58 and did not consistently work for Staff #54, and Resident #48 continued to demonstrate aggressive behavioral expressions. The administrator stated the residence did not investigate or report the incident of physical abuse that occurred on 8/31/24 between residents #48 and #51. He added he was not notified of the incident; however, the residence should have investigated the incident and reported it to the appropriate agencies, such as the Department and LE, and should have ensured that other residents were protected, as the incident was documented in progress notes. He stated he was aware of the behavioral expressions of Resident #48 and that the approaches of redirection were not adequate, and the residence's former health and wellness director (HWD) should have followed up with the practitioner for Resident #48 to request a medication review and behavioral assessment. He added he was unaware of any other incidents of verbal or physical aggression expressed by Resident #48.

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 7.5.1 Assisted living residence personnel engaged in the admission, care or treatment of at-risk persons shall report suspected physical or sexual abuse, exploitation and/or caretaker neglect to law enforcement within 24 hours of observation or discovery pursuant to Section 18-6.5-108, C.R.S. 5.3 An assisted living residence shall comply with all occurrence reporting required by state law and shall follow the reporting procedures set forth in 6 CCR 1011-1, Chapter 2, Part 4.2. (A) Any occurrence that results in the death of a client of the facility or agency and is required to be reported to the coroner pursuant to section 30-10-606, C.R.S., as arising from an unexplained cause or under suspicious circumstances; (B)(1) Brain or spinal cord injuries; (2) Life-threatening complications of anesthesia or life-threatening transfusion errors or reactions; (3) Second or third degree burns involving twenty percent (20%) or more of the body surface area of an adult client or fifteen percent (15%) or more of the body surface area of a child client; (C) An assisted living residence shall investigate an occurrence to determine the circumstances of the event and institute appropriate measures to prevent similar future situations. (1) Documentation regarding the investigation, including the appropriate measures to be instituted, shall be made available to the Department, upon request. An assisted living residence shall submit its final investigation report to the Department within five business days after the initial report of the occurrence. Nothing in this Part 5.3 shall be construed to limit or modify any statutory or common law right, privilege, confidentiality, or immunity.

A complaint revisit was completed on 8/21/24 for all previous deficiencies cited on 3/7/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Based on observation, interview and record review the residence failed to ensure care plans were updated whenever a resident's condition changed from baseline status affecting two of two sample residents (#41,#42). Cross-reference This deficiency was cited previously during a state licensure survey on 3/07/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. References and Residence Policy The residence's Care Plan Policy, undated, read in part: A Care Plan will be completed by the Wellness Director prior to move-in. The Wellness Director and team will visit with the resident and family to complete the plan which will: (a) Reflect the most current assessment information; (c ) detail specific personal service needs and preferences along with the staffing necessary to meet those needs. 2. Resident #42 was admitted to the residence on 5/26/21 with diagnoses consisting of diabetes and hypertension. Resident #42 was readmitted to the residence on 8/16/24 with a diagnosis of closed fracture of ramus of right pubis.a. Observation:On 8/20/24 at 10:20 a.m., Resident #42 was observed laying in her bed. The surveyor attempted to interview Resident #42 but was unable to. The resident was able to recognize that there was someone there to talk with them; however, was unable or unwilling to answer questions. b. Records Review:Hospital discharge orders dated 8/6-8/16/24, read in part: Resident #42 was diagnosed with a closed fracture of ramus of the right pubis, initial encounter. A late entry progress note for Resident #42, dated 8/13/24, read in part: On 8/6/24 at 10:00 a.m., a resident stood up and fell on resident #42. Resident #42 fell to the ground and hit her right hip and her head on the floor. A care plan for Resident #42, dated 8/20/24, read in part: Resident #41 was independent with showering, toileting, transferring, and medication. c. Interview:On 8/20/24 a family member stated that since the accident Resident #42 had become completely dependent on staff and family members for assistance with all ADL ' s. On 8/21/24 at approximately 10:50 a.m. the wellness director (WD) stated that he was responsible for updating and managing the care plans for all of the residents. He also stated that care plans were updated after admission or when there was a change in condition. On 8/21/24 at approximately 1:35 p.m. the administrator stated that he expected care plans to have been updated when a resident returned from the hospital or rehabilitation and that with Resident #42 "there may have been an assumption that she was going to be fine."3. Resident #41 who was admitted to the residence on 10/10/23 with a diagnosis of cardiac, hypertension, fracture, diabetes and depression . Resident #41 was then readmitted to the residence on 8/16/24 with a diagnosis of chronic obstructive pulmonary disease, chronic hypoxemia respiratory failure from neglect, diabetes and depression.a. Interviews:On 8/20/24 at 1:17 p.m., the WD stated Resident #41 had a fall on 7/18/24 which resulted in a hospitalization and subsequent rehabilitation stay. He stated the resident was readmitted to the residence on 8/16/24. On 8/20/24, at 3:06 p.m., Staff #53 stated that Resident #41 fell twice on 8/18/24. On 8/20/24 at 5:00 p.m., Staff #49 stated that she was working during the incident on 8/18/24 around 3:30 p.m. with Resident #41. Staff #49 stated she saw Resident #41 on the floor blue and shaking. The staff stated she telephoned the WD and administrator immediately and did not get a response and subsequently telephoned emergency medical services. On 8/21/24 at approximately 10:50 a.m. the WD stated that he was not aware that Resident #41 fell twice on 8/18/24. He stated that he was responsible for developing care plans and that care plans were completed after any change in condition. On 8/21/24 at approximately 1:35 p.m. the administrator confirmed the wellness director had not been organizing care plans or assessments based on the instructions that were given to him when he had started his position. He further stated he was not aware care plans had not been updated. b. Observation:On 8/20/24 at 10:00 a.m., Resident #41 was observed in her room attempting to eat her breakfast. Resident #41 was agitated and confused and did not have her nasal cannula on.c. Record ReviewA care plan, dated 10/10/23, read in part: Resident #41 was independent with transfer, escorts, oxygen use, and toileting. However the care plan for Resident #41 failed to detail specific personal service needs and preference along with staff tasks necessary to meet those needs as it was not updated after the residents hospitalization, rehabilitation stay and hypoxic event.

Based on interview and record review the residence failed to ensure residents were free from neglect affecting 98 current residents. Cross-reference S1110 and S1150 This deficiency was cited previously during a state licensure survey on 3/7/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, the residence failed to protect Resident #41 who was diagnosed with chronic hypoxemic respiratory failure from neglect. On 8/18/24 at 3:30 p.m., Resident #41 sustained a fall which caused her prescribed four liters of continuous oxygen per minute to fall off. Two staff responded to the fall and noticed the resident's face and hands were discolored. Staff subsequently took the resident's oxygen statistics which they reported were between 60-65 percent saturation; however, both staff failed to reapply the resident's oxygen. Staff reported they had been trained to leave the resident alone when a fall occurred and not provide care. When emergency medical services arrived the resident was not wearing her oxygen and Resident 41's face and hands were purple in color. Emergency medical services (EMS) reported the resident's oxygen were in the mid 60's. On 8/20/24 neither the administrator or wellness director (WD) reported knowing of the incident therefore no direction had been provided to staff to prevent a recurrence. This failure created an immediate jeopardy risk of neglect to all (98) current residents residing in the residence. On 8/20/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Residence Policy:a. The residence's Resident Rights policy, undated, read in part: Residents have the right to be free from neglect. Neglect was defined as the failure of the residence, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. b. The residence's Resident Fall Management and Injury Response Policy, undated, read in part: for major injury; airway/breathing problems, provide first aid consistent with training if appropriate.c. Chapter VII regulations governing assisted living residences defines caretaker neglect as neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise. d. A residence staff training document titled Condition that Require Notification of a Manager, undated, stated in part: "You (residence staff) must notify your immediate supervisor of the following resident, facility or staff conditions:" All falls or any facility emergency that required emergency measures. 2. Resident #41 was admitted to the residence on 10/10/23 with a diagnosis of chronic hypoxemic respiratory failure from neglect, cardiac, hypertension, fracture, diabetes and depression.a. Interview:On 8/20/24 at 1:17 p.m., the WD stated Resident #41 had been discharged from rehabilitation on 8/16/24. He stated he was not aware of any incident that happened with the resident on 8/18/24. He stated if something happened it should have been documented and he should have been informed. On 8/20/24 at approximately 1:59 p.m., the responding EMS responder stated that the dispatch notes they received read On 8/18/24 staff reported Resident #41 was purple in color. The EMS responder stated that upon arrival Resident #41 ' s face was purple and there were two residence staff at her side, the nasal cannula was hooked up to oxygen but not on Resident #41. Resident #41 had a pulse oximeter reading of 64%. The EMS responder stated that they were on scene for an extended period of time stabilizing Resident #41. EMS further stated he informed the two staff present that not putting the resident's oxygen back on was neglect and stated staff reported they were not allowed to help any resident who had fallen without permission from management. EMS responder added the incident was filed as neglect in thier system. On 8/20/24 at approximately 2:06 p.m. a family member for Resident #41 stated that EMS staff on 8/18/24 telephoned him regarding the incident with Resident #41. On 8/20/24 at 3:06 p.m., Staff #53 stated that Resident #41 was found on the floor of her room, her hands cold, still responsive, and a little blueish to the face. Staff #53 stated she took Resident #41 ' s oxygen level and it was around 60-65%. The staff stated she did not assist the resident with putting her oxygen back on and when EMS arrived they put on her oxygen and helped bring her oxygen levels back up. Staff #53 stated that residence staff was directed to help residents put their oxygen on, however, if a resident fell residence staff was directed to not touch the resident and to call the wellness director (WD), assistant wellness director, EMS, practitioner, and/or external hospice; directions would then be given to residence staff of what to do. Staff #53 stated that when the incident occurred, on 8/18/24 with Resident #41, She and her coworker attempted to call the WD but were unable to get a hold of him. They then called EMS. On 8/20/24 at approximately 4:50 p.m., the administrator stated that he was out of the office on 8/18/24 for the week. He stated the WD was his designee. The administrator stated he was not made aware of any incident that happened with Resident #41. He confirmed he had not done anything regarding the incident as he had not been made aware of what had happened. On 8/20/24 at 5:00 p.m., Staff #49 stated that she was working during the incident on 8/18/24 around 3:30 p.m., with Resident #41. Staff #49 stated she saw Resident #41 on the floor blue and shaking. The staff stated she called management immediately and did not get a response and subsequently telephoned EMS. Staff #49 said she did not put Resident #41 ' s oxygen back because she had received strict instructions from management to always leave any resident as is until management had been reached. She stated when EMS arrived and measured Resident #41 ' s oxygen level which was around 60%. Staff #49 stated that EMS notified the resident's family. On 8/20/24 at approximately 5:24 p.m., the administrator stated that the residence did have a policy on not helping a resident up in regards to falls. He stated the residence also had a policy in regards to assisting residents. He stated staff should have helped Resident #41. The administrator further stated staff was supposed to notify the WD and himself then write an incident report. He stated the incident report would have also notified both he and the WD. The administrator confirmed there was no documentation regarding the incident with Resident #41. The administrator stated staff telephoning management was the residence's "fail safe" and did not respond if he or the WD had any missed telephone calls. b. Record Review:A written practitioner's order, dated 5/1/24, directed the residence to administer oxygen four liters per minute continuously. The record for Resident #41 contained no evidence of the fall and subsequent incident with oxygen. The staff schedule dated 8/18-8/24/24 read Staff #49 and Staff #53 worked together during the incident that occurred on 8/18 with Resident #41. The staff schedule also read Staff #53 worked on 8/19-8/22 and Staff #49 worked 8/19, 8/23, and 8/24/24. 3. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 98 current residents at immediate jeopardy risk for neglect. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 8/20/24 at 6:56 p.m. the administrator submitted written evidence that read in pertinent part: "(The residence) will ensure that resident affected by the incident that occurred on 8/18/24 will be reassessed on 8/20/24. Practitioner and hospice will be informed and requested for interventions. To be completed on 8/20/24. Incident was reported to hospice. All residents on oxygen will be reassessed for proper levels and fitment to be completed on 8/21/24. The residence care team to be re-trained on how to re-attach oxygen lines and how to respond, assess and assist resident falls to be completed 8/22/24. The residence care team will be re-trained on the use of incident reporting system and will make sure they speak to the nurse after completing an incident report to be completed by 8/23/24. All team members will undergo training and in-service on the risks and consequences of neglect. All staff including managers and directors will be in-serviced by the Regional Nurse on the policies regarding falls and neglect to be completed by 8/28/24. The (WD) will monitor residence care team members response time(s) to residents ' calls and (WD) will over two weeks beginning 8/21/24 review care and services provided to all residents on oxygen. The (administrator) will meet daily with the (WD) to review all incidents from the previous day to determine resident(s) change of condition and the planned interventions. The Regional Nurse Director will conduct bi-monthly audits on incident reporting and ensure policies and procedures are being followed as regard to resident falls and neglect." However, the written evidence did not indicate that the risk had been removed because it did not include acceptable guidance for all residence staff regarding oxygen administration, an acceptable timeline for implementation, an investigation element, acceptable dates when training would be completed with residence staff and how each element would be documented and implemented or an acceptable timeline for investigation. Evidence did not include guidance for residence staff for emergency situations and steps to take. The administrator was directed to submit additional written evidence. On 8/20/24 at 7:44 p.m. the administrator submitted a second written evidence that read in pertinent part: "(The residence) will investigate the residence care team regarding response to resident. Residence staff will be retrained on all resident care needs by 8/20/24. An on-going training and review for neglect will be conducted every two weeks. An agenda and attendance sign-in sheet will be kept on record. The care team will be re-trained in the use of the incident reporting system and will make sure they speak to the (WD, assistant wellness director (AWD), or administrator) after completing an incident report to begin on 8/20/24. All care team members will undergo training and in-service on the risks and consequence(s) of neglect by 8/21/24. All staff including managers and directors will be in-serviced by the Regional Nurse on the policies regarding falls and neglect to be completed by 8/21/24. The (WD) will over the next two weeks beginning 8/20/24 review care and services provided to all residents. All care plans and services on the electronic device will be reviewed by (WD, AWD, and administrator) for completion. All residents service plans will be reviewed and updated to reflect oxygen and ADL needs specific to each resident. Staff will be re-trained on how to view the (care) plans at the start of each shift beginning 8/20/24. The (administrator) will meet daily with the (WD) to review all incidents from the previous day to determine resident(s) change of condition and the planned interventions. The regional Nurse Director will conduct bi-monthly audits on incident reporting and ensure policies and procedures are being followed as regards to resident falls and neglect. All care team members including WD and AWD working on 8/18/24 will be asked to give a statement regarding the incident that occurred to resident ... (Resident #41). APS and ombudsman will be informed of the incident. All care team members will be in-serviced for neglect for the next six weeks. All new hires will undergo training specific but not limited to resident care, neglect, incident reporting prior to getting assigned to a shift. WD, AWD, and ED (administrator) will review service plans bi-weekly and review care team documentation for services provided to residents daily."However, the written evidence did not indicate that the risk had been removed because it did not include occurrence reporting to the department. It also did not include immediate actions to ensure all residents were free from neglect immediately. The administrator was directed to submit additional written evidence. During the second onsite investigation on 8/21/24 , at 8:36 a.m., the administrator submitted a final written evidence that read in pertinent part: "(The residence) will investigate the care team on how they responded to the the resident ' s fall (dated 8/18/24). Oxygen was added to the care plan on 8/20/24, as well as 2-hour frequency checks. The incident was reported to hospice agency on 8/18/24 at approximately 8:14 p.m. The (WD) and (AWD) will undergo performance review by the (administrator) to assess capacity and ability to perform their duties and responsibilities towards the care and safety of all residents to be completed by 8/21/24. (WD) will monitor care team member response time(s) to residents ' calls. All care plans and services on the (electronic device) will be reviewed by (WD, AWD, and administrator) for completion beginning 8/20/24. The care team will be re-trained on how to view the service plans at the start of each shift beginning 8/20/24. The evening and night shift care team have been informed to ensure all care services are done properly and in a timely manner. Also, they have been informed to ensure that all incident reports are completed and to inform WD, AWD, and (administrator) of all incidents. (The administrator) and WD together with the care team will perform root cause analyses on any incidents to determine underlying issues. Regularly review and update policies and procedures to reflect current best practices and regulatory changes and ensure that all staff are aware of and understand these updates through regularly scheduled training. The regional Nurse Director will conduct bi-monthly audits on incident reporting and ensure policies and procedures are being followed as regards to residents ' care, fall prevention, and safety. (The administrator) and WD will actively monitor and promote a culture of safety, quality care and incident reporting. Discuss compliance and care concerns during daily Stand Up (team meetings). Occurrence report will be filed in (department) portal. Root cause analysis will be performed to determine the underlying causes for neglect, proper incident reporting and compliance with policies and procedures for resident care and safety. WD and AWD will conduct regular audits of care team performance and resident safety. A detailed record of audits and inspections will include issues discovered and corresponding corrective actions."

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 7.11.1 The assisted living residence shall accept only those persons whose needs can be fully met bythe existing staff, physical environment, and services already being provided. The assisted livingresidence's ability to meet resident needs shall be based upon a comprehensive pre-admissionassessment of a resident's physical, mental, and social needs; cultural, religious and activityneeds; preferences; and capacity for self-care. 14.3 An assisted living residence shall not allow a QMAP or a CNA-Med to assist a resident withmedication administration unless the resident is able to consent and participate in theconsumption of the medication. 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing.

A complaint revisit was completed on 8/21/24 for all previous deficiencies cited on 3/7/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Based on interview and record review, the residence failed to provide access upon request to full resident records affecting five of five sample residents (#41-#45). Findings include 1. Referencea. Chapter VII regulations governing assisted living residences, part 18.8, requires that the resident record shall contain but not be limited to the following items: (B) Practitioner order; (E) Medication Administration Record (MAR). 2. Record review On 8/20/24 at 7:41 a.m., access to all resident records was requested from the administrator. 8/20/24 at 1:00 p.m., resident records in their completion for Residents #41-#45 of the non-secure environment was requested from the wellness director. On 8/20/24 the following was received:At approximately 3:30 p.m., practitioner orders for Resident #45 and Resident #43. At 6:50 p.m. pregabalin order for Resident #41. At approximately 7:32 p.m. hospice orders for Resident #42. The following was not received until the following day 8/21/24:At 12:13 p.m., a practitioner's order for oxycodone for Resident #42. At 12:25 p.m., practitioner's annual order for self administering medications for Resident #42. At 1:00 p.m., practitioner medication list, dated 8/1/24, for Resident #44.2. InterviewsOn 8/20/24 at 1:22 p.m., the wellness director said the residence was behind with uploading paper copies of documentation into electronic system.

Based on record review and interview, the residence failed to ensure a name-based criminal history record check from the Colorado Bureau of Investigation (CBI) was requested for each prospective staff member, prior to hire for one sample staff (#45), affecting 95 current residents. This deficiency was cited previously during a complaint revisit on 3/7/23. 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 policy Criminal Background Checks, undated, read in part: "In order to ensure that staff members and volunteers are of good, moral and responsible character, the assisted living residence shall request, prior to hire, a name-based criminal history record check, Colorado Bureau of Investigations (CBI), and Colorado Caps Check for each prospective staff member and volunteer providing ALR services. Background check results must be reviewed and accepted prior to any resident contact"2. Record ReviewThe personnel file for Staff #49 revealed they were hired on 12/20/23. However, the personnel file failed to contain a criminal background check through the CBI as required. The staff schedule for August 2024 read Staff #49 worked from 2:00 p.m. to 10:15 p.m. on 8/4, 8/5, 8/12, 8/18, 8/19, 8/24 and at 10:00 p.m. to 6:15 a.m. on 8/11 and 8/24/24.3. InterviewOn 8/21/24 at approximately 1:34 p.m., the administrator stated background checks were required through the CBI and that staff were not able to start orientation or have hands-on care until background checks were completed. He stated the staff member was a transfer from another state and the CBI was probably missed.

