MEADOWVIEW OF GREELEY

An administrative relicensure survey was completed on 4/21/26. No deficiencies were cited.

A licensure complaint survey prompted by #CO40265 and #CO40624 was completed on 4/1/26. Two deficiencies were cited.

Based on observation and interview, the residence failed to provide social care and resident engagement activities as scheduled, affecting 14 of 14 residents in the secure environment. 1. ObservationAn observation of the residence's secure environment was conducted on 3/31/26 from 7:45 a.m. until 11:05 a.m. During this time, the only activity conducted was a movie. Observation revealed a calendar that was hung up on the wall across from the dining room. The calendar reflected activities scheduled for the secure environment during the month of March 2026. The calendar noted the following morning activities, specific to 3/31/26: 9:00 a.m. Daily News, 9:30 a.m. Fit and Fabulous, 10:30 a.m. Tuesday Trivia and Tea, and 11:00 a.m. Guess That TasteAt 9:05 a.m., the residential care coordinator (RCC) in the commons asking residents if they would like to engage in watching a movie after breakfast. There was no activity of "Daily News" conducted as the activity calendar reflected. At 9:15 a.m., the RCC put a movie on for the residents to watch in the commons area. At 9:45 a.m., a movie activity was conducted in the commons area. There was no activity of "Fit and Fabolous" conducted as the activity calendar reflected. At 10:30 a.m., a movie activity was conducted in the commons area. There was no activity of "Tuesday Trivia and Tea" as the activity calendar reflected. At 11:00 a.m., an activity was not conducted..2. InterviewAn interview with Resident #8 was conducted on 3/31/26 at 12:45 p.m. Resident #8 said movies were a common activity for residents. She said she wanted additional activities to participate in as she was not an individual who enjoyed movies. An interview with Resident #2 was conducted on 3/31/26 at 12:55 p.m. Resident #2 said she preferred to stay in her room because the activities were not something she enjoyed. She said she would go out to the commons area before meal services when there were activities sometimes but it was only to greet her friends. Resident #2 said there were only so many country western movies she could watch in a lifetime. An interview conducted with the RCC, the health and wellness director (HWD) and the regional director (RD) on 4/1/26 at approximately 11:00 a.m. revealed the residence had been without an activities director for about three months. The RCC acknowledged the residence did not provide activities as scheduled on the activity calendar in the secured environment. The RCC said the secured environment had an activities assistant (AA) but since there was no activity director, the AA split her time between the secured environment and the non-secure portion of the residence. Additionally the RCC stated, the AA was not at the residence on 3/31/26 which made it that much more challenging. She said staff were able to provide activities however it was difficult to engage residents and provide the needed care, specifically in the secured environment.