Based on record review, observations and interviews, the residence failed to have staff sufficient in number to help residents needing or potentially needing assistance, affecting 95 current residents. This deficiency was cited previously during a licensure complaint survey on 3/7/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. ObservationsOn 8/20/24 at approximately 8:10 a.m., Resident #47 approached the qualifed medication administration person (QMAP) and stated she had waited so long to take her medication that she was too hungry to wait for her synthroid. Resident #47 stated she was concerned because she was aware that medication was supposed to be taken prior to breakfast and she had already eaten. She further stated "I don't think it will kill me" if I take my medication late. Resident #47 subsequently asked the QMAP if her medications would always be administered so late. On 8/21/24 at approximately 10:42 a.m., no staff were available in the secure environment. 2. InterviewsOn 8/20/24 at 7:30 a.m., Staff #57 said there was one caregiver and one QMAP scheduled on each of the two floors of assisted living. She said she was the only caregiver on the second floor the day of the onsite visit and as a result of insufficient staffing she had to work both floors. Staff #57 said if there were call offs then they worked short staffed because the residence was not incorporating contracted staff to assist with call offs. Staff #57 said it was expected that care staff work both floors if needed. She said residents had to wait a long time for call light responses sometimes when there were two caregivers and two QMAPs and even longer when they were working short staffed. Staff #57 said the QMAPs had to assist with resident care which took them away from passing medication at times. On 8/20/24 at approximately 8:15 a.m., Staff #48 stated the residence was short staffed often. She stated the assisted living was supposed to have two QMAPs and two caregivers each shift. Staff #48 stated the secure environment staff often had to leave the secure environment to help provide resident care. She stated that call lights were not responded to in a timely manner, resident care had to wait and medications were often administered late. The staff member further stated the day of the onsite the assisted living portion of the residence had to pull a staff from the secure environment which left them short on staff. Additionally, Staff #48 stated the residence had approximately five residents that were two person assistance with transfers. On 8/20/24 at 8:30 a.m., Resident #45 said there was usually only one staff to assist with transferring her into her wheelchair. She said she had a stroke and was left side affected and two caregivers were supposed to help her in the bathroom. Resident #57 said she had to wait 20 to 30 minutes for assistance to transfer. On 8/20/24 at 10:20 a.m., a family member said their mother in law needed more care recently and there was not enough staff providing assistance. She said her mother in law needed three care staff to assist with incontinence care at night and she was told there were only two care staff in the building. On 8/20/24 at 10:50 a.m., the wellness director said there was not always proper staffing and it resulted in later response to call lights, late medication administration and delays attending to resident care in general. On 8/20/24 at 1:17 p.m., in a second interview the wellness director said the residence was struggling to keep staff and was not using a staffing agency. On 8/20/24 at approximately 6:15 p.m., a family member of Resident #42 stated that they were unhappy with the care that the resident received. The family member stated they hired an outside agency to assist with care for Resident #42 during the overnight shift. On 8/21/24 at approximately11:30 a.m., a family member stated she was in the secure environment and was not able to find staff the day of the onsite visit at approximately 10:30 a.m., and had to look for staff by exiting the secure environment and going to the main entrance of the residence to locate staff for assistance of her family member. On 8/21/24 at approximately 11:50 a.m., Staff #55 stated the reason why the secure environment looked abandoned was because she was caring for residents. She stated as the secure environment usually had sufficient staff; however, the staff would often get pulled to the non-secure environment to provide care. On 8/21/24 at approximately 12:00 p.m., Staff #55 stated the secure environment usually had two to three staff members scheduled. Staff #55 stated currently there were two staff members in the secure environment; however, she stated there were three originally scheduled but one was moved to the non-secure portion of the residence. 3. Record reviewThe staff schedule for 8/4/24 to 8/24/24 read the residence had three shifts, first, second, third and had in sufficient staffing as follows:a. First shift from 6:00 a.m. to 2:15 p.m. On 8/4/24 there were two caregivers and two QMAP.On 8/17/24 there were two caregivers and three QMAPs. On 8/19/24 there were three caregivers and three QMAPs. On 8/21/24 There were four caregivers and two QMAPs.b. Second shift from 2:00 p.m. to 10:15 p.m. On 8/13/24 there were four caregivers and two QMAPs. On 8/17/24 there were two caregivers and three QMAPs. On 8/21/24 there were four caregivers and two QMAPs. On 8/22/24 there were two caregivers and two QMAPs. On 8/23/24 there were three caregivers and two QMAPs. On 8/24/24 there were three caregivers and two QMAPs.c. Third shift from 10:00 p.m. to 6:15 a.m. On 8/6/24 there were two caregivers and one QMAP.On 8/10/24 and 8/12/24 there were two caregivers and one QMAP.On 8/15/24 there were zero caregivers and two QMAPs.

Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting 95 current residents. Cross-reference S1324This deficiency was cited previously during a licensure complaint survey on 3/7/23. 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 policy First Aid Response Policy, undated, read in part: "This community will always have at least one staff member onsite who has current certification in cardiopulmonary resuscitation [CPR], obstructed airway techniques and first aid from one of the following nationally recognized organizations: American Red Cross, American Heart Association, National Safety Council or American Safety and Health Institute."2. Record Review The staff schedule and first aid certifications revealed there was no staff onsite certified from a nationally recognized organization for all three shifts from 8/4-8/24/24 (20 days). 3. InterviewOn 8/21/24 at approximately 1:34 p.m., the administrator stated he was not aware that the trainer who completed all staff first aid training was not certified by a nationally recognized organization.

Based on observation, record review, and interview, the residence failed to place in a visible location, an up-to-date 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 95 current residents. Cross-reference S0730This deficiency was cited previously during a licensure revisit on 3/7/23. 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 policy CPR & First Aid Response Policy, undated, read in part: "The community will place in a visible location a list of all team members who have current certification in first aid and/or CPR so that the information is readily available. The list will be kept up to date and indicate by team member whether the certification is in first aid and/or CPR."2. Record ReviewOn 8/20/24 CPR and first aid certifications for all current staff were requested. However, the certifications revealed no staff were certified from a nationally recognized organization. 3. ObservationOn 8/20/24 at approximately 7:39 a.m., the list of staff who were first aid CPR certified at the front desk. 4. InterviewOn 8/21/24 at approximately 1:34 p.m. the administrator stated he was not aware that the trainer who completed all staff CPR and first aid training was not certified by a nationally recognized organization. He acknowledged that the CPR and first aid certification list located at the front desk was inaccurate.

Based on observation, interview and record review the residence failed to either directly or indirectly provide protective oversight and personal services affecting two of two sample residents with changes in condition (#41, #42). Cross-reference B290, S1150 and S1324This deficiency was cited previously during a state licensure survey on 3/7/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. References:Chapter 24 regulations governing assisted living residences, requires in part 7.1 "that prescription and non-prescription medications shall be administered by qualified medication administration persons only upon written order of an authorized practitioner. Such orders shall be current for all medications. (A) New orders from an authorized practitioner shall be obtained and followed whenever a resident or client returns to the facility after an inpatient hospitalization."Chapter VII regulations governing assisted living residences, defines 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. 2. Resident #42 was admitted to the residence on 5/26/21 with diagnoses consisting of diabetes and hypertension. Resident #42 was readmitted to the residence on 8/16/24 with a diagnosis of closed fracture of ramus of right pubis.a. ObservationOn 8/20/24 at 10:20 a.m., Resident #42 was observed laying in her bed. The surveyor attempted to interview Resident #42 but was unable to. The resident was able to recognize that there was someone there to talk with them; however, was unable or unwilling to answer questions. b. The record for Resident #42 revealed the following:A care plan, dated 8/21/23, read in part: Resident #42 was independent with medication. A written practitioner's order, dated 6/19/24, read in part: Resident #42 was independent with medications and took the following: Aspirin EC 81 mg once daily, furosemide 20 mg once daily, Humulin 100U/ML 20 units subcutaneously one time a day, letrozole 2.5 mg once daily, blood glucose test strips four times a day, spironolactone 25 mg two tablets by mouth twice daily, vitamin D3 tab 2,000 U two tablets once daily, lidocaine patch 4% one patch topically once daily for eight hours, omeprazole cap 20 mg once daily, gabapentin cap 100 mg once daily at bedtime, and simvastatin 10 mg once daily. However, a medication cart audit revealed the following inconsistencies between the signed self administer practitioners order and the bottles in the cart: Vitamin D3 1000 iu had no instructions to administer four pills, gabapentin 100 mg take three once daily instead of 100 mg once daily and letrozole 2.5 mg once daily was not in the cart. Additionally the cart contained a medication that was not on the signed practitioner's order Colace. A late entry progress note for Resident #42, dated 8/13/24, read in part: On 8/6/24 at 10:00 a.m., a resident stood up and fell on Resident #42. Resident #42 fell to the ground and hit her right hip and her head on the floor. Hospital discharge records, dated 8/6/24- 8/16/24, read in part: Resident #42 was diagnosed with a closed fracture of ramus of right pubis, initial encounter. A progress note for Resident #42, dated 8/19/24, read in part: Resident #42 was sleeping 80-90% of the time and that an increase in care level would be discussed with the family. On 8/20/24 at 11:25 a.m., the medication administration record (MAR) was requested from the administrator. However, the administrator stated there was no MAR as the resident was able to independently administer her own medication. On 8/20/24 at 5:55 p.m., review of the residence's electronic record for Resident #42 revealed the resident did not have any medications listed on the MAR.A written practitioner's order, dated 8/20/24 (four days after discharge from the hospital), directed the residence to discontinue all medication orders prior to 8/20/24, administer oxycodone 10 mg every four hours, discontinue when morphine arrived, administer lidocaine 4% transdermal patch once daily in the morning and remove at night, and administer morphine oral concentrate 0.5 ml every six hours. b. Interviews:On 8/20/24 at approximately 7:45 a.m., Staff #48 stated that approximately four to five days prior to the onsite investigation Resident #42 was participating in a structured exercise activity at the residence when another resident fell on top of her. The staff further stated Resident #42 had fractured her pelvis as a result of the fall. On 8/20/24 at 10:20 a.m., a family member for Resident #42 stated that before Resident #42 had a change in condition, the resident was independent with activities of daily living (ADLs) and medications. The family member further stated since 8/16/24 (the date of discharge from the hospital) the resident became fully dependent on residence staff for all ADLs including medication administration. The family member further stated that the resident had slept all morning the day of the onsite investigation and had not woken often since the incident on 8/06/24 when she fractured her pelvisOn 8/20/24 at approximately 3:06 p.m., Staff #53 stated that in order to check for changes in medications for Resident #42 staff would check the computer (MAR) and look in the medication cart. Staff #53 stated that before the fall Resident #42 was self administering all medications but since the fall she had been administering all medications based off of the descriptions on the medication packaging. On 8/20/24 at 6:00 p.m. a second family member of Resident #42 stated since Resident #42's change in condition residence staff was administering medications to the resident #42 ' s. On 8/21/24 at 10:50 a.m., the wellness director (WD) stated, in regards to Resident #42, that he directed the residence staff to administer medications on 8/17/24 (the day after readmission) without having written practitioners orders. The WD stated that he discussed the medications with the admitting nurse from external hospice and that he would write a nursing note in the system about administering the medications. He also stated that he directed staff to administer medications based off the self medication orders. He further stated there was no MAR documentation because the resident did not have a MAR until 8/21/24. 3. Resident #41 was admitted to the residence on 10/10/23 with diagnoses of cardiac, hypertension, fracture, diabetes and depression. Resident #41 was readmitted to the residence on 8/16/24 with additional diagnoses including chronic obstructive pulmonary disease, chronic hypoxemic respiratory failure, chronic hypoxemic respiratory failure from neglect, and depression and chronic kidney disease.a. Observations:On 8/20/24 at 10:00 a.m., Resident #41 was observed in her room without her nasal cannula on. On 8/21/24 at 7:23 a.m., Resident #41 was laying in her bed with her oxygen nasal cannula on her nose sleeping. The oxygen concentrator Resident #41 read the resident was being administered oxygen at 4.5 liters per minute. b. Records Review:A written practitioner's order, dated 5/1/24, directed the residence to administer continuous oxygen at 4 liters per minute. However, the record for Resident #41 revealed no evidence the residence was monitoring oxygen use such as ensuring it was on at all times and being administered at the correct liters per minute. c. Interviews:On 8/20/24 at 7:00 p.m., the administrator stated that he was under the impression that the WD was assessing oxygen needs based on acuity level. On 8/21/24 at 10:50 a.m., the WD confirmed that the oxygen concentrator for Resident #41 read 4.5 liters per minute. The WD stated that the residence was responsible for administering and maintaining oversight over the oxygen level. He added the residence had no formal checks and balances in place to ensure protective oversight was provided regarding the oxygen for Resident #41. In a second interview on 8/21/24 at 1:35 p.m., the administrator stated that he was not aware that the caregivers were not checking the resident's oxygen level.

Based on observation, interview and record review the residence failed to ensure care plans were updated whenever a resident's condition changed from baseline status affecting two of two sample residents (#41,#42). Cross-reference S1110 This deficiency was cited previously during a state licensure survey on 3/07/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. References and Residence Policy The residence's Care Plan Policy, undated, read in part: A Care Plan will be completed by the Wellness Director prior to move-in. The Wellness Director and team will visit with the resident and family to complete the plan which will: (a) Reflect the most current assessment information; (c ) detail specific personal service needs and preferences along with the staffing necessary to meet those needs. 2. Resident #42 was admitted to the residence on 5/26/21 with diagnoses consisting of diabetes and hypertension. Resident #42 was readmitted to the residence on 8/16/24 with a diagnosis of closed fracture of ramus of right pubis.a. Observation:On 8/20/24 at 10:20 a.m., Resident #42 was observed laying in her bed. The surveyor attempted to interview Resident #42 but was unable to. The resident was able to recognize that there was someone there to talk with them; however, was unable or unwilling to answer questions. b. Records Review:Hospital discharge orders dated 8/6-8/16/24, read in part: Resident #42 was diagnosed with a closed fracture of ramus of the right pubis, initial encounter. A late entry progress note for Resident #42, dated 8/13/24, read in part: On 8/6/24 at 10:00 a.m., a resident stood up and fell on resident #42. Resident #42 fell to the ground and hit her right hip and her head on the floor. A care plan for Resident #42, dated 8/20/24, read in part: Resident #41 was independent with showering, toileting, transferring, and medication. c. Interview:On 8/20/24 a family member stated that since the accident Resident #42 had become completely dependent on staff and family members for assistance with all ADL ' s. On 8/21/24 at approximately 10:50 a.m. the wellness director (WD) stated that he was responsible for updating and managing the care plans for all of the residents. He also stated that care plans were updated after admission or when there was a change in condition. On 8/21/24 at approximately 1:35 p.m. the administrator stated that he expected care plans to have been updated when a resident returned from the hospital or rehabilitation and that with Resident #42 "there may have been an assumption that she was going to be fine."3. Resident #41 who was admitted to the residence on 10/10/23 with a diagnosis of cardiac, hypertension, fracture, diabetes and depression . Resident #41 was then readmitted to the residence on 8/16/24 with a diagnosis of chronic obstructive pulmonary disease, chronic hypoxemia respiratory failure from neglect, diabetes and depression.a. Interviews:On 8/20/24 at 1:17 p.m., the WD stated Resident #41 had a fall on 7/18/24 which resulted in a hospitalization and subsequent rehabilitation stay. He stated the resident was readmitted to the residence on 8/16/24. On 8/20/24, at 3:06 p.m., Staff #53 stated that Resident #41 fell twice on 8/18/24. On 8/20/24 at 5:00 p.m., Staff #49 stated that she was working during the incident on 8/18/24 around 3:30 p.m. with Resident #41. Staff #49 stated she saw Resident #41 on the floor blue and shaking. The staff stated she telephoned the WD and administrator immediately and did not get a response and subsequently telephoned emergency medical services. On 8/21/24 at approximately 10:50 a.m. the WD stated that he was not aware that Resident #41 fell twice on 8/18/24. He stated that he was responsible for developing care plans and that care plans were completed after any change in condition. On 8/21/24 at approximately 1:35 p.m. theadministrator confirmed the wellness director had not been organizing care plans or assessments based on the instructions that were given to him when he had started his position. He further stated he was not aware care plans had not been updated. b. Observation:On 8/20/24 at 10:00 a.m., Resident #41 was observed in her room attempting to eat her breakfast. Resident #41 was agitated and confused and did not have her nasal cannula on.c. Record ReviewA care plan, dated 10/10/23, read in part: Resident #41 was independent with transfer, escorts, oxygen use, and toileting. However the care plan for Resident #41 failed to detail specific personal service needs and preference along with staff tasks necessary to meet those needs as it was not updated after the residents hospitalization, rehabilitation stay and hypoxic event.

Based on interview and record review the residence failed to ensure residents were free from neglect affecting 98 current residents. Cross-reference S1110, S1150 and S2230 This deficiency was cited previously during a state licensure survey on 3/7/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, the residence failed to protect Resident #41 who was diagnosed with chronic hypoxemic respiratory failure from neglect. On 8/18/24 at 3:30 p.m., Resident #41 sustained a fall which caused her prescribed four liters of continuous oxygen per minute to fall off. Two staff responded to the fall and noticed the resident's face and hands were discolored. Staff subsequently took the resident's oxygen statistics which they reported were between 60-65 percent saturation; however, both staff failed to reapply the resident's oxygen. Staff reported they had been trained to leave the resident alone when a fall occurred and not provide care. When emergency medical services arrived the resident was not wearing her oxygen and Resident 41's face and hands were purple in color. Emergency medical services (EMS) reported the resident's oxygen were in the mid 60's. On 8/20/24 neither the administrator or wellness director (WD) reported knowing of the incident therefore no direction had been provided to staff to prevent a recurrence. This failure created an immediate jeopardy risk of neglect to all (98) current residents residing in the residence. On 8/20/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Residence Policy:a. The residence's Resident Rights policy, undated, read in part: Residents have the right to be free from neglect. Neglect was defined as the failure of the residence, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. b. The residence's Resident Fall Management and Injury Response Policy, undated, read in part: for major injury; airway/breathing problems, provide first aid consistent with training if appropriate.c. Chapter VII regulations governing assisted living residences defines caretaker neglect as neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise. d. A residence staff training document titled Condition that Require Notification of a Manager, undated, stated in part: "You (residence staff) must notify your immediate supervisor of the following resident, facility or staff conditions:" All falls or any facility emergency that required emergency measures. 2. Resident #41 was admitted to the residence on 10/10/23 with a diagnosis of chronic hypoxemic respiratory failure from neglect, cardiac, hypertension, fracture, diabetes and depression.a. Interview:On 8/20/24 at 1:17 p.m., the WD stated Resident #41 had been discharged from rehabilitation on 8/16/24. He stated he was not aware of any incident that happened with the resident on 8/18/24. He stated if something happened it should have been documented and he should have been informed. On 8/20/24 at approximately 1:59 p.m., the responding EMS responder stated that the dispatch notes they received read On 8/18/24 staff reported Resident #41 was purple in color. The EMS responder stated that upon arrival Resident #41 ' s face was purple and there were two residence staff at her side, the nasal cannula was hooked up to oxygen but not on Resident #41. Resident #41 had a pulse oximeter reading of 64%. The EMS responder stated that they were on scene for an extended period of time stabilizing Resident #41. EMS further stated he informed the two staff present that not putting the resident's oxygen back on was neglect and stated staff reported they were not allowed to help any resident who had fallen without permission from management. EMS responder added the incident was filed as neglect in thier system. On 8/20/24 at approximately 2:06 p.m. a family member for Resident #41 stated that EMS staff on 8/18/24 telephoned him regarding the incident with Resident #41. On 8/20/24 at 3:06 p.m., Staff #53 stated that Resident #41 was found on the floor of her room, her hands cold, still responsive, and a little blueish to the face. Staff #53 stated she took Resident #41 ' s oxygen level and it was around 60-65%. The staff stated she did not assist the resident with putting her oxygen back on and when EMS arrived they put on her oxygen and helped bring her oxygen levels back up. Staff #53 stated that residence staff was directed to help residents put their oxygen on, however, if a resident fell residence staff was directed to not touch the resident and to call the wellness director (WD), assistant wellness director, EMS, practitioner, and/or external hospice; directions would then be given to residence staff of what to do. Staff #53 stated that when the incident occurred, on 8/18/24 with Resident #41, She and her coworker attempted to call the WD but were unable to get a hold of him. They then called EMS. On 8/20/24 at approximately 4:50 p.m., the administrator stated that he was out of the office on 8/18/24 for the week. He stated the WD was his designee. The administrator stated he was not made aware of any incident that happened with Resident #41. He confirmed he had not done anything regarding the incident as he had not been made aware of what had happened. On 8/20/24 at 5:00 p.m., Staff #49 stated that she was working during the incident on 8/18/24 around 3:30 p.m., with Resident #41. Staff #49 stated she saw Resident #41 on the floor blue and shaking. The staff stated she called management immediately and did not get a response and subsequently telephoned EMS. Staff #49 said she did not put Resident #41 ' s oxygen back because she had received strict instructions from management to always leave any resident as is until management had been reached. She stated when EMS arrived and measured Resident #41 ' s oxygen level which was around 60%. Staff #49 stated that EMS notified the resident's family. On 8/20/24 at approximately 5:24 p.m., the administrator stated that the residence did have a policy on not helping a resident up in regards to falls. He stated the residence also had a policy in regards to assisting residents. He stated staff should have helped Resident #41. The administrator further stated staff was supposed to notify the WD and himself then write an incident report. He stated the incident report would have also notified both he and the WD. The administrator confirmed there was no documentation regarding the incident with Resident #41. The administrator stated staff telephoning management was the residence's "fail safe" and did not respond if he or the WD had any missed telephone calls. b. Record Review:A written practitioner's order, dated 5/1/24, directed the residence to administer oxygen four liters per minute continuously. The record for Resident #41 contained no evidence of the fall and subsequent incident with oxygen. The staff schedule dated 8/18-8/24/24 read Staff #49 and Staff #53 worked together during the incident that occurred on 8/18 with Resident #41. The staff schedule also read Staff #53 worked on 8/19-8/22 and Staff #49 worked 8/19, 8/23, and 8/24/24. 3. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 98 current residents at immediate jeopardy risk for neglect. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 8/20/24 at 6:56 p.m. the administrator submitted written evidence that read in pertinent part: "(The residence) will ensure that resident affected by the incident that occurred on 8/18/24 will be reassessed on 8/20/24. Practitioner and hospice will be informed and requested for interventions. To be completed on 8/20/24. Incident was reported to hospice. All residents on oxygen will be reassessed for proper levels and fitment to be completed on 8/21/24. The residence care team to be re-trained on how to re-attach oxygen lines and how to respond, assess and assist resident falls to be completed 8/22/24. The residence care team will be re-trained on the use of incident reporting system and will make sure they speak to the nurse after completing an incident report to be completed by 8/23/24. All team members will undergo training and in-service on the risks and consequences of neglect. All staff including managers and directors will be in-serviced by the Regional Nurse on the policies regarding falls and neglect to be completed by 8/28/24. The (WD) will monitor residence care team members response time(s) to residents ' calls and (WD) will over two weeks beginning 8/21/24 review care and services provided to all residents on oxygen. The (administrator) will meet daily with the (WD) to review all incidents from the previous day to determine resident(s) change of condition and the planned interventions. The Regional Nurse Director will conduct bi-monthly audits on incident reporting and ensure policies and procedures are being followed as regard to resident falls and neglect." However, the written evidence did not indicate that the risk had been removed because it did not include acceptable guidance for all residence staff regarding oxygen administration, an acceptable timeline for implementation, an investigation element, acceptable dates when training would be completed with residence staff and how each element would be documented and implemented or an acceptable timeline for investigation. Evidence did not include guidance for residence staff for emergency situations and steps to take. The administrator was directed to submit additional written evidence. On 8/20/24 at 7:44 p.m. the administrator submitted a second written evidence that read in pertinent part: "(The residence) will investigate the residence care team regarding response to resident. Residence staff will be retrained on all resident care needs by 8/20/24. An on-going training and review for neglect will be conducted every two weeks. An agenda and attendance sign-in sheet will be kept on record. The care team will be re-trained in the use of the incident reporting system and will make sure they speak to the (WD, assistant wellness director (AWD), or administrator) after completing an incident report to begin on 8/20/24. All care team members will undergo training and in-service on the risks and consequence(s) of neglect by 8/21/24. All staff including managers and directors will be in-serviced by the Regional Nurse on the policies regarding falls and neglect to be completed by 8/21/24. The (WD) will over the next two weeks beginning 8/20/24 review care and services provided to all residents. All care plans and services on the electronic device will be reviewed by (WD, AWD, and administrator) for completion. All residents service plans will be reviewed and updated to reflect oxygen and ADL needs specific to each resident. Staff will be re-trained on how to view the (care) plans at the start of each shift beginning 8/20/24. The (administrator) will meet daily with the (WD) to review all incidents from the previous day to determine resident(s) change of condition and the planned interventions. The regional Nurse Director will conduct bi-monthly audits on incident reporting and ensure policies and procedures are being followed as regards to resident falls and neglect. All care team members including WD and AWD working on 8/18/24 will be asked to give a statement regarding the incident that occurred to resident ... (Resident #41). APS and ombudsman will be informed of the incident. All care team members will be in-serviced for neglect for the next six weeks. All new hires will undergo training specific but not limited to resident care, neglect, incident reporting prior to getting assigned to a shift. WD, AWD, and ED (administrator) will review service plans bi-weekly and review care team documentation for services provided to residents daily."However, the written evidence did not indicate that the risk had been removed because it did not include occurrence reporting to the department. It also did not include immediate actions to ensure all residents were free from neglect immediately. The administrator was directed to submit additional written evidence. During the second onsite investigation on 8/21/24 , at 8:36 a.m., the administrator submitted a final written evidence that read in pertinent part: "(The residence) will investigate the care team on how they responded to the the resident ' s fall (dated 8/18/24). Oxygen was added to the care plan on 8/20/24, as well as 2-hour frequency checks. The incident was reported to hospice agency on 8/18/24 at approximately 8:14 p.m. The (WD) and (AWD) will undergo performance review by the (administrator) to assess capacity and ability to perform their duties and responsibilities towards the care and safety of all residents to be completed by 8/21/24. (WD) will monitor care team member response time(s) to residents ' calls. All care plans and services on the (electronic device) will be reviewed by (WD, AWD, and administrator) for completion beginning 8/20/24. The care team will be re-trained on how to view the service plans at the start of each shift beginning 8/20/24. The evening and night shift care team have been informed to ensure all care services are done properly and in a timely manner. Also, they have been informed to ensure that all incident reports are completed and to inform WD, AWD, and (administrator) of all incidents. (The administrator) and WD together with the care team will perform root cause analyses on any incidents to determine underlying issues. Regularly review and update policies and procedures to reflect current best practices and regulatory changes and ensure that all staff are aware of and understand these updates through regularly scheduled training. The regional Nurse Director will conduct bi-monthly audits on incident reporting and ensure policies and procedures are being followed as regards to residents ' care, fall prevention, and safety. (The administrator) and WD will actively monitor and promote a culture of safety, quality care and incident reporting. Discuss compliance and care concerns during daily Stand Up (team meetings). Occurrence report will be filed in (department) portal. Root cause analysis will be performed to determine the underlying causes for neglect, proper incident reporting and compliance with policies and procedures for resident care and safety. WD and AWD will conduct regular audits of care team performance and resident safety. A detailed record of audits and inspections will include issues discovered and corresponding corrective actions."

Based on interview, observations, and record review the residence failed to ensure residents received the maximum degree of benefit from those services made available by the assisted living residence affecting four of four sample residents (#41, #43, #44, and #45). Cross-reference S722, S1110 and S1324This deficiency was cited previously during a state licensure survey on 3/7/23. 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 agreement, undated, read in part: Emergency Call Pendant. The residence would provide the resident with an emergency call pendant to make it easier to alert staff of an emergency. 2. Resident #43 was admitted to the residence on 5/14/24 with diagnoses that consisted of Parkinson's disease, muscle wasting and atrophy, adult failure to thrive, type two diabetes mellitus without complications, other recurrent depressive disorders, restless legs syndrome, and chronic pain syndrome. Call light times from 8/9 to 8/19/24 revealed the following six responses took ten minutes or more as follows:On 8/1/24 at 1:59 p.m., time taken 14 minutes; 8/2/24 at 2:09 p.m., time taken 14 minutes; 8/9/24 at 12:24 p.m., time taken 12 minutes; 8/15/24 at 6:16 p.m., time taken 18 minutes;8/17/24 at 11:19 a.m., time taken 11 minutes; and 8/19/24 at 4:48 p.m., time taken 17 minutes. 3. Resident #41 was admitted to the residence on 10/10/23 with a diagnosis of cardiac, hypertension, fracture, diabetes and depression. Call light times between 8/17/24 and 8/18/24 revealed the following four responses took ten minutes or more as follows:On 8/17/24 at 2:01 p.m., time taken 14 minutes; 8/17/24 at 3:54 p.m., time taken 16 minutes; 8/18/24 at 9:56 a.m., time taken 10 minutes; and 8/18/24 at 1:54 p.m., time taken 14 minutes. 4. Similar deficient practice was identified for Residents #44 and #45.a. InterviewsOn 8/20/24 at approximately 8:30 a.m., Staff #48 stated resident call lights were to be responded to by staff within seven minutes. On 8/20/24 at approximately 10:00 a.m. Resident #44 stated that the call light system went down twice in six months and that he wasn't sure if management had another system in place when it did go down. On 8/21/24 at 10:50 a.m., the wellness director stated that call light response times should have not been more than ten minutes. On 8/21/24 at 1:34 p.m., in a second interview, the wellness director stated that all staff were trained on responding to call lights. The wellness director stated that the residence was auditing the call logs and sending the information to the residence corporate office. The wellness director additionally stated that staffing was an issue as to why there was a delay in responding to call lights and the residence was also looking at root causes for the long call light responses. On 8/21/24 at 2:28 p.m., the administrator stated the residence's goal was to respond to call times in eight minutes. He acknowledged that call lights would go unanswered as staff were attending or assisting another resident with a shower. The administrator further stated the residence was looking for a different call light system as the residents had a bracelet or pendant that they push and it took approximately 15 seconds to notify staff phones, and then the only way to reset the call light system was to reset the button for several seconds. He stated all staff were trained on the call light system. The administrator also confirmed the residence audited the call system alerts and response times. b. Observations:On 8/20/24 at approximately 3:00 p.m. heard a walkie talkie on the upstairs med cart notifying staff that a call light had been going off for room number 220 and requesting staff to go check on the call light, however, no staff was present at the time

Based on observation, record review and interview the residence failed to comply with authorized practitioner's orders associated with medication administration affecting four of four sample residents (#41, #43, #44, and #45). Cross-reference S1604Findings include 1. Residence Policy and References:a. The residence's Medication Administration policy, undated, read in part: "For orders that are incomplete or unclear: Team members will contact the resident's authorized practitioner for clarification. The community will complete a list of each resident's medications and verify the accuracy and completeness of the list with the resident and the authorized practitioner at the time of admission.b. Chapter 24 regulations governing assisted living residences, requires in part 7.1 that prescription and non-prescription medications shall be administered by qualified medication administration persons only upon written order of an authorized practitioner. Such orders shall be current for all medications. (A) New orders from an authorized practitioner shall be obtained and followed whenever a resident or client returns to the facility after an inpatient hospitalization. 2. Resident #41 was admitted to the residence on 10/10/24 for a diagnosis of cardiac, fracture and pulmonary. Resident #41 was out of the residence for hospitalization and rehabilitation on 7/19/24 and returned to the residence on 8/16/24. a. A written practitioner's order, dated 5/14/24, directed the residence to administer the following medications: Pregabalin 150 mg capsule taken twice daily. However, the July 2024 medication administration record (MAR) read Pregabalin 100 mg and was administered from 7/1/24 to 7/18/24. Losartan 25 mg tablet once daily. However, the July 2024 MAR read the medication was not administered on 7/1/24 and 7/2/24. b. A written practitioner's order, dated 8/7/24, directed the residence to administer the following medications:Duloxetine HCI delayed release sprinkle 30 mg twice daily. However, the August 2024 MAR read the medication was not administered 8/16-8/19/24. During a medication cart audit the medication was noted as not in the cart. Pregabalin 100 mg twice daily. However, the August 2024 MAR read the medication was not administered in the evening from 8/17 p.m. through 8/19/24. During a medication cart audit it was noted that the medication was in stock. Losartan potassium 12.5 mg once daily. However, the August 2024 MAR revealed no evidence of the medication and was not administered 8/17-8/19/24. During a medication cart audit it was noted the medication was not in stock c. A written practitioner's order, dated 8/7/24, directed the residence to discontinue the following medications:Eliquis 2.5 mg twice daily. However, the August 2024 MAR read Eliquis 5 mg tablet twice daily was administered on 8/16-8/19/24. During a medication cart audit it was noted that medication was in stock. 3. Additionally, Resident's #43, #44 and #45 were noted to have similar deficient practice. 4. InterviewsOn 8/21/24 at 10:45 a.m., the wellness director said he was responsible for reviewing practitioner's orders and updating the MAR with accurate information. He stated that when a medication was discontinued the residence had to reach out to practitioners to verify. On 8/21/24 at 1:35 p.m. the administrator said when the residence received practitioner instructions to discontinue or adjust a medication the MAR should have reflected those instructions. He said the residence was responsible for reviewing, clarifying and following new orders when a resident is admitted or readmitted to the residence.

Based on interview and record review the residence failed to have an accurate medication administration record (MAR) affecting one sample readmission residents (#41). Cross-reference S1604This deficiency was cited previously during a state licensure survey on 3/7/23. 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 Medication Administration procedure, undated, read in part: Each qualified medication administration person, nurse or authorized practitioner would document accurate information on the MAR including any medication omissions, refusals and resident reported responses to medication. 2. Resident #41 who was admitted to the residence on 10/10/23 with a diagnosis of cardiac, hypertension, fracture, diabetes and depression . Resident #41 was then readmitted to the residence on 8/16/24 with a diagnosis of cardiac, hypertension, fracture, chronic obstructive pulmonary disease, chronic hypoxemic respiratory failure from neglect, diabetes and depression. Written practitioner's orders, dated 5/15 and 8/16/24, directed the residence to administer metformin 500 mg once daily. However, the July-August MARs read metformin 500 mg once daily being administered twice each morning from 7/3, 7/4, 7/6, 7/9-7/11, and 8/18-8/20/24. A written practitioner's order, dated 5/15/24, directed the residence to administer furosemide 20 mg once daily. However, the July MAR read furosemide 20 mg once daily being administered twice each morning on 7/2-7/5, 7/9-7/11, and 7/14/24. On 8/21/24 at 10:45 a.m., the wellness director (WD) said he was responsible for reviewing practitioner's orders and updating the MAR with accurate information. On 8/21/24 at 1:35 p.m. the administrator stated that it was the responsibility of the wellness director to organize and update the MAR and that he did not check the MAR after the WD updated the MARs.

Based on interview and record review, the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting 95 current residents. Cross-reference S1600 and S1568This deficiency was cited previously during a state licensure survey on 3/07/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record reviewOn 8/20/24 at approximately 4:27 p.m., the last two quarterly medication audits were requested from the administrator. On 6/14/24 the assistant wellness director and the wellness director completed audits. The medication audits were not completed by the administrator and the qualified medication administration supervisor, they were completed by the assistant wellness director on the following dates: 7/12/24, 8/1/24, and 8/13/24. The last two quarterly audit forms revealed the form focused on the following areas of the medication program: All scheduled medications available and if those medications were missing medications and if so what is the plan to obtain medications. All pro re nata (PRN) medications available and if those medications were missing medications and if so what is the plan to obtain medications?The audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. 2. InterviewsOn 8/21/24 at approximately 10:50 a.m., the wellness director stated the residence has been reviewing medications twice a week, specifically reviewing medications, missing medications, expired medications, and anything out of the ordinary. He stated anything out of the ordinary were items that were not labeled. The wellness director further stated that during the quarterly medication audit, the residence reviewed the medication bottles/boxes, practitioner's orders, made sure all information was correct and matched the MAR contrary to what the audit form read was completed. The wellness director stated that either he or the assistant wellness director was part of the audits. The wellness director was not aware that the administrator was also part of the audit until the surveyor read the regulation. On 8/21/24 at 11:45 a.m. the assistant wellness director said she conducted medication cart audits on Tuesdays and Thursdays and ordered medications that were not in carts. She said cart audits were conducted by looking at the MARs and looking in the carts for the medications. She said reviewing practitioner's orders was not part of the audit. The assistant wellness director was not aware that the administrator was required to be part of the quarterly medication audit. On 8/21/24 at approximately 1:34 p.m., the administrator stated medication audits were the responsibility of the assistant wellness director and the regional registered nurse (RN) was on the phone while the assistant wellness director was completing the audit. Additionally, the administrator stated that the assistant wellness director should have made sure all medication, orders, and supplies are accurate and no medications are being held in the cart; if found the medications need to be discontinued.

Based on interview and record review, the residence failed to ensure progress notes included information on resident status, wellbeing, documentation on out of the ordinary events along with the action taken by staff to address the residents's changing needs affecting two of two residents with changes in condition (#41, #42). Cross-reference S1110 and S1324Findings include:1. Residence PolicyThe residence's Resident Record policy, undated, read in part: Daily documentation was not necessary. Documentation would occur when an activity, event, and incident that is not usual for the resident or change in level of assistance occurs. 2. Resident #41 was admitted to the residence on 10/10/23 with a diagnosis of cardiac, hypertension, fracture, diabetes, chronic hypoxemic respiratory failure from neglect, and depression. Interviews:On 8/20/24 at approximately 1:59 p.m. emergency medical services (EMS) stated that on 8/18/24 EMS was dispatched for a resident that had fallen and was purple in color. EMS stated upon arrival two staff were present and the resident was on the floor without her prescribed oxygen on. EMS stated Resident #41 ' s oxygen levels were below 65% and she was purple in color. EMS further stated it took a long time to get the resident's oxygen levels back at baseline. On 8/20/24 at 5:00 p.m., Staff #53 confirmed the above incident happened and added Resident #41 fell again on 8/18/24. On 8/20/24 at approximately 1:17 p.m. the wellness director (WD) stated Resident #41 had a fall on 7/18/24 and was sent to the hospital. He stated the resident was then transferred to a rehabilitation center and then on 8/16/24 she was readmitted to the residence. Record Review:The record for Resident #41 contained one progress note regarding the above mentioned events as follows: On 7/18/24 Resident #41 was walked out of her bathroom and fell on the floor hitting her head on the wall in the shower. The resident pressed her pendant, a caregiver went to go assist and found her on the floor. She had hit her head, EMS was notified, they checked on her and helped her up. However, the record failed to update the progress note of the subsequent hospitalization, transfer to rehabilitation, discharge from rehabilitation, the fall resulting in oxygen deprivation and the subsequent fall on 8/18/24. 3. Additional deficient practice was was revealed for Resident #42.4. InterviewOn 8/20/24 at 1:22 p.m., The wellness director said he was aware documentation needed to be completed by the end of shift on the same day. On 8/20/24 at 1:35 p.m., the administrator said he was unaware of the delay in completing documentation and confirming practitioner orders timely.

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 7.11.1 The assisted living residence shall accept only those persons whose needs can be fully met bythe existing staff, physical environment, and services already being provided. The assisted livingresidence's ability to meet resident needs shall be based upon a comprehensive pre-admissionassessment of a resident's physical, mental, and social needs; cultural, religious and activityneeds; preferences; and capacity for self-care. 14.3 An assisted living residence shall not allow a QMAP or a CNA-Med to assist a resident withmedication administration unless the resident is able to consent and participate in theconsumption of the medication. 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing.

A licensure compliant event prompted by #CO36479 and #CO37234 was completed on 8/21/24. Deficiencies were cited.

Based on interview and record review, the residence failed to provide access upon request to full resident records affecting five of five sample residents (#41-#45). Findings include 1. Referencea. Chapter VII regulations governing assisted living residences, part 18.8, requires that the resident record shall contain but not be limited to the following items: (B) Practitioner order; (E) Medication Administration Record (MAR). 2. Record review On 8/20/24 at 7:41 a.m., access to all resident records was requested from the administrator. 8/20/24 at 1:00 p.m., resident records in their completion for Residents #41-#45 of the non-secure environment was requested from the wellness director. On 8/20/24 the following was received:At approximately 3:30 p.m., practitioner orders for Resident #45 and Resident #43. At 6:50 p.m. pregabalin order for Resident #41. At approximately 7:32 p.m. hospice orders for Resident #42. The following was not received until the following day 8/21/24:At 12:13 p.m., a practitioner's order for oxycodone for Resident #42. At 12:25 p.m., practitioner's annual order for self administering medications for Resident #42. At 1:00 p.m., practitioner medication list, dated 8/1/24, for Resident #44.2. InterviewsOn 8/20/24 at 1:22 p.m., the wellness director said the residence was behind with uploading paper copies of documentation into electronic system

Based on record review and interview, the residence failed to ensure a name-based criminal history record check from the Colorado Bureau of Investigation (CBI) was requested for each prospective staff member, prior to hire for one sample staff (#45), affecting 95 current residents. Findings include:1. Residence PolicyThe residence's policy Criminal Background Checks, undated, read in part: "In order to ensure that staff members and volunteers are of good, moral and responsible character, the assisted living residence shall request, prior to hire, a name-based criminal history record check, Colorado Bureau of Investigations (CBI), and Colorado Caps Check for each prospective staff member and volunteer providing ALR services. Background check results must be reviewed and accepted prior to any resident contact"2. Record ReviewThe personnel file for Staff #49 revealed they were hired on 12/20/23. However, the personnel file failed to contain a criminal background check through the CBI as required. The staff schedule for August 2024 read Staff #49 worked from 2:00 p.m. to 10:15 p.m. on 8/4, 8/5, 8/12, 8/18, 8/19, 8/24 and at 10:00 p.m. to 6:15 a.m. on 8/11 and 8/24/24.3. InterviewOn 8/21/24 at approximately 1:34 p.m., the administrator stated background checks were required through the CBI and that staff were not able to start orientation or have hands-on care until background checks were completed. He stated the staff member was a transfer from another state and the CBI was probably missed.