Based on record review and interview, the residence failed to follow the residence policy and procedure for the identification, reporting, and investigation of injuries of unknown origin, affecting two out of two (#1, #3) residents with injuries. Findings include:1. Record ReviewA review of residence documentation revealed a policy titled, "Resident Abuse, Neglect and Exploitation" revised on 8/20/22. The policy read, specific in part, "Injuries of Unknown Origin - The assisted living residence shall identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either: The resident cannot explain how the injury occurred or the resident can explain the source of the injury, but the source could be addressed to prevent future injuries." 2. Resident #1Resident #1 was admitted to the residence's secure environment on 1/12/25 with a diagnosis of dementia. A review of Resident #1's record revealed a document titled "Third Party Coordination Form" dated 2/18/26. The form read, pertinent in part, "bruising to neck right shoulder." The note further read, "possible dislocation, unsure." The form was signed by the visiting hospice nurse on 2/18/26. Further review revealed a document titled progress note dated 2/19/26. The note read, pertinent in part, "Resident has right clavicle fracture. The resident could not recall how fracture happened. No noted falls or staff observation. Dark purple to red bruising observed." The progress note was signed by the health and wellness director (HWD) on 2/19/26. Further review failed to reveal documentation the residence completed an investigation for Resident #1's injury of unknown origin. 3. Resident #3Resident #3 was admitted to the residence secure environment on 4/10/25 with diagnoses of Alzheimer's disease. A review of Resident #3s record revealed a progress note, dated 1/31/26. The note read, pertinent in part, "Resident had a fall on 1/31/26 resulting in swelling and bruising on the resident's calf and ankle." The note further read, "Resident did not remember what happened." The note was signed by the HWD on 1/31/26. Further review revealed a progress note dated 2/2/26, that read, pertinent in part, "The resident received an order for an X-ray from her primary care physician (PCP) on 2/2/26." The progress note was signed by the HWD on 2/2/26. Additional review revealed a PCP note dated 2/2/26 that read xray results showed that Resident #3 had sustained a hairline fracture on her ankle. Further review failed to reveal documentation the residence completed an investigation for Resident #3's injury of unknown origin. 4. InterviewAn interview with Resident #3's family member on 3/31/26 at 12:10 p.m. revealed that during a visit with the resident on 2/2/26 she noticed swelling in the resident's calf and the bruise on the ankle. She said she asked the residence's staff to take a look at the injuries to rule out a fracture. She said there was no order for an x-ray before she requested a follow up. She further stated the x-ray showed that Resident #3 had a hairline fracture in her foot, and she was not sure how the injury occurred. An interview conducted on 4/1/26 at approximately 10:30 a.m., with the regional director (RD) and the health and wellness director (HWD) revealed the residence did not complete an investigation for Resident #1's injury of unknown origin resulting in a clavicle fracture or for Resident #3's injury of unknown origin resulting in a hairline fracture. The HWD said she found out about Resident #1's injury after speaking with the hospice nurse on 2/18/26, however she only wrote a progress note about the injury and did not investigate. She also stated Resident #3 had an injury of unknown origin that she documented as an unwitnessed fall on 1/31/26, however, she did not investigate this injury of unknown origin further and thought the progress note was enough. The HWD acknowledged the residence should have completed an investigation of unknown injury for Resident #1 and Resident #3 for the aforementioned injuries. The HWD said she thought the progress notes were sufficient enough. She also said the residence was going through personnel change and all staff were picking up additional responsibilities and as a result, the investigations were overlooked. During the same interview, the RD said the residence did not follow their policy to complete an investigation for unknown injuries. The RD said additional training would be provided to the HWD to ensure investigations for future unknown injuries were conducted as the residence policy reads.

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 7.13.1 D The right to choice and personal involvement regarding care and services, including: (1) The right to be informed and participate in decision making regarding care and services, in coordination with family members who may have different opinions; (2) The right to be informed about and formulate advance directives; (3) The right to freedom of choice in selecting a health care service or provider; (4) The right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services which are made available by the assisted living residence; (a) For residents with limited English proficiency or impairments that inhibit communication, the assisted living residence shall find a way to facilitate communication of care needs. (5) The right to make decisions and choices in the management of personal affairs, funds, and property in accordance with resident ability; (6) The right to refuse to perform tasks requested by the assisted living residence or staff in exchange for room, board, other goods or services; (7)The right to have advocates, including members of community organizations whose purposes include rendering assistance to the residents; (8) The right to receive services in accordance with the resident agreement and the care plan; 18.8 The assisted living residence shall have a means of securing resident records that preserves their confidentiality and provides protection from loss, damage, and unauthorized access. The confidentiality of the resident record including all medical, psychological, and sociological information shall be protected in accordance with all applicable federal and state laws and regulations. Each resident or legal representative of a resident shall be allowed to inspect that resident ' s own record in accordance with Section 25-1-801, C.R.S. Upon request, resident records shall also be made available for inspection by the state long-term care ombudsman and local ombudsman pursuant to Section 26-11.5-108, C.R.S., Department representatives and other lawfully authorized individuals. Resident records shall contain, but not be limited to, the following items: (A) Face Sheet; (B) Practitioner order; (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident ' s condition changes from baseline status.

A relicensure survey with complaint #CO36853 was completed on 2/24/25. No deficiencies were cited.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: (B) Detailing in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment;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. (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. 18.8 Resident records shall contain, but not be limited to, the following items: (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs;(1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following:(A) A description of the resident's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact;(B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR's plan to protect the resident from unwanted visitation by other residents;(C) Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and(D) Documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents.

A revisit survey was completed on 8/1/24 for all previous deficiencies cited on 5/1/24. The facility is in compliance with all deficiencies that were cited.

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

A licensure complaint, prompted by #CO33757, #CO35420 and #CO35723, was completed on 5/1/24. Deficiencies were cited.