Based on interview and record review, the residence failed to ensure personnel files included orientation and training, documentation of initial dementia training and continuing education for direct care-staff members, for five of five staff members (#49, #50, #51, #52, and #53), affecting 95 current residents. Findings include:1. ReferencesChapter VII regulations governing assisted living residences, part 7.13, requires each personnel file shall include, but not be limited to, written documentation regarding the following items:(A) A description of the employee or volunteer duties;(B) Date of hire or acceptance of volunteer service and date duties commenced;(C) Orientation and training, including first aid and CPR certification, if applicable;(D) Verification from the Department of Regulatory Agencies, or other state agency, of anactive license or certification, if applicable;(E) Results of background checks and follow up, as applicable; and(F) Tuberculin test results, if applicable.(G) Documentation of initial dementia training and continuing education for direct-care staffmembers:2. Residence PolicyThe residence's policy Personnel Files, undated, read in part: "Each employee will have a personnel file which may include the following: a. Application. b. Resume, if applicable. c. Minimum of two reference checks. d. Criminal background checks. e. Copy of license or certificates, if applicable. f. Three-month and annual performance appraisals. g. Personnel administration form. h. Signed copy of job description. i. W-4. j. Verification of employment eligibility. K. Copy of social security card. l. Record of orientation and continuing education. m. Record of completion of Civitas Passion Program Training. n. I-9 form. o. Motor vehicle license record (if the position requires they drive the residence vehicle). p. Health documentation requirements (TB testing)."3. Record reviewOn 8/20/24 the personnel files for Staff #49-#53 was requested from the administrator. Staff #49's personel file read the staff was hired on 12/20/23; however the file was missing orientation,and documentation of initial dementia training. Staff #50's personnel file read the staff was hired on 5/8/24; however the file was missing orientation,and documentation of initial dementia training. Staff #51's personnel file read the staff was hired on 11/15/23; however the file was missing orientation, and documentation of initial dementia training. Staff #52's personnel file read the staff was hired on 8/23/23; however the file was missing orientation, documentation of initial dementia training, and continuing education for direct care-staff members. Staff #53's personnel file read the staff was hired on 9/12/23; however the file was missing orientation,and documentation of initial dementia training. 4. InterviewOn 8/21/24 at approximately 1:34 p.m., the administrator stated all staff records should have been kept in the personnel file and the residence was working towards all records being kept electronically.

Based on record review, observations and interviews, the residence failed to have staff sufficient in number to help residents needing or potentially needing assistance, affecting 95 current residents. Findings include:1. ObservationsOn 8/20/24 at approximately 8:10 a.m., Resident #47 approached the qualifed medication administration person (QMAP) and stated she had waited so long to take her medication that she was too hungry to wait for her synthroid. Resident #47 stated she was concerned because she was aware that medication was supposed to be taken prior to breakfast and she had already eaten. She further stated "I don't think it will kill me" if I take my medication late. Resident #47 subsequently asked the QMAP if her medications would always be administered so late. On 8/21/24 at approximately 10:42 a.m., no staff were available in the secure environment. 2. InterviewsOn 8/20/24 at 7:30 a.m., Staff #57 said there was one caregiver and one QMAP scheduled on each of the two floors of assisted living. She said she was the only caregiver on the second floor the day of the onsite visit and as a result of insufficient staffing she had to work both floors. Staff #57 said if there were call offs then they worked short staffed because the residence was not incorporating contracted staff to assist with call offs. Staff #57 said it was expected that care staff work both floors if needed. She said residents had to wait a long time for call light responses sometimes when there were two caregivers and two QMAPs and even longer when they were working short staffed. Staff #57 said the QMAPs had to assist with resident care which took them away from passing medication at times. On 8/20/24 at approximately 8:15 a.m., Staff #48 stated the residence was short staffed often. She stated the assisted living was supposed to have two QMAPs and two caregivers each shift. Staff #48 stated the secure environment staff often had to leave the secure environment to help provide resident care. She stated that call lights were not responded to in a timely manner, resident care had to wait and medications were often administered late. The staff member further stated the day of the onsite the assisted living portion of the residence had to pull a staff from the secure environment which left them short on staff. Additionally, Staff #48 stated the residence had approximately five residents that were two person assistance with transfers. On 8/20/24 at 8:30 a.m., Resident #45 said there was usually only one staff to assist with transferring her into her wheelchair. She said she had a stroke and was left side affected and two caregivers were supposed to help her in the bathroom. Resident #57 said she had to wait 20 to 30 minutes for assistance to transfer. On 8/20/24 at 10:20 a.m., a family member said their mother in law needed more care recently and there was not enough staff providing assistance. She said her mother in law needed three care staff to assist with incontinence care at night and she was told there were only two care staff in the building. On 8/20/24 at 10:50 a.m., the wellness director said there was not always proper staffing and it resulted in later response to call lights, late medication administration and delays attending to resident care in general. On 8/20/24 at 1:17 p.m., in a second interview the wellness director said the residence was struggling to keep staff and was not using a staffing agency. On 8/20/24 at approximately 6:15 p.m., a family member of Resident #42 stated that they were unhappy with the care that the resident received. The family member stated they hired an outside agency to assist with care for Resident #42 during the overnight shift. On 8/21/24 at approximately 11:30 a.m., a family member stated she was in the secure environment and was not able to find staff the day of the onsite visit at approximately 10:30 a.m., and had to look for staff by exiting the secure environment and going to the mainentrance of the residence to locate staff for assistance of her family member. On 8/21/24 at approximately 11:50 a.m., Staff #55 stated the reason why the secure environment looked abandoned was because she was caring for residents. She stated as the secure environment usually had sufficient staff; however, the staff would often get pulled to the non-secure environment to provide care. On 8/21/24 at approximately 12:00 p.m., Staff #55 stated the secure environment usually had two to three staff members scheduled. Staff #55 stated currently there were two staff members in the secure environment; however, she stated there were three originally scheduled but one was moved to the non-secure portion of the residence. 3. Record reviewThe staff schedule for 8/4/24 to 8/24/24 read the residence had three shifts, first, second, third and had in sufficient staffing as follows:a. First shift from 6:00 a.m. to 2:15 p.m. On 8/4/24 there were two caregivers and two QMAP.On 8/17/24 there were two caregivers and three QMAPs. On 8/19/24 there were three caregivers and three QMAPs. On 8/21/24 There were four caregivers and two QMAPs.b. Second shift from 2:00 p.m. to 10:15 p.m. On 8/13/24 there were four caregivers and two QMAPs. On 8/17/24 there were two caregivers and three QMAPs. On 8/21/24 there were four caregivers and two QMAPs. On 8/22/24 there were two caregivers and two QMAPs. On 8/23/24 there were three caregivers and two QMAPs. On 8/24/24 there were three caregivers and two QMAPs.c. Third shift from 10:00 p.m. to 6:15 a.m. On 8/6/24 there were two caregivers and one QMAP.On 8/10/24 and 8/12/24 there were two caregivers and one QMAP.On 8/15/24 there were zero caregivers and two QMAPs.

Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting 95 current residents. Cross-reference S1324Findings include: 1. Residence PolicyThe residence's policy First Aid Response Policy, undated, read in part: "This community will always have at least one staff member onsite who has current certification in cardiopulmonary resuscitation [CPR], obstructed airway techniques and first aid from one of the following nationally recognized organizations: American Red Cross, American Heart Association, National Safety Council or American Safety and Health Institute."2. Record Review The staff schedule and first aid certifications revealed there was no staff onsite certified from a nationally recognized organization for all three shifts from 8/4-8/24/24 (20 days). 3. InterviewOn 8/21/24 at approximately 1:34 p.m., the administrator stated he was not aware that the trainer who completed all staff first aid training was not certified by a nationally recognized organization.

Based on observation, record review, and interview, the residence failed to place in a visible location, an up-to-date 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 95 current residents. Cross-reference S0730Findings include:1. Residence PolicyThe residence's policy CPR & First Aid Response Policy, undated, read in part: "The community will place in a visible location a list of all team members who have current certification in first aid and/or CPR so that the information is readily available. The list will be kept up to date and indicate by team member whether the certification is in first aid and/or CPR."2. Record ReviewOn 8/20/24 CPR and first aid certifications for all current staff were requested. However, the certifications revealed no staff were certified from a nationally recognized organization. 3. ObservationOn 8/20/24 at approximately 7:39 a.m., the list of staff who were first aid CPR certified at the front desk. 4. InterviewOn 8/21/24 at approximately 1:34 p.m. the administrator stated he was not aware that the trainer who completed all staff CPR and first aid training was not certified by a nationally recognized organization. He acknowledged that the CPR and first aid certification list located at the front desk was inaccurate.

Based on observation, interview and record review the residence failed to either directly or indirectly provide protective oversight and personal services affecting two of two sample residents with changes in condition (#41, #42). Cross-reference B290, S1146, S1150 and S1324Findings include:1. References:Chapter 24 regulations governing assisted living residences, requires in part 7.1 "that prescription and non-prescription medications shall be administered by qualified medication administration persons only upon written order of an authorized practitioner. Such orders shall be current for all medications. (A) New orders from an authorized practitioner shall be obtained and followed whenever a resident or client returns to the facility after an inpatient hospitalization."Chapter VII regulations governing assisted living residences, defines 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. 2. Resident #42 was admitted to the residence on 5/26/21 with diagnoses consisting of diabetes and hypertension. Resident #42 was readmitted to the residence on 8/16/24 with a diagnosis of closed fracture of ramus of right pubis.a. ObservationOn 8/20/24 at 10:20 a.m., Resident #42 was observed laying in her bed. The surveyor attempted to interview Resident #42 but was unable to. The resident was able to recognize that there was someone there to talk with them; however, was unable or unwilling to answer questions. b. The record for Resident #42 revealed the following:A care plan, dated 8/21/23, read in part: Resident #42 was independent with medication. A written practitioner's order, dated 6/19/24, read in part: Resident #42 was independent with medications and took the following: Aspirin EC 81 mg once daily, furosemide 20 mg once daily, Humulin 100U/ML 20 units subcutaneously one time a day, letrozole 2.5 mg once daily, blood glucose test strips four times a day, spironolactone 25 mg two tablets by mouth twice daily, vitamin D3 tab 2,000 U two tablets once daily, lidocaine patch 4% one patch topically once daily for eight hours, omeprazole cap 20 mg once daily, gabapentin cap 100 mg once daily at bedtime, and simvastatin 10 mg once daily. However, a medication cart audit revealed the following inconsistencies between the signed self administer practitioners order and the bottles in the cart: Vitamin D3 1000 iu had no instructions to administer four pills, gabapentin 100 mg take three once daily instead of 100 mg once daily and letrozole 2.5 mg once daily was not in the cart. Additionally the cart contained a medication that was not on the signed practitioner's order Colace. A late entry progress note for Resident #42, dated 8/13/24, read in part: On 8/6/24 at 10:00 a.m., a resident stood up and fell on Resident #42. Resident #42 fell to the ground and hit her right hip and her head on the floor. Hospital discharge records, dated 8/6/24- 8/16/24, read in part: Resident #42 was diagnosed with a closed fracture of ramus of right pubis, initial encounter. A progress note for Resident #42, dated 8/19/24, read in part: Resident #42 was sleeping 80-90% of the time and that an increase in care level would be discussed with the family. On 8/20/24 at 11:25 a.m., the medication administration record (MAR) was requested from the administrator. However, the administrator stated there was no MAR as the resident was able to independently administer her own medication. On 8/20/24 at 5:55 p.m., review of the residence's electronic record for Resident #42 revealed the resident did not have any medications listed on the MAR.A written practitioner's order, dated 8/20/24 (four days after discharge from the hospital), directed the residence to discontinue all medication orders prior to 8/20/24, administer oxycodone 10 mg every four hours, discontinue when morphine arrived, administer lidocaine 4% transdermal patch once daily in the morning and remove at night, and administer morphine oral concentrate 0.5 ml every six hours. b. Interviews:On 8/20/24 at approximately 7:45 a.m., Staff #48 stated that approximately four to five days prior to the onsite investigation Resident #42 was participating in a structured exercise activity at the residence when another resident fell on top of her. The staff further stated Resident #42 had fractured her pelvis as a result of the fall. On 8/20/24 at 10:20 a.m., a family member for Resident #42 stated that before Resident #42 had a change in condition, the resident was independent with activities of daily living (ADLs) and medications. The family member further stated since 8/16/24 (the date of discharge from the hospital) the resident became fully dependent on residence staff for all ADLs including medication administration. The family member further stated that the resident had slept all morning the day of the onsite investigation and had not woken often since the incident on 8/06/24 when she fractured her pelvisOn 8/20/24 at approximately 3:06 p.m., Staff #53 stated that in order to check for changes in medications for Resident #42 staff would check the computer (MAR) and look in the medication cart. Staff #53 stated that before the fall Resident #42 was self administering all medications but since the fall she had been administering all medications based off of the descriptions on the medication packaging. On 8/20/24 at 6:00 p.m. a second family member of Resident #42 stated since Resident #42's change in condition residence staff was administering medications to the resident #42 ' s. On 8/21/24 at 10:50 a.m., the wellness director (WD) stated, in regards to Resident #42, that he directed the residence staff to administer medications on 8/17/24 (the day after readmission) without having written practitioners orders. The WD stated that he discussed the medications with the admitting nurse from external hospice and that he would write a nursing note in the system about administering the medications. He also stated that he directed staff to administer medications based off the self medication orders. He further stated there was no MAR documentation because the resident did not have a MAR until 8/21/24. 3. Resident #41 was admitted to the residence on 10/10/23 with diagnoses of cardiac, hypertension, fracture, diabetes and depression. Resident #41 was readmitted to the residence on 8/16/24 with additional diagnoses including chronic obstructive pulmonary disease, chronic hypoxemic respiratory failure, chronic hypoxemic respiratory failure from neglect, and depression and chronic kidney disease.a. Observations:On 8/20/24 at 10:00 a.m., Resident #41 was observed in her room without her nasal cannula on. On 8/21/24 at 7:23 a.m., Resident #41 was laying in her bed with her oxygen nasal cannula on her nose sleeping. The oxygen concentrator Resident #41 read the resident was being administered oxygen at 4.5 liters per minute. b. Records Review:A written practitioner's order, dated 5/1/24, directed the residence to administer continuous oxygen at 4 liters per minute. However, the record for Resident #41 revealed no evidence the residence was monitoring oxygen use such as ensuring it was on at all times and being administered at the correct liters per minute. c. Interviews:On 8/20/24 at 7:00 p.m., the administrator stated that he was under the impression that the WD was assessing oxygen needs based on acuity level. On 8/21/24 at 10:50 a.m., the WD confirmed that the oxygen concentrator for Resident #41 read 4.5 liters per minute. The WD stated that the residence was responsible for administering and maintaining oversight over the oxygen level. He added the residence had no formal checks and balances in place to ensure protective oversight was provided regarding the oxygen for Resident #41. In a second interview on 8/21/24 at 1:35 p.m., the administrator stated that he was not aware that the caregivers were not checking the resident's oxygen level.

Based on observation, interview and record review the residence failed to ensure comprehensive assessments were updated whenever a resident's condition changed from baseline status affecting two of two sample residents (#41, #42). Cross-reference S1110 and S1150Findings include:1. References and Residence Policya. The residence's Comprehensive Assessment Policy, undated, read in part: For current residents the assessment tool was required every quarter or upon a change in condition. b. Chapter VII regulations governing assisted living residence's, requires in part 12.7 that the comprehensive assessment shall include all the following items: (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; and (L) Types of physical, mental, and social support required. 2. Resident #42 was admitted to the residence on 5/26/21 with diagnoses consisting of diabetes and hypertension. Resident #42 was readmitted to the residence on 8/16/24 with a diagnosis of closed fracture of ramus of right pubis.a. Observation:On 8/20/24 at 10:20 a.m., Resident #42 was observed laying in her bed. The surveyor attempted to interview Resident #42 but was unable to. The resident was able to recognize that there was someone there to talk with them; however, was unable or unwilling to answer questions. b. Record ReviewHospital discharge orders dated 8/6-8/16/24, read in part: Resident #42 was diagnosed with a closed fracture of ramus of the right pubis, initial encounter. A late entry progress note for Resident #42, dated 8/13/24, read in part: On 8/6/24 at 10:00 a.m., a resident stood up and fell on resident #42. Resident #42 fell to the ground and hit her right hip and her head on the floor. A comprehensive assessment for Resident #42, dated 8/16/24, read in part: Resident #42 has had no traumatic events and had one change which read the resident was signed up to receive services with external hospice. However, the assessment failed to address any known or anticipated needs related to the recent diagnosis of closed fracture of ramus of right pubis. c. Interviews:On 8/20/24 at approximately 10:20 a.m. a family member of Resident #42 stated that Resident #42 had been sleeping all morning and did not wake often since the incident on 8/06/24 when she fractured her pubis. On 8/21/24 at approximately 12:19 p.m. the wellness director (WD) stated that he was responsible for updating resident assessments and that he performed resident assessments one for pre-admission, every thirty days, after admission, and once during change of condition. On 8/21/24 at approximately 1:35 p.m. the administrator stated that his instructions to the WD were to organize assessments based off of level acuity levels 1, 2, and 3, to begin with level three, and to ensure accuracy and higher acuity residents were assessed first. He stated he was not aware the assessment for Resident #42 had not been updated to reflect the resident's current diagnoses and any known or anticipated need or impact related to the diagnoses 3. Resident #41 who was admitted to the residence on 10/10/23 with a diagnosis of cardiac, hypertension, fracture, diabetes and depression . Resident #41 was then readmitted to the residence on 8/16/24 with a diagnosis of chronic obstructive pulmonary disease, chronic hypoxemic respiratory failure from neglect, diabetes and depression.a. Observation:On 8/20/24 at 10:00 a.m., Resident #41 was observed in her room attempting to eat her breakfast. Resident #41 was agitated and confused and did not have her nasal cannula on.b. Interviews:On 8/20/24 at approximately 1:59 p.m., the responding EMS stated that the dispatch notes read the resident was purple in color. The EMS responder stated that upon arrival Resident #41 ' s face was purple and there were two residence staff at her side, the nasal cannula was hooked up to oxygen but not on Resident #41. Resident #41 had a pulse oximeter reading of 64%. The EMS responder stated that they were on scene for an extended period of time stabilizing Resident #41. On 8/20/24, at 3:06 p.m., Staff #53 stated that Resident #41 fell twice on 8/18/24. On 8/20/24 at 5:00 p.m., Staff #49 stated that she was working during the incident on 8/18/24 around 3:30 p.m. with Resident #41. Staff #49 stated she saw Resident #41 on the floor blue and shaking. The staff stated she telephoned the WD and administrator immediately and did not get a response and subsequently telephoned emergency medical services. On 8/21/24, at 10:50 a.m., the WD stated he had not updated the assessment for Resident #41 as he was not aware the resident had fallen twice and went to the emergency department on 8/18/24. The WD further stated he expected to document falls and changes in conditions. c. Record Review:A progress note, dated 7/18/24, read in part: Resident #41 was observed on the floor. Resident #41 fell on the floor hitting her head on the shower and medical care was received. A comprehensive assessment for Resident #41, dated 8/18/24, read in part: Resident #41 had no traumatic events and Resident #41 was aware of safety in their environment; chronic illnesses/diagnosis mentioned were as follows: Diabetes, hypertension, respiratory conditions, and renal disease. Additionally, no further known or anticipated needs related to the diagnoses were mentioned in the medical records.

Based on observation, interview and record review the residence failed to ensure care plans were updated whenever a resident's condition changed from baseline status affecting two of two sample residents (#41,#42). Cross-reference S1110 and S1146Findings include:1. References and Residence Policy The residence's Care Plan Policy, undated, read in part: A Care Plan will be completed by the Wellness Director prior to move-in. The Wellness Director and team will visit with the resident and family to complete the plan which will: (a) Reflect the most current assessment information; (c ) detail specific personal service needs and preferences along with the staffing necessary to meet those needs. 2. Resident #42 was admitted to the residence on 5/26/21 with diagnoses consisting of diabetes and hypertension. Resident #42 was readmitted to the residence on 8/16/24 with a diagnosis of closed fracture of ramus of right pubis.a. Observation:On 8/20/24 at 10:20 a.m., Resident #42 was observed laying in her bed. The surveyor attempted to interview Resident #42 but was unable to. The resident was able to recognize that there was someone there to talk with them; however, was unable or unwilling to answer questions. b. Records Review:Hospital discharge orders dated 8/6-8/16/24, read in part: Resident #42 was diagnosed with a closed fracture of ramus of the right pubis, initial encounter. A late entry progress note for Resident #42, dated 8/13/24, read in part: On 8/6/24 at 10:00 a.m., a resident stood up and fell on resident #42. Resident #42 fell to the ground and hit her right hip and her head on the floor. A care plan for Resident #42, dated 8/20/24, read in part: Resident #41 was independent with showering, toileting, transferring, and medication. c. Interview:On 8/20/24 a family member stated that since the accident Resident #42 had become completely dependent on staff and family members for assistance with all ADL ' s. On 8/21/24 at approximately 10:50 a.m. the wellness director (WD) stated that he was responsible for updating and managing the care plans for all of the residents. He also stated that care plans were updated after admission or when there was a change in condition. On 8/21/24 at approximately 1:35 p.m. the administrator stated that he expected care plans to have been updated when a resident returned from the hospital or rehabilitation and that with Resident #42 "there may have been an assumption that she was going to be fine."3. Resident #41 who was admitted to the residence on 10/10/23 with a diagnosis of cardiac, hypertension, fracture, diabetes and depression . Resident #41 was then readmitted to the residence on 8/16/24 with a diagnosis of chronic obstructive pulmonary disease, chronic hypoxemia respiratory failure from neglect, diabetes and depression.a. Interviews:On 8/20/24 at 1:17 p.m., the WD stated Resident #41 had a fall on 7/18/24 which resulted in a hospitalization and subsequent rehabilitation stay. He stated the resident was readmitted to the residence on 8/16/24. On 8/20/24, at 3:06 p.m., Staff #53 stated that Resident #41 fell twice on 8/18/24. On 8/20/24 at 5:00 p.m., Staff #49 stated that she was working during the incident on 8/18/24 around 3:30 p.m. with Resident #41. Staff #49 stated she saw Resident #41 on the floor blue and shaking. The staff stated she telephoned the WD and administrator immediately and did not get a response and subsequently telephoned emergency medical services. On 8/21/24 at approximately 10:50 a.m. the WD stated that he was not aware that Resident #41 fell twice on 8/18/24. He stated that he was responsible for developing care plans and that care plans were completed after any change in condition. On 8/21/24 at approximately 1:35 p.m. the administrator confirmed the wellness director had not been organizing care plans or assessments based on the instructions that were given to him when he had started his position. He further stated he was not aware care plans had not been updated. b. Observation:On 8/20/24 at 10:00 a.m., Resident #41 was observed in her room attempting to eat her breakfast. Resident #41 was agitated and confused and did not have her nasal cannula on.c. Record ReviewA care plan, dated 10/10/23, read in part: Resident #41 was independent with transfer, escorts, oxygen use, and toileting. However the care plan for Resident #41 failed to detail specific personal service needs and preference along with staff tasks necessary to meet those needs as it was not updated after the residents hospitalization, rehabilitation stay and hypoxic event.

Based on interview and record review the residence failed to ensure residents were free from neglect affecting 98 current residents. Cross-reference S1110, S1146, S1150 and S2230Specifically, the residence failed to protect Resident #41 who was diagnosed with chronic hypoxemic respiratory failure from neglect. On 8/18/24 at 3:30 p.m., Resident #41 sustained a fall which caused her prescribed four liters of continuous oxygen per minute to fall off. Two staff responded to the fall and noticed the resident's face and hands were discolored. Staff subsequently took the resident's oxygen statistics which they reported were between 60-65 percent saturation; however, both staff failed to reapply the resident's oxygen. Staff reported they had been trained to leave the resident alone when a fall occurred and not provide care. When emergency medical services arrived the resident was not wearing her oxygen and Resident 41's face and hands were purple in color. Emergency medical services (EMS) reported the resident's oxygen were in the mid 60's. On 8/20/24 neither the administrator or wellness director (WD) reported knowing of the incident therefore no direction had been provided to staff to prevent a recurrence. This failure created an immediate jeopardy risk of neglect to all (98) current residents residing in the residence. On 8/20/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Residence Policy:a. The residence's Resident Rights policy, undated, read in part: Residents have the right to be free from neglect. Neglect was defined as the failure of the residence, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. b. The residence's Resident Fall Management and Injury Response Policy, undated, read in part: for major injury; airway/breathing problems, provide first aid consistent with training if appropriate.c. Chapter VII regulations governing assisted living residences defines caretaker neglect as neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise. d. A residence staff training document titled Condition that Require Notification of a Manager, undated, stated in part: "You (residence staff) must notify your immediate supervisor of the following resident, facility or staff conditions:" All falls or any facility emergency that required emergency measures. 2. Resident #41 was admitted to the residence on 10/10/23 with a diagnosis of chronic hypoxemic respiratory failure from neglect, cardiac, hypertension, fracture, diabetes and depression.a. Interview:On 8/20/24 at 1:17 p.m., the WD stated Resident #41 had been discharged from rehabilitation on 8/16/24. He stated he was not aware of any incident that happened with the resident on 8/18/24. He stated if something happened it should have been documented and he should have been informed. On 8/20/24 at approximately 1:59 p.m., the responding EMS responder stated that the dispatch notes they received read On 8/18/24 staff reported Resident #41 was purple in color. The EMS responder stated that upon arrival Resident #41 ' s face was purple and there were two residence staff at her side, the nasal cannula was hooked up to oxygen but not on Resident #41. Resident #41 had a pulse oximeter reading of 64%. The EMS responder stated that they were on scene for an extended period of time stabilizing Resident #41. EMS further stated he informed the two staff present that not putting the resident's oxygen back on was neglect and stated staff reported they were not allowed to help any resident who had fallen without permission from management. EMS responder added the incident was filed as neglect in thier system. On 8/20/24 at approximately 2:06 p.m. a family member for Resident #41 stated that EMS staff on 8/18/24 telephoned him regarding the incident with Resident #41. On 8/20/24 at 3:06 p.m., Staff #53 stated that Resident #41 was found on the floor of her room, her hands cold, still responsive, and a little blueish to the face. Staff #53 stated she took Resident #41 ' s oxygen level and it was around 60-65%. The staff stated she did not assist the resident with putting her oxygen back on and when EMS arrived they put on her oxygen and helped bring her oxygen levels back up. Staff #53 stated that residence staff was directed to help residents put their oxygen on, however, if a resident fell residence staff was directed to not touch the resident and to call the wellness director (WD), assistant wellness director, EMS, practitioner, and/or external hospice; directions would then be given to residence staff of what to do. Staff #53 stated that when the incident occurred, on 8/18/24 with Resident #41, She and her coworker attempted to call the WD but were unable to get a hold of him. They then called EMS. On 8/20/24 at approximately 4:50 p.m., the administrator stated that he was out of the office on 8/18/24 for the week. He stated the WD was his designee. The administrator stated he was not made aware of any incident that happened with Resident #41. He confirmed he had not done anything regarding the incident as he had not been made aware of what had happened. On 8/20/24 at 5:00 p.m., Staff #49 stated that she was working during the incident on 8/18/24 around 3:30 p.m., with Resident #41. Staff #49 stated she saw Resident #41 on the floor blue and shaking. The staff stated she called management immediately and did not get a response and subsequently telephoned EMS. Staff #49 said she did not put Resident #41 ' s oxygen back because she had received strict instructions from management to always leave any resident as is until management had been reached. She stated when EMS arrived and measured Resident #41 ' s oxygen level which was around 60%. Staff #49 stated that EMS notified the resident's family. On 8/20/24 at approximately 5:24 p.m., the administrator stated that the residence did have a policy on not helping a resident up in regards to falls. He stated the residence also had a policy in regards to assisting residents. He stated staff should have helped Resident #41. The administrator further stated staff was supposed to notify the WD and himself then write an incident report. He stated the incident report would have also notified both he and the WD. The administrator confirmed there was no documentation regarding the incident with Resident #41. The administrator stated staff telephoning management was the residence's "fail safe" and did not respond if he or the WD had any missed telephone calls. b. Record Review:A written practitioner's order, dated 5/1/24, directed the residence to administer oxygen four liters per minute continuously. The record for Resident #41 contained no evidence of the fall and subsequent incident with oxygen. The staff schedule dated 8/18-8/24/24 read Staff #49 and Staff #53 worked together during the incident that occurred on 8/18 with Resident #41. The staff schedule also read Staff #53 worked on 8/19-8/22 and Staff #49 worked 8/19, 8/23, and 8/24/24. 3. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 98 current residents at immediate jeopardy risk for neglect. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 8/20/24 at 6:56 p.m. the administrator submitted written evidence that read in pertinent part: "(The residence) will ensure that resident affected by the incident that occurred on 8/18/24 will be reassessed on 8/20/24. Practitioner and hospice will be informed and requested for interventions. To be completed on 8/20/24. Incident was reported to hospice. All residents on oxygen will be reassessed for proper levels and fitment to be completed on 8/21/24. The residence care team to be re-trained on how to re-attach oxygen lines and how to respond, assess and assist resident falls to be completed 8/22/24. The residence care team will be re-trained on the use of incident reporting system and will make sure they speak to the nurse after completing an incident report to be completed by 8/23/24. All team members will undergo training and in-service on the risks and consequences of neglect. All staff including managers and directors will be in-serviced by the Regional Nurse on the policies regarding falls and neglect to be completed by 8/28/24. The (WD) will monitor residence care team members response time(s) to residents ' calls and (WD) will over two weeks beginning 8/21/24 review care and services provided to all residents on oxygen. The (administrator) will meet daily with the (WD) to review all incidents from the previous day to determine resident(s) change of condition and the planned interventions. The Regional Nurse Director will conduct bi-monthly audits on incident reporting and ensure policies and procedures are being followed as regard to resident falls and neglect." However, the written evidence did not indicate that the risk had been removed because it did not include acceptable guidance for all residence staff regarding oxygen administration, an acceptable timeline for implementation, an investigation element, acceptable dates when training would be completed with residence staff and how each element would be documented and implemented or an acceptable timeline for investigation. Evidence did not include guidance for residence staff for emergency situations and steps to take. The administrator was directed to submit additional written evidence. On 8/20/24 at 7:44 p.m. the administrator submitted a second written evidence that read in pertinent part: "(The residence) will investigate the residence care team regarding response to resident. Residence staff will be retrained on all resident care needs by 8/20/24. An on-going training and review for neglect will be conducted every two weeks. An agenda and attendance sign-in sheet will be kept on record. The care team will be re-trained in the use of the incident reporting system and will make sure they speak to the (WD, assistant wellness director (AWD), or administrator) after completing an incident report to begin on 8/20/24. All care team members will undergo training and in-service on the risks and consequence(s) of neglect by 8/21/24. All staff including managers and directors will be in-serviced by the Regional Nurse on the policies regarding falls and neglect to be completed by 8/21/24. The (WD) will over the next two weeks beginning 8/20/24 review care and services provided to all residents. All care plans and services on the electronic device will be reviewed by (WD, AWD, and administrator) for completion. All residents service plans will be reviewed and updated to reflect oxygen and ADL needs specific to each resident. Staff will be re-trained on how to view the (care) plans at the start of each shift beginning 8/20/24. The (administrator) will meet daily with the (WD) to review all incidents from the previous day to determine resident(s) change of condition and the planned interventions. The regional Nurse Director will conduct bi-monthly audits on incident reporting and ensure policies and procedures are being followed as regards to resident falls and neglect. All care team members including WD and AWD working on 8/18/24 will be asked to give a statement regarding the incident that occurred to resident ... (Resident #41). APS and ombudsman will be informed of the incident. All care team members will be in-serviced for neglect for the next six weeks. All new hires will undergo training specific but not limited to resident care, neglect, incident reporting prior to getting assigned to a shift. WD, AWD, and ED (administrator) will review service plans bi-weekly and review care team documentation for services provided to residents daily."However, the written evidence did not indicate that the risk had been removed because it did not include occurrence reporting to the department. It also did not include immediate actions to ensure all residents were free from neglect immediately. The administrator was directed to submit additional written evidence. During the second onsite investigation on 8/21/24 , at 8:36 a.m., the administrator submitted a final written evidence that read in pertinent part: "(The residence) will investigate the care team on how they responded to the the resident ' s fall (dated 8/18/24). Oxygen was added to the care plan on 8/20/24, as well as 2-hour frequency checks. The incident was reported to hospice agency on 8/18/24 at approximately 8:14 p.m. The (WD) and (AWD) will undergo performance review by the (administrator) to assess capacity and ability to perform their duties and responsibilities towards the care and safety of all residents to be completed by 8/21/24. (WD) will monitor care team member response time(s) to residents ' calls. All care plans and services on the (electronic device) will be reviewed by (WD, AWD, and administrator) for completion beginning 8/20/24. The care team will be re-trained on how to view the service plans at the start of each shift beginning 8/20/24. The evening and night shift care team have been informed to ensure all care services are done properly and in a timely manner. Also, they have been informed to ensure that all incident reports are completed and to inform WD, AWD, and (administrator) of all incidents. (The administrator) and WD together with the care team will perform root cause analyses on any incidents to determine underlying issues. Regularly review and update policies and procedures to reflect current best practices and regulatory changes and ensure that all staff are aware of and understand these updates through regularly scheduled training. The regional Nurse Director will conduct bi-monthly audits on incident reporting and ensure policies and procedures are being followed as regards to residents ' care, fall prevention, and safety. (The administrator) and WD will actively monitor and promote a culture of safety, quality care and incident reporting. Discuss compliance and care concerns during daily Stand Up (team meetings). Occurrence report will be filed in (department) portal. Root cause analysis will be performed to determine the underlying causes for neglect, proper incident reporting and compliance with policies and procedures for resident care and safety. WD and AWD will conduct regular audits of care team performance and resident safety. A detailed record of audits and inspections will include issues discovered and corresponding corrective actions."

Based on interview, observations, and record review the residence failed to ensure residents received the maximum degree of benefit from those services made available by the assisted living residence affecting four of four sample residents (#41, #43, #44, and #45). Cross-reference S722, S1110 and S1324Findings include:1. Residence PolicyThe residence's resident agreement, undated, read in part: Emergency Call Pendant. The residence would provide the resident with an emergency call pendant to make it easier to alert staff of an emergency. 2. Resident #43 was admitted to the residence on 5/14/24 with diagnoses that consisted of Parkinson's disease, muscle wasting and atrophy, adult failure to thrive, type two diabetes mellitus without complications, other recurrent depressive disorders, restless legs syndrome, and chronic pain syndrome. Call light times from 8/9 to 8/19/24 revealed the following six responses took ten minutes or more as follows:On 8/1/24 at 1:59 p.m., time taken 14 minutes; 8/2/24 at 2:09 p.m., time taken 14 minutes; 8/9/24 at 12:24 p.m., time taken 12 minutes; 8/15/24 at 6:16 p.m., time taken 18 minutes;8/17/24 at 11:19 a.m., time taken 11 minutes; and 8/19/24 at 4:48 p.m., time taken 17 minutes. 3. Resident #41 was admitted to the residence on 10/10/23 with a diagnosis of cardiac, hypertension, fracture, diabetes and depression. Call light times between 8/17/24 and 8/18/24 revealed the following four responses took ten minutes or more as follows:On 8/17/24 at 2:01 p.m., time taken 14 minutes; 8/17/24 at 3:54 p.m., time taken 16 minutes; 8/18/24 at 9:56 a.m., time taken 10 minutes; and 8/18/24 at 1:54 p.m., time taken 14 minutes. 4. Similar deficient practice was identified for Residents #44 and #45.a. InterviewsOn 8/20/24 at approximately 8:30 a.m., Staff #48 stated resident call lights were to be responded to by staff within seven minutes. On 8/20/24 at approximately 10:00 a.m. Resident #44 stated that the call light system went down twice in six months and that he wasn't sure if management had another system in place when it did go down. On 8/21/24 at 10:50 a.m., the wellness director stated that call light response times should have not been more than ten minutes. On 8/21/24 at 1:34 p.m., in a second interview, the wellness director stated that all staff were trained on responding to call lights. The wellness director stated that the residence was auditing the call logs and sending the information to the residence corporate office. The wellness director additionally stated that staffing was an issue as to why there was a delay in responding to call lights and the residence was also looking at root causes for the long call light responses. On 8/21/24 at 2:28 p.m., the administrator stated the residence's goal was to respond to call times in eight minutes. He acknowledged that call lights would go unanswered as staff were attending or assisting another resident with a shower. The administrator further stated the residence was looking for a different call light system as the residents had a bracelet or pendant that they push and it took approximately 15 seconds to notify staff phones, and then the only way to reset the call light system was to reset the button for several seconds. He stated all staff were trained on the call light system. The administrator also confirmed the residence audited the call system alerts and response times. b. Observations:On 8/20/24 at approximately 3:00 p.m. heard a walkie talkie on the upstairs med cart notifying staff that a call light had been going off for room number 220 and requesting staff to go check on the call light, however, no staff was present at the time.

Based on observation, record review and interview the residence failed to comply with authorized practitioner's orders associated with medication administration affecting four of four sample residents (#41, #43, #44, and #45). Cross-reference S1604Findings include 1. Residence Policy and References:a. The residence's Medication Administration policy, undated, read in part: "For orders that are incomplete or unclear: Team members will contact the resident's authorized practitioner for clarification. The community will complete a list of each resident's medications and verify the accuracy and completeness of the list with the resident and the authorized practitioner at the time of admission.b. Chapter 24 regulations governing assisted living residences, requires in part 7.1 that prescription and non-prescription medications shall be administered by qualified medication administration persons only upon written order of an authorized practitioner. Such orders shall be current for all medications. (A) New orders from an authorized practitioner shall be obtained and followed whenever a resident or client returns to the facility after an inpatient hospitalization. 2. Resident #41 was admitted to the residence on 10/10/24 for a diagnosis of cardiac, fracture and pulmonary. Resident #41 was out of the residence for hospitalization and rehabilitation on 7/19/24 and returned to the residence on 8/16/24. a. A written practitioner's order, dated 5/14/24, directed the residence to administer the following medications: Pregabalin 150 mg capsule taken twice daily. However, the July 2024 medication administration record (MAR) read Pregabalin 100 mg and was administered from 7/1/24 to 7/18/24. Losartan 25 mg tablet once daily. However, the July 2024 MAR read the medication was not administered on 7/1/24 and 7/2/24. b. A written practitioner's order, dated 8/7/24, directed the residence to administer the following medications:Duloxetine HCI delayed release sprinkle 30 mg twice daily. However, the August 2024 MAR read the medication was not administered 8/16-8/19/24. During a medication cart audit the medication was noted as not in the cart. Pregabalin 100 mg twice daily. However, the August 2024 MAR read the medication was not administered in the evening from 8/17 p.m. through 8/19/24. During a medication cart audit it was noted that the medication was in stock. Losartan potassium 12.5 mg once daily. However, the August 2024 MAR revealed no evidence of the medication and was not administered 8/17-8/19/24. During a medication cart audit it was noted the medication was not in stock c. A written practitioner's order, dated 8/7/24, directed the residence to discontinue the following medications:Eliquis 2.5 mg twice daily. However, the August 2024 MAR read Eliquis 5 mg tablet twice daily was administered on 8/16-8/19/24. During a medication cart audit it was noted that medication was in stock. 3. Additionally, Resident's #43, #44 and #45 were noted to have similar deficient practice. 4. InterviewsOn 8/21/24 at 10:45 a.m., the wellness director said he was responsible for reviewing practitioner's orders and updating the MAR with accurate information. He stated that when a medication was discontinued the residence had to reach out to practitioners to verify. On 8/21/24 at 1:35 p.m. the administrator said when the residence received practitioner instructions to discontinue or adjust a medication the MAR should have reflected those instructions. He said the residence was responsible for reviewing, clarifying and following new orders when a resident is admitted or readmitted to the residence.

Based on interview and record review the residence failed to have an accurate medication administration record (MAR) affecting one sample readmission residents (#41). Cross-reference S1604This deficiency was cited previously during a state licensure survey on 3/7/23. 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 Medication Administration procedure, undated, read in part: Each qualified medication administration person, nurse or authorized practitioner would document accurate information on the MAR including any medication omissions, refusals and resident reported responses to medication. 2. Resident #41 who was admitted to the residence on 10/10/23 with a diagnosis of cardiac, hypertension, fracture, diabetes and depression . Resident #41 was then readmitted to the residence on 8/16/24 with a diagnosis of cardiac, hypertension, fracture, chronic obstructive pulmonary disease, chronic hypoxemic respiratory failure from neglect, diabetes and depression. Written practitioner's orders, dated 5/15 and 8/16/24, directed the residence to administer metformin 500 mg once daily. However, the July-August MARs read metformin 500 mg once daily being administered twice each morning from 7/3, 7/4, 7/6, 7/9-7/11, and 8/18-8/20/24. A written practitioner's order, dated 5/15/24, directed the residence to administer furosemide 20 mg once daily. However, the July MAR read furosemide 20 mg once daily being administered twice each morning on 7/2-7/5, 7/9-7/11, and 7/14/24. On 8/21/24 at 10:45 a.m., the wellness director (WD) said he was responsible for reviewing practitioner's orders and updating the MAR with accurate information. On 8/21/24 at 1:35 p.m. the administrator stated that it was the responsibility of the wellness director to organize and update the MAR and that he did not check the MAR after the WD updated the MARs.