Based on interview and record review the residence failed to ensure residents were provided with, and acknowledged receipt of, information regarding whether or not the assisted living residence had smoking prohibitions and a designated area for smoking, affecting one of one sample residents who smoked (#3). Findings include:An undated smoking policy posting read smoking was allowed outside the residence in designated smoking areas. The resident record for Resident #3 included no signed acknowledgement on whether smoking was prohibited nor where the designated smoking area was. On 4/30/24 at 11:14 a.m., the regional operations director (ROD) pointed out the designated smoking area for residents to be at a bench that was over 100 feet from the building. On 4/30/24 at 12:55 p.m., the administrator provided a resident roster that identified Resident #3 as a smoker. On 5/1/24 at 1:21 p.m., Resident #3 stated she smoked either in front of the residence in the parking lot or in the designated smoking area behind the residence that was over 100 feet from the building. She stated both were the designated smoking areas. On 5/1/24 at approximately 3:30 p.m., the ROD stated the designated area where residents could smoke included the bench located over 100 feet from the building. The ROD stated she was aware of the requirement for residents who smoke to sign a disclosure on the residence's smoking prohibitions and the location designated for smoking. The ROD stated she looked in Resident #3's electronic health record system and could not find a signed disclosure and stated she was unsure why.

Based on interview and record review, the residence failed to complete a comprehensive assessment whenever the resident had a change from baseline status, affecting two of five sample residents (#2 and #3) who experienced a change from baseline status. Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(B) Information regarding the resident's overall health and physical functioning ability;(J) History and circumstances of recent falls and any known approaches to prevent future falls 2. Resident #3 was admitted to the residence on 4/30/21. The residence's most recent care plan which was also the residence's assessment for Resident #3, dated 7/27/23, read the resident was independent with mobility and required no assistive devices. The assessment did not mention Resident #3 was a fall risk or include any safety approaches. An internal incident report, dated 3/12/24, read Resident #3 sustained a fall with an injury to her skull. Resident #3 was transported to the emergency department. A hospital discharge summary dated 3/12/24, read Resident #3 had low oxygen levels, low blood pressure and altered mental status following a fall. On 4/30/24 at 1:21 p.m., Resident #3 stated on 3/12/24 she was trying to sit down and missed her chair which had fallen over. She stated she hit her head when she fell. Resident #3 stated she had not fallen previously. On 5/1/24 at approximately 3:30 p.m., the regional operations director (ROD) stated she considered a fall, when a resident had not previously fallen, to be a change in baseline status. The ROD stated she would also consider Resident #3's hospitalization, altered mental status, low oxygen levels and low blood pressure changes in her baseline status. The ROD stated the former health and wellness nurse (HWN) worked at the residence on 3/12/24 and should have updated Resident #3's comprehensive assessment. The ROD stated that she and the regional nurse were currently responsible for updating comprehensive assessments. 3. There was similar deficient practice for Resident #2.

Based on observation, interview and record review, the residence failed to ensure each resident care plan identified all external service providers and detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting two of five sample residents (#3 and #5). Findings include:1. Residence PolicyThe residence's Resident Agreement dated 7/22/20, read in part, pre-screening procedures provided updated information regarding a resident's preferences and need for services. 2. Resident #5 was admitted to the residence on 12/22/17 with a diagnosis of dementia. A care plan, dated 11/13/23, read in part, the resident and their family member were responsible for coordination of care with third party services. However, the care plan did not include that the resident required external hospice services. There were no additional care plans provided for Resident #5. A progress note, dated 3/28/24, read Resident #5 was admitted to external hospice services. On 3/1/24 at 12:25 p.m., the external hospice provider for Resident #5 stated the resident was admitted to hospice services on 3/28/24 who provided assistance with showers twice weekly and medication management. The external hospice provider further stated they provided the resident with a new wheelchair and walker. On 3/1/24 at approximately 3:30 p.m., the regional operations director stated she was aware of the requirement to detail external service providers, resident preferences, and service needs in the care plan. She stated that since the former health and wellness nurse (HWN) resigned in the middle of March 2024, the residence had not updated care plans as required. 3. There was similar deficient practice for Resident #3.