Based on interview and record review, the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting 95 current residents. Cross-reference S1600 and S1568Findings include:1. Record reviewOn 8/20/24 at approximately 4:27 p.m., the last two quarterly medication audits were requested from the administrator. On 6/14/24 the assistant wellness director and the wellness director completed audits. The medication audits were not completed by the administrator and the qualified medication administration supervisor, they were completed by the assistant wellness director on the following dates: 7/12/24, 8/1/24, and 8/13/24. The last two quarterly audit forms revealed the form focused on the following areas of the medication program: All scheduled medications available and if those medications were missing medications and if so what is the plan to obtain medications. All pro re nata (PRN) medications available and if those medications were missing medications and if so what is the plan to obtain medications?The audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. 2. InterviewsOn 8/21/24 at approximately 10:50 a.m., the wellness director stated the residence has been reviewing medications twice a week, specifically reviewing medications, missing medications, expired medications, and anything out of the ordinary. He stated anything out of the ordinary were items that were not labeled. The wellness director further stated that during the quarterly medication audit, the residence reviewed the medication bottles/boxes, practitioner's orders, made sure all information was correct and matched the MAR contrary to what the audit form read was completed. The wellness director stated that either he or the assistant wellness director was part of the audits. The wellness director was not aware that the administrator was also part of the audit until the surveyor read the regulation. On 8/21/24 at 11:45 a.m. the assistant wellness director said she conducted medication cart audits on Tuesdays and Thursdays and ordered medications that were not in carts. She said cart audits were conducted by looking at the MARs and looking in the carts for the medications. She said reviewing practitioner's orders was not part of the audit. The assistant wellness director was not aware that the administrator was required to be part of the quarterly medication audit. On 8/21/24 at approximately 1:34 p.m., the administrator stated medication audits were the responsibility of the assistant wellness director and the regional registered nurse (RN) was on the phone while the assistant wellness director was completing the audit. Additionally, the administrator stated that the assistant wellness director should have made sure all medication, orders, and supplies are accurate and no medications are being held in the cart; if found the medications need to be discontinued.

Based on observation and interview, the residence failed to ensure residents had independent access to drinks at all times, affecting 95 current residents. Findings include:1. ObservationOn 8/20/24 at 7:20 a.m., there was no drinking water container or independent access to drinking water, drinks, or cups for residents in the secure environment. Staff would pour water/liquid into glasses for each resident as they were being served breakfast. There was a drinking water pitcher and a colored liquid pitcher which Staff #54 stated was enhanced water (water with electrolytes and fruit that changed the color), behind a small enclosed kitchen area on the countertop. There were no cups in the surrounding area to ensure the residents in the secure environment had independent access to drinking water/drinks at all times. On 8/20/24 at 7:41 a.m., Staff #55 had a pitcher of drinking water on top of the medication administration cart for use when administering medications. On 8/20/24 at 8:05 a.m., Staff #54 assisted Resident #46 with drinking water that Staff #54 poured from the small kitchen water container. On 8/20/24 from approximately 8:32 a.m. to 10:00 a.m., there was a water container along with the enhanced water in the small kitchen area on the inside of the same counter; however, there were no cups in the surrounding area to ensure that residents in the secure environment had independent access to drinks at all times. On 8/20/24 at approximately 7:33 p.m., there was no independent access to other drinks available for any residents in both the secure environment and the non-secure environment of the residence. Additionally, there was no independent access to water for the residents in the secure environment. On 8/21/24 at 1:09 p.m., there was a drinking water and enhanced water dispenser on the countertop inside the small kitcken area in the secured environment. Residents in the secure environment did not have independent access to drinking water or enhanced water. 2. InterviewOn 8/20/24 at approximately 7:30 a.m., Staff #54 stated that residents in the secure environment did not have independent access to drinking water as the residents tend to make a mess and play with the water container. On 8/20/24 at approximately 7:43 a.m., Staff #55 stated the water on top of the medication administration cart was exclusively for medication administration and not used as independent access to drinking water for residents in the secureenvironment. On 8/20/24 at approximately 9:06 a.m., a family member of Resident #46 stated she would grab two cups of coffee when she arrived to visit the resident from the non-secure area and bring the coffee to Resident #46. The family member stated she was aware no drinks were offered to her loved one unless it was at meal times. Additionally, she stated that prior to the pandemic there was a hydration station for the secure environment. On 8/21/24 at 10:42 a.m., a second family member of Resident #46 stated that as she during her visits with Resident #46 there was no independent access for residents in the secure environment to beverages. She stated she would often bring beverages with her or ask staff for beverages on behalf of the resident. On 8/21/24 at 12:45 p.m., Staff #56 stated that in between meals residents in the non-secure environment of the residence had independent access to drinking water at the residence's hydration station located near the front entrance of the residence. Additionally, Staff #56 stated that the hydration station was set up in the non-secure environment of the residence between 9:30 a.m. and 10:00 a.m. every day. Staff #56 further stated that the hydration station was dismantled around 6:30 p.m. Staff #54 clarified the secure environment did not have independent access as the residents in the secure environment made a mess and played with the drinking water. On 8/21/24 at approximately 1:45 p.m., the administrator stated residents in the secure environment had a cup and residence staff were supposed to fill up the cups for residents but the cups for each resident had not been used yet as it was new. The administrator also stated that hydration was encouraged after each activity in the secure environment. The administrator stated that he was aware that all residents should have access to drinking water and other liquids at all times whether the residents resided in the secure environment or non-secure environment.

Based on interview and record review, the residence failed to ensure progress notes included information on resident status, wellbeing, documentation on out of the ordinary events along with the action taken by staff to address the residents's changing needs affecting two of two residents with changes in condition (#41, #42). Cross-reference S1110 and S1324Findings include:1. Residence PolicyThe residence's Resident Record policy, undated, read in part: Daily documentation was not necessary. Documentation would occur when an activity, event, and incident that is not usual for the resident or change in level of assistance occurs. 2. Resident #41 was admitted to the residence on 10/10/23 with a diagnosis of cardiac, hypertension, fracture, diabetes, chronic hypoxemic respiratory failure from neglect, and depression. Interviews:On 8/20/24 at approximately 1:59 p.m. emergency medical services (EMS) stated that on 8/18/24 EMS was dispatched for a resident that had fallen and was purple in color. EMS stated upon arrival two staff were present and the resident was on the floor without her prescribed oxygen on. EMS stated Resident #41 ' s oxygen levels were below 65% and she was purple in color. EMS further stated it took a long time to get the resident's oxygen levels back at baseline. On 8/20/24 at 5:00 p.m., Staff #53 confirmed the above incident happened and added Resident #41 fell again on 8/18/24. On 8/20/24 at approximately 1:17 p.m. the wellness director (WD) stated Resident #41 had a fall on 7/18/24 and was sent to the hospital. He stated the resident was then transferred to a rehabilitation center and then on 8/16/24 she was readmitted to the residence. Record Review:The record for Resident #41 contained one progress note regarding the above mentioned events as follows: On 7/18/24 Resident #41 was walked out of her bathroom and fell on the floor hitting her head on the wall in the shower. The resident pressed her pendant, a caregiver went to go assist and found her on the floor. She had hit her head, EMS was notified, they checked on her and helped her up. However, the record failed to update the progress note of the subsequent hospitalization, transfer to rehabilitation, discharge from rehabilitation, the fall resulting in oxygen deprivation and the subsequent fall on 8/18/24. 3. Additional deficient practice was was revealed for Resident #42.4. InterviewOn 8/20/24 at 1:22 p.m., The wellness director said he was aware documentation needed to be completed by the end of shift on the same day. On 8/20/24 at 1:35 p.m., the administrator said he was unaware of the delay in completing documentation and confirming practitioner orders timely.

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 7.11.1 The assisted living residence shall accept only those persons whose needs can be fully met bythe existing staff, physical environment, and services already being provided. The assisted livingresidence's ability to meet resident needs shall be based upon a comprehensive pre-admissionassessment of a resident's physical, mental, and social needs; cultural, religious and activityneeds; preferences; and capacity for self-care. 14.3 An assisted living residence shall not allow a QMAP or a CNA-Med to assist a resident withmedication administration unless the resident is able to consent and participate in theconsumption of the medication. 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing.

A licensure complaint, prompted by #CO34584, was completed on 1/31/24. The complaint allegation was unsubstantiated, although there was related deficient practice related to the complaint allegations. However, the residence was not cited with deficient practice given that on 1/31/24, the residence was operating under the terms of an intermediate condition of a consultant imposed by the department who was in process of assisting the residence to correct the deficient practice identified.

A licensure complaint, prompted by #CO31554, #CO32266, #CO32700, #CO33718 was completed on 10/17/23. No deficiencies were cited given that on 10/17/23, the residence was operating under the terms of an intermediate condition imposed by the department.

A licensure complaint, prompted by #CO31022 and #CO31093, was completed on 3/7/23. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 77 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for 12 months. Following the completion of Event 7XLZ11 on 8/11/22, a complaint investigation, the department imposed a nurse consultant for 12 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the nurse consultant was required to complete, during the first month of the contract period:- Review each of the cited deficiencies identified in the Deficiency List, for Event 7XLZ11 and dated August 11, 2022, with the Administrator, and evaluate the Residence's current compliance with corresponding regulations as outlined in 6 CCR 1011-1 Chapters 2, 7, and 24, where applicable. The nurse consultant was required to complete the following during the first two months of the contract period:- Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Administrator on any additional areas of noncompliance. The RN Consultant would also implement a monitoring program, to be completed at least monthly, to ensure the Residence remains in compliance with previously cited deficiencies. The monitoring program will be incorporated into the Residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, Section 4. The RN Consultant will make certain that the QMP was designed to improve resident safety and well-being, and promoted continued quality improvement to enhance service delivery. The RN consultant was required to complete the following during the first through the sixth months of the contract period:- Conduct onsite visits at least weekly. The RN consultant was required to complete the following during the seventh through twelve months of the contract period:- Conduct onsite visits at least twice monthly, increasing the frequency as necessary to assist the Residence in maintaining compliance with 6 CCR 1011-1 Chapter 2, Chapter 7, and Chapter 24 and, to prepare the Administrator to independently manage the residence. Additionally, the RN consultant was required to ensure, during the entire 12-month contract period, for each of the deficiencies identified in the Deficiency List, for Event 7XLZ11 and dated August 11, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. The RN Consultant will make certain that the monitoring identified the scope of review, how a sample was identified for monitoring purposes, the total length of time the monitoring would continue, and how the monitoring would be documented. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 11/10/22.- Submit executed consultant contract to the department, due by 11/18/22.- Submit final consultant report, due by 11/15/23. Department records read the residence had chosen the RN consultant on 11/8/22 and the contract for the RN consultant was received on 11/15/22. Therefore, on the day of the completion of the complaint investigation, (3/2/23), the RN consultant would have been in her fourth month as consultant for the residence. 2. Current deficient practiceDuring the 3/2/23 complaint investigation, the investigation established there was current deficient practice. Five deficiencies were cited, including tags 642, 1150, 1180, 1192, and 1312. Tags 642, 1180, 1192, and 1312 were cited at a C level, actual harm. (Cross-reference Q642, Q1150, Q1180, Q1192, Q1312). 3. Interviews On 3/2/23 at approximately 3:47 p.m., the administrator stated she was aware the residence was under an intermediate condition of a RN consultant. The administrator stated she was aware the residence was required to maintain compliance with all regulations while under the intermediate condition term. On 3/2/23 at 4:34 p.m., the RN consultant stated she was aware the residence was required to maintain compliance with all regulations while under the intermediate condition. The RN consultant agreed the residence had not complied with the terms of the intermediate condition. In regards to tags 1150 and 1180, the RN consultant stated she discussed care plans with the administrator; however, the residence used a combined electronic assessment and care plan form which made it difficult to include required information on the care plan. She stated the residence had not created care plans with required information and had struggled to meet this requirement. The RN consultant stated care plans were an ongoing project currently being worked on. The RN consultant stated the residence failed to put interventions in place for Former Resident #40 when he returned from a skilled rehabilitation facility on 2/3/23. She stated the residence was aware that interventions should have been implemented when he returned to the residence because he had fallen prior to being admitted to the skilled rehabilitation facility. In regards to tag 1192, the RN consultant stated she believed the residence staff had not had enough training on lift assistance and what to do after a resident had fallen. In regards to tag 1312, the RN consultant stated the residence staff neglected Former Resident #40 when he reported shortness of breath and difficulty breathing multiple times after being found on the floor and not calling emergency medical services right away.

Based on observation, interview and record review, the residence failed to provide each staff member with training relevant to their specific duties and responsibilities prior to that staff member working independently, affecting 77 current residents. (Cross-reference B0246, Q1150, Q1312). Specifically, Former Resident #40 reported shortness of breath (SOB) on 2/20/23. Staff were not trained in the proper use of the former resident's oxygen and continuous positive airway pressure (CPAP) machine. Subsequently, staff connected the CPAP machine to an incompatible oxygen machine which resulted in the former resident not receiving the continuous flow of oxygen he required. The former resident passed away moments later. Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein. The residence's undated Orientation and Training policy read, in part: "Employees will be trained in accordance with state regulatory requirements."2. Former Resident #40 was admitted to the residence on 8/13/22. A written practitioner's order, dated 2/13/23, read that Former Resident #40 required a continuous flow of oxygen. An investigation, dated 2/20/23, revealed that Former Resident #40 reported SOB. The resident's oxygen concentrator was not working properly, so Staff #15 connected an incompatible portable oxygen machine to the resident's CPAP machine and assisted Former Resident #40 with the application of the CPAP mask. Within three minutes, the former resident stopped breathing and passed away. On 3/2/23 at 2:14 p.m., Staff #47 said she was hired on 2/7/23 and had worked independently since. She stated the residence had not provided training with information specific to the residence. She added she had not been trained in the proper techniques for assisting residents with CPAP machines or oxygen. On 3/2/23 at approximately 2:55 p.m., the health and wellness director (HWD) stated he did not think staff were trained regarding CPAP machines or oxygen specifically before an inservice that was held in February 2023, after Former Resident #40 had passed away. On 3/2/23 at 3:47 p.m., Former Staff #15 was hired on 2/20/20 and let go after the incident on 2/20/23. She stated Former Resident #40 reported SOB on 2/20/23. She stated she connected the resident's CPAP machine to an incompatible oxygen machine and the former resident stopped breathing and passed away moments later. She stated she had not known the oxygen machine was not compatible with the CPAP machine because the residence had not trained her on the use of CPAP machines. She added that residence staff regularly assisted Former Resident #40 with his CPAP machine and oxygen. On 3/2/23 at 4:20 p.m., Staff #24 was hired on 10/26/22 and worked independently at the residence. He stated that Former Resident #40 reported he could not breathe multiple times on 2/20/23. He stated that the former resident's oxygen concentrator was not working properly and Staff #15 connected the resident's CPAP machine to another oxygen machine and applied the CPAP mask to the former resident's face. He stated he was not aware the oxygen machine was not compatible with the CPAP machine because the residence had not trained him on the use of CPAP machines. He added that residence staff regularly assisted Former Resident #40 with his CPAP machine and oxygen. On 3/2/23 at 4:21 p.m., a family member of Former Resident #40 stated another family member had to teach staff how to assist the former resident with his CPAP machine and oxygen because they were not trained by the residence. She stated that on 2/20/23, residence staff connected the former resident's CPAP machine to an incompatible oxygen machine. Therefore, Former Resident #40 did not receive the continuous oxygen he required and passed away. On 3/7/23 at 10:39 a.m., the responsible party for Former Resident #40 stated another family member had to teach staff how to assist the former resident with his CPAP machine and oxygen because they were not trained by the residence. He stated that on 2/20/23, residence staff connected the former resident's CPAP machine to an incompatible oxygen machine. Therefore, Former Resident #40 did not receive the continuous oxygen he required and passed away. 3. Contracted StaffOn 3/2/23 from approximately 7:00 a.m. to 2:00 p.m., Contracted Staff #25 and #26 provided personal care services to residents. Contracted Staff #26 had an unknown hire date. Residence time cards revealed she worked at the residence on 2/16, 2/20, 2/22-2/25, 2/28, and 3/1/23. On 3/2/23 at approximately 10:30 a.m., personnel files for Contracted Staff #25 and #26 were provided. However, the personnel files did not include completed training. A training document read that Contracted Staff #25 completed training on 3/2/23. The document read the staff member was trained on resident rights, hand hygiene and infection control, recognizing emergencies and emergency procedures, house rules, person centered care, and reporting requirements. However, the document did not show that Contracted Staff #25 was trained in an overview of state and regulatory oversight applicable to the assisted living residence, the role of and communication with external service providers, recognizing behavioral expression and management techniques, how to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, training related to fall prevention and ways to monitor residents for signs of heightened fall potential, how to safely provide lift assistance, maintenance of a clean, safe and healthy environment, food safety, and an understanding of their role in end of life care. Contrary to the training document, on 3/2/23 at approximately 7:45 a.m., Contracted Staff #25 stated today was her first day at the residence. She stated the residence provided no training on any specific topic prior to her start date. She stated if she had questions about any resident's individualized needs and her duties that she would ask a residence staff member. A training document read that Contracted Staff #26 completed training on 12/26/22. The document read that Contracted Staff #26 was trained on duties and responsibilities, communication with external providers, emergency procedures, fall prevention, location of resident's advance directive, maintenance of a safe environment, understanding of end of life care, lift assistance, and food safety. However, the document did not show that Contracted Staff #26 was trained in an overview of state regulatory oversight applicable to the assisted living residence, person-centered care, recognizing behavioral expression and management techniques, how to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, On 3/2/23 at 12:55 p.m., the administrator stated that all contracted staff documents were provided. On 3/2/23 at approximately 2:55 p.m., the health and wellness director (HWD) stated that he was not sure what training was provided to contracted or permanent staff. On 3/2/23 at approximately 3:35 p.m., the administrator stated the residence was expected to provide training to all staff that worked in the building. She added she was not surprised that contracted staff stated they were not provided training specific to the residence and residents.

Based on record review and interview, the residence failed to develop a care plan that detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting one former resident (#40). (Cross-Reference B0246, Q1312). Findings include: 1. Residence PolicyThe residence's undated Care Plan policy read in part: "Any personal care services needed will be indicated on the care plan."2. Former Resident #40 was admitted to the residence on 8/13/22. A care plan, dated 1/27/23, read the resident self-managed his continuous positive airway pressure (CPAP) machine. A progress note, dated 2/3/23, read that Former Resident #40 returned from a skilled rehabilitation facility on 2/3/23. On 3/2/23 at 2:14 p.m., Staff #47 stated that Former Resident #40 required assistance with his CPAP machine. She stated the former resident had needed assistance since she started her position on 2/7/23. On 3/2/23 at 2:55 p.m., the health and wellness director stated that Former Resident #40 was initially independent with his CPAP machine and he was not aware that staff helped him with his CPAP machine until 2/20/23. He stated that staff should have reported the resident's change in condition and the former resident's care plan should have been updated to detail that he required staff assistance with his CPAP machine. He was unsure when the change in condition occurred. On 3/2/23 at approximately 3:35 p.m., the administrator stated that Former Resident #40's care plan should have been updated to read that he required assistance with his CPAP machine. She was unsure when the former resident's change in condition occurred. On 3/2/23 at 4:21 p.m., a family member of Former Resident #40 stated that staff assisted the former resident with his CPAP machine and had for several months. On 3/7/23 at 10:39 a.m., the responsible party for Former Resident #40 stated that residence staff assisted the former resident with his CPAP machine for several months.

Based on interview and record review, the residence failed to ensure each resident's care plan detailed the individualized approach necessary to address fall risk, affecting one former resident with falls (#40). (Cross-reference B0246, Q1192). Specifically, Former Resident #40 had a history of falls and sustained a fall on 12/10/22 and a fall on 2/20/23 that resulted in a skin tear. Furthermore, the resident's care plan was updated on 1/27/23, however, it did not detail all individualized approaches necessary to address fall risk. Findings include:1. Residence PolicyThe residence's undated Fall Management and Injury Response policy read in part: "Each resident's care plan will be detailed with the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or effects of medication as identified during the comprehensive assessment."2. Former Resident #40 was admitted to the residence on 8/13/22 with diagnoses including muscle atrophy. A progress note, dated 12/10/22, read the resident fell to his knees while transferring. A care plan, dated 1/27/23, read the former resident had one to two falls within the last 90 days. However, the care plan did not address the individualized approach necessary to address fall related deficits. A progress note, dated 2/3/23, read the former resident returned from a skilled rehabilitation facility. An incident report, dated 2/20/23, read the former resident sustained a fall that resulted in a skin tear to his right hand. A progress note, dated 2/20/23, read the former resident sustained a fall that resulted in a skin tear. On 3/2/23 at 2:14 p.m., Staff #47 stated she did not know that Former Resident #39 was a fall risk and was unaware of interventions in place to prevent falls. On 3/2/23 at 2:55 p.m., the health and wellness director stated he was responsible for updating resident care plans. He stated that Former Resident #40 had a fall around November or December 2022. He added the former resident's care plan should have been updated with the individualized approaches necessary to address fall risk; however, he had just started his position as health and wellness director at the time. The health and wellness director confirmed the former resident sustained a skin tear when he fell on 2/20/23. On 3/2/23 at 3:35 p.m., the administrator stated she was not sure whether or not Former Resident #40 was a fall risk. She stated when a resident fell, their care plan should always be updated with the individualized approaches necessary to address fall risk. She stated the health and wellness director was responsible for updating resident care plans and there should have been an intervention in the care plan for Former Resident #40. On 3/2/23 at 4:21 p.m., a family member of Former Resident #40 stated the resident had fallen at the residence before and was at risk for falls. She stated she was unaware of interventions in place to prevent falls for the former resident.

Based on record review and interview, the residence failed to follow their lift assistance policy affecting one former resident (#40). (Cross-reference B0246, Q1180, Q1312). Specifically, Former Resident #40 experienced a fall and shortness of breath (SOB) on 2/20/23. Staff moved the resident from a seated position on the floor to his bed in a lying position, despite the former resident experiencing SOB and reporting so several times to staff. Subsequently, the resident stopped breathing minutes later and passed away. Findings include:1. Residence PolicyThe residence's undated Fall Management and Injury Response policy read in part, when a resident fell and had breathing problems, the resident should not be moved and staff were required to call emergency services. 2. Former Resident #40 was admitted to the residence on 8/13/22. A progress note, dated 2/20/23, read Former Resident #40 was found on the floor and was unable to describe what happened due to SOB. Staff assisted the resident into bed. An investigation, dated 2/20/23, revealed Former Resident #40 was found on the floor after a fall and reported SOB. Staff moved the former resident to his bed in a lying position. Staff #15 reported she moved the resident after a fall while he complained of SOB and she moved him to a lying position, which was not ideal for someone experiencing SOB. On 3/2/23 at 3:47 p.m., Staff #15 stated Former Resident #40 was found on the floor after a fall on 2/20/23. She stated the former resident reported he could not breathe and she and Staff #24 moved the former resident to a lying position on his bed. She stated the former resident stated he could not breathe multiple times and he should have been allowed to remain in a seated position, not lying down. On 3/2/23 at 4:20 p.m., Staff #24 stated he found Former Resident #40 on the floor after a fall on 2/20/23. He stated the former resident reported he could not breathe and he and Staff #15 moved the former resident to a lying position on his bed. He stated the residence's policy was not followed and emergency services were not contacted. Staff #24 added staff should not have moved Former Resident #40 and emergency services should have been notified. On 3/2/23 at 2:55 p.m., the health and wellness director stated when Former Resident #40 fell and reported SOB on 2/20/23, staff should not have moved the former resident and should have called emergency services. On 3/2/23 at 3:35 p.m., the administrator stated when Former Resident #40 fell and reported SOB on 2/20/23, staff should not have moved the former resident and should have called emergency services.

Based on interview and record review, the resident failed to ensure a resident had the right to be free from neglect, affecting one former resident (#40). (Cross-reference B0246, Q1192). Specifically, Former Resident #40 experienced a fall and shortness of breath (SOB) on 2/20/23 and reported SOB to residence staff multiple times. Residence staff failed to contact emergency services for the former resident. Subsequently, Former Resident #40 stopped breathing and passed away on 2/20/23. Findings include:1. Reference and Residence policiesa. The residence's undated Fall Management and Injury Response policy read in part, when a resident fell and had breathing problems, the resident should not be moved and staff were required to call emergency services. b. The residence's undated Abuse Prohibition and Prevention policy read in part: "Neglect is the failure of the facility (residence), its employees or service providers provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress." The policy additionally read, in part, that not attending to a resident's medical needs was neglect.c. Chapter VII regulations governing assisted living residences, part 2.10, defines "Caretaker neglect" as that which occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person. 2. Former Resident #40 was admitted to the residence on 8/13/22. A progress note, dated 2/20/23, read that Former Resident #40 was found on the floor and was unable to describe what happened due to SOB. Staff assisted the resident into bed. The progress note did not read that emergency services were contacted. An investigation, dated 2/20/23, revealed that Former Resident #40 was found on the floor after a fall and reported SOB. Staff moved the former resident to his bed in a lying position. The investigation read that Staff #15 reported she moved the resident while he complained of SOB into a lying position, which was not ideal for someone experiencing SOB. The investigation read that Staff #15 reported she had not contacted emergency services because she was not aware she was required to do so. On 3/2/23 at 3:47 p.m., Staff #15 stated Former Resident #40 was found on the floor and the former resident reported SOB on 2/20/23. She stated the former resident reported he could not breathe multiple times and passed away approximately 10 minutes after being found. She stated she had not contacted emergency services. She added that it was neglectful that emergency services were not notified. On 3/2/23 at 4:20 p.m., Staff #24 stated he found Former Resident #40 on the floor on 2/20/23. He stated the former resident reported he could not breathe multiple times. He stated the residence's policy was not followed and emergency services were not contacted. Staff #24 added that emergency services should have been notified and the failure to notify emergency services could be considered neglect. On 3/2/23 at 2:55 p.m., the health and wellness director stated that when Former Resident #40 reported SOB on 2/20/23, staff should not have moved the former resident and should have called emergency services. On 3/2/23 at 3:35 p.m., the administrator stated that when Former Resident #40 fell and reported SOB on 2/20/23, staff should not have moved the former resident and should have called emergency services. She stated the failure to contact emergency services resulted in neglect.

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 7.7.12 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicable. 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner.(A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.(B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials.(C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.(D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.

A licensure revisit was completed on 3/7/23 for all previous deficiencies cited on 8/11/22. Deficiencies were cited.

Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring two of seven sample staff (#15, #24) who provided direct care to at-risk residents, affecting eight of 19 sample residents (#10, #14, #18, #35-#39). (Cross-reference B0246). Findings include:1. References a. According to Colorado Revised Statutes (2017) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult."b. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado adult protective services data system pursuant to section 26-3.1-111.c. Chapter VII regulations governing assisted living residences, part 2.7, defines an "At-risk person" as any person who is 18 years of age or older and meets one or more of the following criteria: (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.2. Record Reviewa. StaffPersonnel files for Staff #15 and #24 revealed they were hired on 2/20/20 and 10/26/22 respectively. Review of the personnel files for Staff #15 and #24 revealed no evidence a CAPS check had been completed. Review of the staff schedule for February 2023 and March 2023 revealed the following Staff #15 and #24 worked at the residence as follows:Staff #15 worked on 2/16-2/22, 2/23-2/28 and 3/1-3/2/23. Staff #24 worked on 2/16 and 2/19/23.b. ResidentsResident #10 was 94 years old. Resident #14 was 85 years old with diagnoses including dementia. Resident #18 was 87 years old. Resident #35 was 93 years old with diagnoses including mild cognitive impairment. Resident #36 was 77 years old. Resident #37 was 86 years Resident #38 was 93 years old. Resident #39 was 93 years old. 3. Interviews On 3/2/23 at 3:55 p.m., the administrator acknowledged the staff files for Staff #15 and #24 did not contain documentation of a request for CAPS checks. She stated the administrator hired Staff #15 and #24 but did not request and complete the CAPS checks prior to allowing them to provide care and services to the residents.

Based on observation, record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 77 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for 12 months. Following the completion of Event 7XLZ11 on 8/11/22, a complaint investigation, the department imposed a nurse consultant for 12 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the nurse consultant was required to complete, during the first month of the contract period:- Review each of the cited deficiencies identified in the Deficiency List, for Event 7XLZ11 and dated August 11, 2022, with the Administrator, and evaluate the Residence's current compliance with corresponding regulations as outlined in 6 CCR 1011-1 Chapters 2, 7, and 24, where applicable. The nurse consultant was required to complete the following during the first two months of the contract period:- Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Administrator on any additional areas of noncompliance. The RN Consultant would also implement a monitoring program, to be completed at least monthly, to ensure the Residence remains in compliance with previously cited deficiencies. The monitoring program will be incorporated into the Residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, Section 4. The RN Consultant will make certain that the QMP was designed to improve resident safety and well-being, and promoted continued quality improvement to enhance service delivery. The RN consultant was required to complete the following during the first through the sixth months of the contract period:- Conduct onsite visits at least weekly. The RN consultant was required to complete the following during the seventh through twelve months of the contract period:- Conduct onsite visits at least twice monthly, increasing the frequency as necessary to assist the Residence in maintaining compliance with 6 CCR 1011-1 Chapter 2, Chapter 7, and Chapter 24 and, to prepare the Administrator to independently manage the residence. Additionally, the RN consultant was required to ensure, during the entire 12-month contract period, for each of the deficiencies identified in the Deficiency List, for Event 7XLZ11 and dated August 11, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. The RN Consultant will make certain that the monitoring identified the scope of review, how a sample was identified for monitoring purposes, the total length of time the monitoring would continue, and how the monitoring would be documented. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 11/10/22.- Submit executed consultant contract to the department, due by 11/18/22.- Submit final consultant report, due by 11/15/23. Department records read the residence had chosen the RN consultant on 11/8/22 and the contract for the RN consultant was received on 11/15/22. Therefore, on the day of the completion of the complaint investigation, (3/2/23), the RN consultant would have been in her fourth month as consultant for the residence. 2. Current deficient practiceDuring the 3/2/23 licensure revisit, the investigation established there was current deficient practice. Eleven deficiencies were cited, including tags 610, 732, 734, 736, 1150, 1180, 1192, 1312, 1316, 1468 and 172. Tags 1180, 1192, and 1312 were cited at a C level, actual harm. (Cross-reference Q610, Q732, Q734, Q736, Q1150, Q1180, Q1192, Q1312, Q1316, Q1468, B172). 3. Interviews On 3/2/23 at approximately 3:47 p.m., the administrator stated she was aware the residence was under an intermediate condition of a RN consultant. The administrator stated she was aware the residence was required to maintain compliance with all regulations while under the intermediate condition term. On 3/2/23 at 4:34 p.m., the RN consultant stated she was aware the residence was required to maintain compliance with all regulations while under the intermediate condition. The RN consultant agreed the residence had not complied with the terms of the intermediate condition. In regards to tags 172 and 610, the RN consultant stated she was not aware background checks and Colorado Adult Protective Service checks were still an issue with the residence. She stated she was aware the residence utilized a third party company to complete background checks and believed the company included criminal history records checks completed by the Colorado Bureau of Investigations. In regards to tags 732, 734 and 736, the RN consultant stated her audits had revealed there were concerns with cardiopulmonary resuscitation (CPR) and first aid certifications with staff. She stated she had discussed the nationally recognized company with the administrator, however, the administrator informed her she had difficulty scheduling classes for staff because the class required a certain number of participants. The RN consultant stated the residence was trying to get all staff certified through a nationally recognized organization and had not succeeded as of the date of the onsite survey. The RN consultant stated she had discussed the list of CPR and first aid certified staff with the administrator and had informed the administrator the list needed to be accurate and posted in a location that was publicly visible. She was unsure why the list was not accurate. In regards to tags 1150 and 1180, the RN consultant stated she had discussed with the administrator regarding care plans, however, the residence used a combined assessment and care plan form which made it difficult to include required information on the care plan. She stated the residence had not created care plans with required information and had struggled to meet this requirement. The RN consultant stated care plans were an ongoing project currently being worked on. The RN consultant stated the residence failed to put interventions in place for Former Resident #40 when he returned from a skilled rehabilitation facility on 2/3/23. She stated the residence was aware that interventions should have been implemented when he returned to the residence because he had fallen prior to being admitted to the skilled rehabilitation facility. In regards to tag 1192, the RN consultant stated she believed the residence staff had not had enough training on lift assistance and what to do after a resident had fallen. In regards to tag 1312, the RN consultant stated the residence staff neglected Former Resident #40 when he reported shortness of breath and difficulty breathing multiple times after being found on the floor and not calling emergency medical services right away. In regards to tag 1316, the RN consultant stated resident call pendants were still a concern with the residence. She stated they had measures in place, however, they were not following those measures. She stated the response times over 10 minutes were not consistently being investigated by management as outlined in their plan. In regards to tag 1468, The RN consultant stated medication administration was still a concern for the residence. She stated the residence utilized contracted staff to administer medications often which resulted in medications not being administered as ordered. She stated contracted staff often did not administer medications as ordered because they could not locate the medications to administer and would mark the medications as unavailable.

Based on record review and interview, the residence failed to ensure a name-based criminal history report from the Colorado Bureau of Investigation (CBI) was requested for each prospective staff member, prior to hire for two of seven sample staff (#15, #24), affecting 77 current residents. (Cross-reference B0246). Findings include:Staff #15 and #24 were hired on 2/20/20 and 10/26/22, respectively. Review of staff schedules for February and March 2023 revealed Staff #15 and #24 had worked with residents each week since their hire. On 3/2/23 at 3:55 p.m., the administrator confirmed the residence did not include a CBI as part of prospective employees' name-based criminal history checks, prior to their hire. The administrator was aware that CBIs were required.

Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting 77 current residents. (Cross-reference B0246, Q0734)This deficiency was cited previously during a licensure complaint survey on 8/11/22. 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 Policya. The residence undated CPR and First Aid Response policy, read in part, "This community will always have at least one staff member onsite who has current certification ... with first aid ... "b. According to VeryWell Health, "First aid is the emergency care a sick or injured person gets. In some cases, it may be the only care someone needs, while in others, it may help them until paramedics arrive or they are taken to the hospital. The best way to prepare for these events is to get official first aid training" Brouhard, R., EMT (11/30/21) First Aid, 10 Basic First Aid Procedures. Retrieved from: https://www.verywellhealth.com/basic-first-aid-procedures-1298578c. According to the National CPR Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own (teacher). Our services are designed with OSHA (Occupational Safety and Health Administration ), the ECC (Emergency Cardiovascular Care)/ILCOR (The International Liaison Committee on Resuscitation) and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2022) Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/2. Record Review a. Time cardsTime cards revealed the residence did not have a staff member who was first aid certified from a nationally recognized organization from 6:00 a.m. to 2:00 p.m. on 2/18, 2/24-2/25/23 and from 10:00 p.m. to 6:00 a.m. on 2/17-2/18, 2/21-2/26,2/28, and 3/1/23, for a total of 13 shifts in the previous two weeks.b. Personnel FilesThe personnel files for Staff #29 and #33 contained a first aid certification that expired in February 2023. The personnel files for Staff #28, #30, #31, #35, #37 and #38 contained a first aid certification that was not from a nationally recognized organization. The personnel files for Staff #24, #27,#36, and #39 did not contain any first aid certification documentation. 3. InterviewsOn 3/2/23 at 9:45 a.m., the assistant wellness director stated some staffs' first aid certifications had expired, and the residence provided a class in October 2022. She stated she thought newer staff had taken the first aid class but was mistaken. On 3/2/23 at 3:29 p.m., the health and wellness director stated he had not been aware that staffs' current first aid certifications were not from nationally recognized organizations. He was also unaware of the expired certifications and those staff without any certifications. He stated that the deficiency was not corrected because he was unaware that the first aid certifications were not from a nationally recognized organization and the expired certificates.

Based on observation, record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 77 current residents. (Cross-reference B0246, Q0732)This deficiency was cited previously during a licensure complaint survey on 8/11/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. References and Residence Policya. The residence's undated CPR and First Aid Response policy, read in part, "This community will always have at least one staff member onsite who has current certification in cardiopulmonary resuscitation (CPR), obstructed airway techniques ... " b. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that's useful in many emergencies, such as a heart attack or near drowning, in which someone's breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to both untrained bystanders and first responders." Mayo Clinic (5/1/21) Cardiopulmonary Resuscitation, retrieved from: https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600c. According to the American Red Cross: "Obstructed Airway Care for Adults ... If the patient is able to speak to you or is coughing forcefully: Encourage the patient to keep coughing but be prepared to clear the airway if the patient's condition changes ... Obtain consent ... Perform abdominal thrusts ... Perform alternate techniques-back blows, chest thrusts, or airway management ... Continue to clear the airway ... If the patient becomes unresponsive, carefully lower them to a firm, flat surface, while protecting their head. Immediately begin CPR, starting with chest compressions. After each set of compressions and before ventilation, open the patient's mouth and look for the object-if seen, remove it using a finger sweep." Skill Sheet: Obstructed Airway Care for Adults and Children (2019). Retrieved from: https://www.redcrosslearning.com/course-bin/bls-healthcare-resuscitation/app/content/a/en-US/resources/SS-Obstructed-Airway-Care-for-Adults-and-Children.pdfd. According to the National CPR Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own (teacher). Our services are designed with OSHA (Occupational Safety and Health Administration), the ECC (Emergency Cardiovascular Care)/ILCOR (The International Liaison Committee on Resuscitation) and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2022) Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/2. Record Review a. Time cardsTime cards revealed the residence did not have a staff member who was first aid certified from a nationally recognized organization from 6:00 a.m. to 2:00 p.m. on 2/18, 2/24-2/25/23 and from 10:00 p.m. to 6:00 a.m., on 2/17-2/18, 2/21-2/26,2/28, and 3/1/23, for a total of 13 shifts in the previous two weeks.b. Personnel FilesThe personnel file for Staff #29 and #33 contained CPR/obstructed airway techniques certificates that expired in February 2023. The personnel file for Staff #28, #30,#35,#31,#35,#37 and #38 contained a CPR/obstructed airway techniques certificate that was not from a nationally recognized organization. The personnel files for Staff #24, #27,#36, and #39 did not contain any CPR/obstructed airway techniques certificates documentation. 3. InterviewsOn 3/2/23 at 9:45 a.m., the assistant wellness director stated some staffs' CPR certifications had expired, and the residence provided a class in October 2022. She stated she thought newer staff had taken the CPR class but was mistaken. She said, "I didn't follow up with them about getting the certification." On 3/2/23 1:05 p.m., the RN consultant thought the deficient practice related to a lack of CPR/obstructed airway technique certification had been corrected.

Based on observation, record review and interview, the residence failed to place in a visible location, an up to date 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 77 current residents. (Cross-reference B0246). This deficiency was cited previously during a licensure revisit on 8/11/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 3/2/23 at approximately 8:00 a.m., a list of staff who were certified in first aid or CPR was posted in the secure environment. There was no date on the posting. The posting still listed Former Staff #2, #6, #9, #11, #13, #16, #42, #43, #44, #45, and #46. On 3/2/23 at 8:29 a.m., a list of staff who were certified in first aid or CPR was posted in the kitchen on a bulletin board. The date on the posting was 12/2/22. The posting still listed Former Staff #2, #6, #43 and #44. On 3/2/23 at approximately 8:30 a.m., a list of staff who were certified in first aid or CPR was posted in the copy room on a bulletin board. The date on the posting was 1/3/23. At approximately 8:30 a.m., a list of staff who were certified in CPR or first aid was posted in the health and wellness director's office on a bulletin board. The posting was dated 1/3/23. On 3/2/23 at approximately 3:30 p.m., the administrator stated she was responsible for posting and updating the list of staff who had current certification in first aid or CPR. The administrator said there should have been a list posted that was recently updated in February 2023. She added the February 2023 list was not posted because the residence planned to terminate some staff members. The administrator acknowledged that the list that was posted was required to be accurate.

Based on record review and interview, the residence failed to develop a care plan that detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting one former resident (#40). (Cross-Reference B0246, Q1312). This deficiency was cited previously during a licensure revisit on 8/11/22. 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 undated Care Plan policy read in part: "Any personal care services needed will be indicated on the care plan."2. Former Resident #40 was admitted to the residence on 8/13/22. A care plan, dated 1/27/23, read the resident self-managed his continuous positive airway pressure (CPAP) machine. A progress note, dated 2/3/23, read that Former Resident #40 returned from a skilled rehabilitation facility on 2/3/23. On 3/2/23 at 2:14 p.m., Staff #47 stated that Former Resident #40 required assistance with his CPAP machine. She stated the former resident had needed assistance since she started her position on 2/7/23. On 3/2/23 at 2:55 p.m., the health and wellness director stated that Former Resident #40 was initially independent with his CPAP machine and he was not aware that staff helped him with his CPAP machine until 2/20/23. He stated that staff should have reported the resident's change in condition and the former resident's care plan should have been updated to detail that he required staff assistance with his CPAP machine. He was unsure when the change in condition occurred. On 3/2/23 at approximately 3:35 p.m., the administrator stated that Former Resident #40's care plan should have been updated to read that he required assistance with his CPAP machine. She was unsure when the former resident's change in condition occurred. On 3/2/23 at 4:21 p.m., a family member of Former Resident #40 stated that staff assisted the former resident with his CPAP machine and had for several months. On 3/7/23 at 10:39 a.m., the responsible party for Former Resident #40 stated that residence staff assisted the former resident with his CPAP machine for several months.