Based on observation, interview and record review, the residence failed to implement a fall management program detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance and providing staff training related to fall prevention, affecting three of four sample residents who sustained falls (#2, #3 and #5). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.10, defines "care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual's need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual's needs. In order to deliver person-centered care, the care plan shall take into account the resident's preferences and desired outcomes. b. The residence's Fall Management Policy dated 7/1/12, read in part that "the (administrator) is responsible (for evaluating) each incident of fall(s) and ... update the plan of care as appropriate to reduce future risk of falls." 2. Resident #3 was admitted to the residence on 4/30/21. a. ObservationOn 4/30/24 at 1:21 p.m., Resident #3 was observed with a walker and a cane. b. Record ReviewsA care plan for Resident #3, dated 7/27/23, read in part that the resident was independent with mobility and required no assistive devices. The care plan did not mention Resident #3 was a fall risk. An internal incident report, dated 3/12/24, read Resident #3 sustained a fall with injury to her skull. Resident #3 was transported to the hospital. A hospital discharge summary dated 3/12/24, read Resident #3 had low oxygen levels, low blood pressure and altered mental status following a fall. There were no other care plans in Resident #3's record detailing the individualized approaches necessary to address fall risk, after Resident #3's fall on 3/12/24. Further, the care plan did not address the resident's use of a walker and cane for mobility assistance.c. InterviewsOn 4/30/24 at 1:21 p.m., Resident #3 stated on 3/12/24 she was trying to sit down and missed her chair which had fallen over. Resident #3 stated she hit her head and was in pain. Resident #3 stated she had not fallen previously. On 5/1/24 at 1:06 p.m., Staff #1 stated Resident #3 used a walker for longer distances when she left her room and a cane for short distances (such as within her room). Staff #1 stated the walker and cane had been in place for at least eight months. Staff #1 stated she was unsure what fall interventions were and then stated that the residence did not implement individualized fall intervention protocols. She stated that fall management was the same for all residents: "call emergency medical services for a fall and clear (their) room of clutter."On 5/1/24 at approximately 3:30 p.m., the regional operations director (ROD) stated the former health and wellness nurse (HWN) was responsible for updating care plans; however, she resigned the third week of March 2024. The ROD stated she herself and the regional nurse had been updating care plans while trying to fill the open position. The ROD stated the former HWN should have updated Resident #3's care plan to include her use of ambulatory devices for mobility and individualized interventions following the resident's fall on 3/12/24.3. There was similar deficient practice for Residents #2 and #5.

Based on record review and interview, the residence failed to direct staff to assist residents who have fallen or are otherwise unable to get up off the floor independently, affecting 36 current residents. Findings include: 1. Record ReviewOn 4/30/24 at 10:00 a.m., the residence's lift assistance policy and procedure was requested; however, it was not provided. 2. InterviewsOn 4/30/24 at 11:53 a.m., the regional operations director (ROD) stated that the residence did not have a lift assist policy. The ROD stated the residence did not have a staff nurse to perform an assessment on residents unable to get up off the floor, so staff were instructed to notify emergency medical services (EMS). On 4/30/24 at 1:54 p.m., Staff #3 stated that staff did not lift residents at all. Staff #3 stated when a resident fell, regardless of whether they were injured, staff notified the qualified administration person (QMAP) and the QMAP examined the resident and contacted EMS.On 4/30/24 at 1:55 p.m., Staff #4 stated she was not allowed to lift residents and was trained to contact EMS to provide lift assistance whenever a resident fell. On 5/1/24 at 1:06 p.m., Staff #1 stated she was required, as the QMAP, to telephone EMS to lift a resident after they fell since the administrator directed her not to lift residents. Staff #1 stated the administrator informed her they could not lift residents because staff were not able to conduct an assessment on residents once they had fallen, and only a nurse was able to do that. On 5/1/24 at 3:18 p.m., Staff #5 stated if a resident was injured from a fall, staff immediately telephoned EMS. Staff #5 stated if a resident was not injured in a fall, staff was trained to call for a non-emergency lift, performed by firefighters or paramedics. On 5/1/24 at approximately 3:30 p.m., the ROD stated they did not have a lift assist assist policy because the residence did not perform "fireman full body lift assistance." The ROD stated if a resident's feet were still on the floor when they fell, staff needed to lift the resident off the ground; however, if feet were not on the ground staff did not lift the resident. Contrary to the ROD's previous statement, the ROD then acknowledged staff were trained to lift a resident whose feet were not on the ground as long as their mental status had not changed.