Based on interview and record review, the residence failed to ensure each resident's care plan detailed the individualized approach necessary to address fall risk, affecting one former resident with falls (#40). (Cross-reference B0246, Q1192). This deficiency was cited previously during a licensure revisit on 8/11/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #40 had a history of falls and sustained a fall on 12/10/22 and a fall on 2/20/23 that resulted in a skin tear. Furthermore, the resident's care plan was updated on 1/27/23, however, it did not detail all individualized approaches necessary to address fall risk. Findings include:1. Residence PolicyThe residence's undated Fall Management and Injury Response policy read in part: "Each resident's care plan will be detailed with the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or effects of medication as identified during the comprehensive assessment."2. Former Resident #40 was admitted to the residence on 8/13/22 with diagnoses including muscle atrophy. A progress note, dated 12/10/22, read the resident fell to his knees while transferring. A care plan, dated 1/27/23, read the former resident had one to two falls within the last 90 days. However, the care plan did not address the individualized approach necessary to address fall related deficits. A progress note, dated 2/3/23, read the former resident returned from a skilled rehabilitation facility. An incident report, dated 2/20/23, read the former resident sustained a fall that resulted in a skin tear to his right hand. A progress note, dated 2/20/23, read the former resident sustained a fall that resulted in a skin tear. On 3/2/23 at 2:14 p.m., Staff #47 stated she did not know that Former Resident #39 was a fall risk and was unaware of interventions in place to prevent falls. On 3/2/23 at 2:55 p.m., the health and wellness director stated he was responsible for updating resident care plans. He stated that Former Resident #40 had a fall around November or December 2022. He added the former resident's care plan should have been updated with the individualized approaches necessary to address fall risk; however, he had just started his position as health and wellness director at the time. The health and wellness director confirmed the former resident sustained a skin tear when he fell on 2/20/23. On 3/2/23 at 3:35 p.m., the administrator stated she was not sure whether or not Former Resident #40 was a fall risk. She stated when a resident fell, their care plan should always be updated with the individualized approaches necessary to address fall risk. She stated the health and wellness director was responsible for updating resident care plans and there should have been an intervention in the care plan for Former Resident #40. On 3/2/23 at 4:21 p.m., a family member of Former Resident #40 stated the resident had fallen at the residence before and was at risk for falls. She stated she was unaware of interventions in place to prevent falls for the former resident.

Based on observation, record review and interview the residence failed to follow their lift assistance policy affecting one former resident (#40). (Cross-reference B0246, Q1180, Q1312). This deficiency was cited previously during a licensure revisit on 8/11/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #40 experienced a fall and shortness of breath (SOB) on 2/20/23. Staff moved the resident to his bed in a lying position, despite the former resident experiencing SOB and reporting so several times to staff. Subsequently, the resident stopped breathing minutes later and passed away. Findings include:1. Residence PolicyThe residence's undated Fall Management and Injury Response policy read in part, when a resident fell and had breathing problems, the resident should not be moved and staff were required to call emergency services. 2. Former Resident #40 was admitted to the residence on 8/13/22. A progress note, dated 2/20/23, read Former Resident #40 was found on the floor and was unable to describe what happened due to SOB. Staff assisted the resident into bed. An investigation, dated 2/20/23, revealed Former Resident #40 was found on the floor after a fall and reported SOB. Staff moved the former resident to his bed in a lying position. Staff #15 reported she moved the resident after a fall while he complained of SOB and she moved him to a lying position, which was not ideal for someone experiencing SOB. On 3/2/23 at 3:47 p.m., Staff #15 stated Former Resident #40 was found on the floor after a fall on 2/20/23. She stated the former resident reported he could not breathe and she and Staff #24 moved the former resident to a lying position on his bed. She stated the former resident stated he could not breathe multiple times and he should have been allowed to remain in a seated position, not lying down. On 3/2/23 at 4:20 p.m., Staff #24 stated he found Former Resident #40 on the floor after a fall on 2/20/23. He stated the former resident reported he could not breathe and he and Staff #15 moved the former resident to a lying position on his bed. He stated the residence's policy was not followed and emergency services were not contacted. Staff #24 added staff should not have moved Former Resident #40 and emergency services should have been notified. On 3/2/23 at 2:55 p.m., the health and wellness director stated when Former Resident #40 fell and reported SOB on 2/20/23, staff should not have moved the former resident and should have called emergency services. On 3/2/23 at 3:35 p.m., the administrator stated when Former Resident #40 fell and reported SOB on 2/20/23, staff should not have moved the former resident and should have called emergency services. She added she was not sure why this had not been corrected.

Based on interview and record review, the resident failed to ensure a resident had the right to be free from neglect, affecting one former resident (#40). (Cross-reference B0246, Q1192). This deficiency was cited previously during a licensure revisit on 8/11/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #40 experienced a fall and shortness of breath (SOB) on 2/20/23 and reported SOB to residence staff multiple times. Residence staff failed to contact emergency services for the former resident. Subsequently, Former Resident #40 stopped breathing and passed away on 2/20/23. Findings include:1. Reference and Residence policya. The residence's undated Fall Management and Injury Response policy read in part, when a resident fell and had breathing problems, the resident should not be moved and staff were required to call emergency services. b. The residence's undated Abuse Prohibition and Prevention policy read in part: "Neglect is the failure of the facility (residence), its employees or service providers provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress." The policy additionally read, in part, that not attending to a resident's medical needs was neglect.c. Chapter VII regulations governing assisted living residences, part 2.10, defines "Caretaker neglect" as neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person. 2. Former Resident #40 was admitted to the residence on 8/13/22. A progress note, dated 2/20/23, read that Former Resident #40 was found on the floor and was unable to describe what happened due to SOB. Staff assisted the resident into bed. The progress note did not read that emergency services were contacted. An investigation, dated 2/20/23, revealed that Former Resident #40 was found on the floor after a fall and reported SOB. Staff moved the former resident to his bed in a lying position. The investigation read that Staff #15 reported she moved the resident while he complained of SOB into a lying position, which was not ideal for someone experiencing SOB. The investigation read that Staff #15 reported she had not contacted emergency services because she was not aware she was required to do so. On 3/2/23 at 3:47 p.m., Staff #15 stated Former Resident #40 was found on the floor and the former resident reported SOB on 2/20/23. She stated the former resident reported he could not breathe multiple times and passed away approximately 10 minutes after being found. She stated she had not contacted emergency services. She added that it was neglectful that emergency services were not notified. On 3/2/23 at 4:20 p.m., Staff #24 stated he found Former Resident #40 on the floor on 2/20/23. He stated the former resident reported he could not breathe multiple times. He stated the residence's policy was not followed and emergency services were not contacted. Staff #24 added that emergency services should have been notified and the failure to notify emergency services could be considered neglect. On 3/2/23 at 2:55 p.m., the health and wellness director stated that when Former Resident #40 reported SOB on 2/20/23, staff should not have moved the former resident and should have called emergency services. On 3/2/23 at 3:35 p.m., the administrator stated that when Former Resident #40 fell and reported SOB on 2/20/23, staff should not have moved the former residentand should have called emergency services. She stated the failure to contact emergency services resulted in neglect. She added she was not sure why this was not corrected.

Based on record review and interview, the residence failed to ensure the residents received the cooperation of the residence to achieve the maximum degree of benefit from staff when residents summoned staff for assistance, affecting two of eight residents (#21, #38) in assisted living, who utilized their emergency call system to summon staff assistance. (Cross-reference B0246). This deficiency was cited previously during a licensure complaint survey on 8/11/22. 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 Policies a. The residence's undated Residence Handbook, read in part: "To assist you in summoning assistance for personal care needs or in the case of an emergency, there are pull cords located in each apartment. Pulling the cord activates an audible call to the caregiver staff members who will respond promptly to the call ..."b. An undated Resident Agreement provided by the administrator read "Residents have the right to expect the cooperation of the community in achieving the maximum degree of benefit from the services which are made available by the community."c. The residence's undated Emergency Care policy, read, in part, "Residents will receive appropriate emergency care and will have an emergency call system in their dwelling ... Prompt response to an activated call system will be provided 24 hours a day."d. The residence's undated 24 Hour Emergency Response policy, read, in part, "Pulling the cord will activate a light and buzzer where the annunciator is located. This will summon a designated staff person. Pushing the button will activate an alarm at the monitoring station and help will be summoned. Emergency pages will be answered as quickly as possible ... This emergency system is to be used for any emergency need, maintenance, health care or personal care need ... Staff is on duty 24 hours a day."2. The emergency call system response times in February and March 2023 for Resident #38 revealed she waited more than 10 minutes for staff assistance, as follows:2/1/23 20 minutes2/1/23 57 minutes2/1/23 48 minutes2/2/23 22 minutes2/2/23 15 minutes2/3/23 110 minutes2/3/23 21 minutes2/4/23 21 minutes2/7/23 15 minutes2/7/23 16 minutes2/8/23 17 minutes2/9/23 16 minutes2/9/23 19 minutes2/12/23 14 minutes2/12/23 114 minutes2/12/23 227 minutes2/13/23 13 minutes2/14/23 36 minutes2/16/23 16 minutes2/16/23 13 minutes2/18/23 11 minutes2/18/23 12 minutes2/18/23 60 minutes2/19/23 19 minutes2/21/23 13 minutes2/22/23 14 minutes2/22/23 33 minutes2/22/23 18 minutes2/23/23 13 minutes2/24/23 16 minutes2/24/23 14 minutes2/25/23 16 minutes2/26/23 61 minutes2/28/23 54 minutes2/28/23 11:52p to 3/1/23 110 minutes total. A handwritten document, written by a family member of Resident #38, dated 3/1/23 read, in part, "12:05 (a.m.) (resident) buzzed- need to go to the bathroom. 12:35 (a.m.), 1:00 (a.m.) 1:15 (a.m.) 1:30 (a.m.) 1:40 (a.m.) pushed button again. Went out to the hall to find help. Two people (staff) were sitting on the couch. I told them that we had been calling for one and a half hours. They took the pendant to exchange it. They came back and said that it worked but the person had their phone off."On 3/2/23 at approximately 4:00 p.m., another family member of Resident #38 stated his family member spent the night at the residence a day prior to the onsite visit and stated Resident #38 pressed her emergency call button to use the bathroom and staff did not arrive until one and one half hours later. He added the resident only pushed her call pendant in the evenings when she needed to use the restroom and when she needed to be escorted to and from the dining room for meals. On 3/2/23 at approximately 4:00 p.m., Resident #38 stated she pushed her call pendant to be taken to and from meals. She added, when she paged later in the evening it was because she needed to use the restroom. 3. The emergency call system response times in February and March 2023 for Resident #21 revealed she waited more than 10 minutes for staff assistance, as follows:2/16/23 12 minutes2/16/23 170 minutes2/16/23 13 minutes2/17/23 202 minutes2/17/23 25 minutes2/17/23 16 minutes2/18/23 24 minutes2/18/23 26 minutes2/18/23 31 minutes2/19/23 23 minutes2/19/23 17 minutes2/19/23 33 minutes2/19/23 28 minutes2/20/23 26 minutes2/21/23 13 minutes2/22/23 33 minutes2/22/23 17 minutes2/23/23 13 minutes2/23/23 33 minutes2/25/23 27 minutes2/26/23 26 minutes2/27/23 20 minutes3/1/23 87 minutesOn 3/2/23 at 3:30 p.m., Resident #21 stated when she paged for assistance with medicaitons she waited at least 30 minutes for staff. 4. InterviewsOn 3/2/23 at 8:15 a.m., the assistant wellness director stated staff were expected to answer call pendants within 10 minutes. However, residents were required to wait up to 30 minutes due to the residence being short of staff. On 3/2/23 at 3:55 p.m.,the administrator stated staff were expected to respond to call lights within 10 minutes and acknowledged some wait times were longer than expected due to staff training or pendant resetting issues. She stated anything over 10 minutes would be unacceptable. On 3/2/23 at 4:34 p.m., the RN consultant stated resident call pendants were still a concern with the residence. She stated they had measures in place; however, they were not following those measures. She stated the response times over 10 minutes were not consistently being investigated by management as outlined in their plan

Based on observation, record review and interview, the residence failed to comply with the authorized practitioner orders associated with medication administration, affecting three of five sample residents (#21, #36, #38). (Cross-reference B0246). This deficiency was cited previously during a licensure complaint survey on 8/11/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. 1. References and Residence Policya. "Hydrocodone is used to relieve severe pain. Hydrocodone is only used to treat people who are expected to need medication to relieve severe pain around-the-clock for a long time and who cannot be treated with other medications or treatments. Hydrocodone extended-release (long-acting) capsules or extended-release tablets should not be used to treat pain that can be controlled by medication that is taken as needed. Hydrocodone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain ... Hydrocodone comes as an extended-release (long-acting) capsule and an extended-release (long-acting) tablet to take by mouth. The extended-release capsule is usually taken once every 12 hours. The extended-release tablet is usually taken once daily. Take hydrocodone at around the same time(s) every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take hydrocodone exactly as directed by your doctor ... Do not stop taking hydrocodone without talking to your doctor. If you suddenly stop taking hydrocodone, you may experience withdrawal symptoms such as restlessness, teary eyes, runny nose, yawning, sweating, chills, hair standing on end, muscle pain, widened pupils (black circles in the middle of the eyes), irritability, anxiety, back or joint pain, weakness, stomach cramps, difficulty falling asleep or staying asleep, nausea, loss of appetite, vomiting, diarrhea, fast breathing, or fast heartbeat." MedlinePlus (2021) Hydrocodone, retrieved from: https://medlineplus.gov/druginfo/meds/a614045.html b. "Take pantoprazole exactly as prescribed by your doctor. Follow all directions on your prescription label and read all medication guides or instruction sheets. Use the medicine exactly as directed. Use the lowest dose for the shortest amount of time needed to treat your condition. Pantoprazole is taken by mouth (oral) or given as an infusion into a vein (injection). A healthcare provider may teach you how to properly use the injection by yourself. Pantoprazole tablets are taken by mouth, with or without food. The oral granules should be taken 30 minutes before a meal." Drugs.com (2023) Pantoprazole, retrieved from: https://www.drugs.com/pantoprazole.html c. The undated residence's Medication and Medication Administration policy, read in part, "All medication orders will be documented in writing by an authorized prescribing practitioner. Verbal orders for medication will not be valid unless received by a licensed team member who is authorized to receive and transcribe such orders. For orders that are incomplete or unclear: team members will contact the resident's authorized practitioner for clarification. All over the counter medications prescribed will be labeled with the resident's full name."d. The undated residence's Assistance with Medication policy, read, in part, "Assistance with medications can include any or all of the following: Giving medication directly to resident at the time the medication is to be taken. Community standard is medication given within one hour of passing time. State regulation allows for medications to be given between one hour before and up to one hour after the listed passing time."2. Resident #38 was admitted to the residence on 10/1/21 with diagnoses including stage three breast cancer and osteoporosis.a. PantoprazoleA written practitioner's order, dated 2/7/23, directed the residence to administer pantoprazole 40 mg once daily 30 minutes before a meal. However, according to the February and March 2023 Medication Passing Detail report, provided by the assistant wellness director, pantoprazole 40 mg was administered to Resident #38 at breakfast and more than an hour over the residence's one hour before and after medication administration window, as follows:2/5/23 at 9:35 a.m. 2/7/23 at 9:29 a.m. 2/8/23 at 9:38 a.m. 2/10/23 at 9:01 a.m. 2/15/23 at 9:03 a.m. 2/19/23 at 9:28 a.m. 2/24/23 at 9:15 a.m. 2/28/23 at 9:01 a.m. 3/2/23 at 8:19 a.m. A handwritten document, written by a family member of Resident #38, dated 2/16/23, read, in part, "8:00 a.m. they brought five pills at breakfast. I am guessing these were the meds (medications); tylenol, aleve, magnesium, pantoprazole, dulcolax?"On 3/2/23 at approximately 7:45 a.m., multiple residents entered the dining room for breakfast. On 3/2/23 at approximately 8:00 a.m. multiple residents were seated and being served breakfast. On 3/2/23 at approximately 8:00 a.m., Staff #29 acknowledged she had not administered the morning medications to Resident #38 the day of the onsite visit. She added, she administered Resident #38's medications while she ate breakfast a day prior to the onsite visit on 3/1/23. On 3/2/23 at approximately 8:15 a.m., Resident #38 was seated eating breakfast. On 3/2/23 at 3:25 p.m., the wellness director (WD) stated he was not aware staff administered Resident #38's pantoprazole while she ate breakfast. He added staff were required to follow the practitioner's orders for pantoprazole. The WD said residents were served breakfast at 8:00 a.m. and Resident #38 was "probably eating at that time."On 3/2/23 at approximately 4:00 p.m., Resident #38 stated in the last few weeks staff administered her morning medications while she was eating. On 3/2/23 at approximately 4:30 p.m., the administrator stated the qualified medication administration person (QMAP) should not have administered the pantoprazole to Resident #38 while she ate. b. Acetaminophen (Tylenol)A written practitioner's order, dated 2/6/23, directed the residence to administer acetaminophen 650 mg three times daily at 7:00 a.m., 1:00 p.m. and 7:00 p.m. However, the February 2023 Medication Passing Detail document, provided by the assistant wellness director, read that the medication was not administered until at least an hour after the required times, as follows:2/10/23 at 8:09 p.m. 2/11/23 at 9:10 a.m. 2/12/23 at 3:23 p.m. 2/13/23 2:27 p.m. 2/16/23 at 10:10 a.m. 2/18/23 9:35 a.m. 2/22/23 at 8:04 a.m. 2/26/23 at 2:10 p.m. 2/28/23 at 9:01 a.m. 3/2/23 at 8:23 a.m. On 3/2/23 at 10:30 a.m., a family member of Resident #38 stated two weeks prior to the onsite visit the QMAPs administered Resident #38's medications late and he said Resident #38 was in pain as a result. On 3/2/23 at 3:12 p.m., the WD stated approximately two weeks prior to the onsite visit a family member of Resident #38 was upset that the Tylenol for Resident #38 ws late and she expressed pain as a result. He added, the residence's policy was that they had a window to administer medications an hour before and an hour after and considered anything after that administered late. On 3/2/23 at approximately 4:30 p.m., the administrator stated she was aware that in February 2023 the acetaminophen for Resident #38 was administered later than required. 3. Resident #21 was admitted to the residence on 9/10/20 with diagnoses including hypothyroidism, muscle weakness and muscle wasting.a. Hydrocodone-AcetaminophenA written practitioner's order, dated 2/3/23, directed the residence to administer hydrocodone-acetaminophen 7.5-325 mg three times daily. However, the February 2023 eMAR for Resident #21 read the medication was not available and not administered on 2/20-2/22 morning, midday and evening doses and 2/23/23 morning and midday doses, for a total of 11 missed doses. A progress note in Resident #21's record, dated2/23/23 at 8:15 a.m., read, in part, "Called (practitioner) 2/20/23 for refill on (Medication), order placed again with (Practitioner) on the 21st. Called again today requesting (sic) new Rx (prescription) be sent to (sic) pharmacy to refill medication. Since this is a Narc (Narcotic) do need new Rx (prescription) every time medication is ordered."On 3/2/23 at 3:30 p.m., Resident #21 stated she was out of her hydrocodone for a period of time in February 2023. She added her pain was in her lower back and when she was administered the medication, her pain was manageable at a level of three and four out of 10. She added when did not receive the medication in February 2023 her pain level was eight out of 10. On 3/2/23 at 4:08 p.m., the administrator stated the pain medication for Resident #21 was out of stock and not administered around 2/23/23. b. LevothyroxineA written practitioner's order, dated 2/11/23, directed the residence to administer levothyroxine 100 mcg once daily. However, the February eMAR read the medication was not on the eMAR and administered until 2/13/23.c. FluticasoneA written practitioner's order, dated 2/11/23, directed the residence to discontinue fluticasone 50 mcg once daily. However, the medication was still administered from 2/12-2/15/23, for a total of four doses administered when the medication was discontinued. 4. InterviewOn 3/2/23 at 3:55 p.m., the administrator stated she expected staff to administer medications to residents according to the practitioner's orders. She added that the wellness department managed the qualified medication administration persons. The administrator stated medications were ordered when 10 pills remained. She added if the back of the eMAR read medication not available or pharmacy not delivered, it meant the medication was not administered to the resident and required follow-up.

A licensure revisit was completed on 3/2/23 for the previous deficiency cited on 8/11/22. The residence is in compliance with all regulations surveyed.