Based on interview and record review, the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting two of three sample residents whose medications were reviewed (#1 and #3). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 14.17, requires the assisted living residence shall ensure that each authorized practitioner's order for medication includes ... the signature of the practitioner.b. The residence's medication administration policy, dated 4/30/19, read in part: "(medications) shall be administered to each resident in accordance with a written practitioner's order."2. Resident #1 was admitted to the residence on 8/30/23 with a diagnosis of Alzheimer's Disease. Vitamin CThe March and April 2024 electronic medication administration records (eMARs) read the residence administered vitamin C 500 mg to Resident #1 daily on 3/1-3/25, 3/27-4/20 and 4/22-4/30/24, for a total of 59 doses. However, the residence was unable to provide a signed practitioner's order for the medication to correspond with the above administrations. 3. InterviewOn 5/1/24 at approximately 3:30 p.m., the regional operations director (ROD) stated she was aware of the requirement to have signed practitioner's orders prior to administering medication and would have expected that to have occurred. The ROD stated that the external hospice provider for Resident #1's did not provide the order. 4. There was similar deficient practice for Resident #3.

Based on observation, interview and record review the residence failed to comply with authorized practitioner's orders affecting three of three sample residents whose medications were reviewed (#1-#3). Findings include:1. Residence PolicyThe residence's medication administration policy dated 4/30/19, read in part: "(medications) shall be administered to each resident in accordance with a written practitioner's order."2. Resident #1 was admitted to the residence on 8/30/23 with a diagnosis of Alzheimer's Disease. a. SpironolactoneA written practitioner's order dated 4/11/24, directed the residence to discontinue spironolactone 25 mg twice daily. However, the April 2024 electronic medication administration record (eMAR) read the residence administered the medication twice daily from 4/12-4/29 and the morning of 4/30/24. On 5/1/24 at 11:10 a.m., Resident #1's practitioner stated Resident #1's spironolactone 25 mg twice daily was discontinued on 4/11/24. The practitioner stated the residence should not have administered the medication. On 5/1/24 at 3:18 p.m., a medication cart audit was conducted and revealed the residence had Resident #1's spironolactone mg in stock. On 5/1/24 at 3:18 p.m., Staff #5 stated staff continued to administer Resident #1 spironolactone because it was still active on the eMAR. Staff #5 stated she was unaware that the practitioner discontinued the medication on 4/11/24.b. Diclofenac 1%A written practitioner's order, dated 12/26/23, directed the residence to administer diclofenac 1% four times daily bilaterally to the shoulders. However, the March 2024 eMAR read the residence failed to administer two doses on 3/5/24 and two doses on 3/8/24, for a total of four missed doses.c. MiconazorbA written practitioner's order, dated 10/11/23, directed the residence to administer Miconazorb 2% twice daily between toes. However, the March 2024 eMAR read the residence failed to administer the medication on 3/5/24 in the morning for one missed dose.d. LidodermA written practitioner's order, dated 11/12/23, directed the residence to administer lidoderm 10% daily. However, the March 2024 eMAR read the residence failed to administer the medication on 3/5/24 for one missed dose. 3. InterviewsOn 5/1/24 at 7:51 a.m., Staff #1 stated that, unless staff documented in the exception notes on the eMAR that a resident refused a medication or was not present at the residence, the medication was not administered as it was either out of stock or not yet delivered from the pharmacy. On 5/1/24 at approximately 3:30 p.m., the regional operations director (ROD) stated she was aware of the requirement to comply with practitioner's orders and she expected that staff did so. The ROD stated the former health and wellness nurse was responsible for removing discontinued medications from the eMAR; however, she resigned in the middle of March 2024 and no one had taken her place. The ROD stated that qualified medication administration persons (QMAPs) and nurses were responsible for ordering medications from the pharmacy that were not on cycle fills. 4. There was similar deficient practice for Residents #2 and #3.

Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event was completed, affecting three of three sample residents whose medications were reviewed (#1-#3). Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated 4/30/19, read in part: "the person responsible for administering medications shall record the medication on the resident's individual drug record."2. Resident #1 was admitted to the residence on 8/30/23 with a diagnosis of Alzheimer's Disease. a. IbuprofenA written practitioner's order, dated 1/3/24, directed the residence to administer ibuprofen 400 mg three times daily. However the March and April 2024 electronic medication administration records (eMARs) contained blank spaces for the morning of 3/26, the afternoons of 3/8 and 3/26, and the evenings of 3/13, 3/19, 3/26 and 4/1/24, for a total of seven inaccurately documented doses. b. Diclofenac sodiumA written practitioner's order, dated 12/26/23, directed the residence to administer diclofenac sodium 1% four times daily to the shoulders. However, the March and April 2024 eMARs contained blank spaces for the morning of 3/26, the afternoons of 3/8 and 3/26, and the nighttime doses on 3/13, 3/19, 3/26, and 4/1/24, for a total of seven inaccurately documented doses.c. SpironolactoneA written practitioner's order, dated 12/6/23, directed the residence to administer spironolactone 25 mg twice daily. However, the March and April 2024 eMARs contained blank spaces for the morning on 3/26 and the evenings of 3/13, 3/19, 3/26 and 4/1/24, for a total of five inaccurately documented doses.d. AcetaminophenA written practitioner's order, dated 12/6/23, directed the residence to administer acetaminophen 500 mg two tablets twice daily. However, the March and April 2024 eMARs contained blank spaces in the morning on 3/26, and in the evening on 3/13, 3/19, 3/26 and 4/1/24, for a total of five inaccurately documented doses.e. TamsulosinA written practitioner's order, dated 12/6/23, directed the residence to administer tamsulosin 0.4 mg daily. However, the March and April 2024 eMARs contained blank spaces on 3/13, 3/19, 3/26 and 4/1/24, for a total of four inaccurately documented doses.f. MiconazorbA written practitioner's order, dated 10/11/23, directed the residence to administer Miconazorb 2% twice daily. However, the March and April 2024 eMARs contained blank spaces for the morning of 3/26, and in the evening of 4/1/24, for a total of two inaccurately documented doses.g. Zinc oxideA written practitioner's order, dated 1/2/24, directed the residence to administer zinc oxide 20% twice daily. However, the March and April 2024 eMARs contained blank spaces for the morning of 3/26, and in the evening of 4/1/24, for a total of two inaccurately documented doses.h. MemantineA written practitioner's order, dated 9/25/23, directed the residence to administer memantine 28 mg daily. However, the March 2024 eMAR contained a blank space on 3/26/24, for one inaccurately documented dose.i. Potassium ChlorideA written practitioner's order, dated 9/25/23, directed the residence to administer potassium chloride 10 MEQ daily. However, the March 2024 eMAR contained a blank space on 3/26/24, for one inaccurately documented dose.j. LidodermA written practitioner's order, dated 11/12/23, directed the residence to administer lidoderm 10% daily. However, the March 2024 eMAR contained a blank space on 3/26/24, for one inaccurately documented dose. 3. InterviewOn 5/1/24 at approximately 3:30 p.m., the regional operations director (ROD) stated blank spaces in the eMAR meant that staff did not click "pass med" in the electronic health information system, so there was no way to know whether staff administered medication. The ROD stated she expected staff to click "pass med" to document that they administered the medication at the time of administration. 4. There was similar deficient practice for Residents #2 and #3.

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 7.25.26 A secure environment shall meet the following criteria: (F) There shall be a secure outdoor area that is available for resident use year-round that: (4) Has one or more areas that provide protection from weather elements.

A revisit survey was completed on 1/18/24 for all previous deficiencies cited on 8/29/23. No deficiencies were cited.

A revisit survey was completed on 1/18/24 for all previous deficiencies cited on 8/29/23. No deficiencies were cited.

A licensure complaint, prompted by #CO32523 and #CO33458, was completed on 8/29/23. A deficiency was cited.

Based on observation, interviews and record review, the residence failed to ensure the residents had the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services which are made available by the assisted living residence, affecting three of eight sample residents (#8-#10) who resided on the second floor of the residence. Findings include: 1. Residence PoliciesThe residence's Resident Rights Policy, dated 7/1/12, read in part, "The company and its employees strive to protect and promote the rights of each resident as afforded to them by citizenry and regulation."The residence's posted and undated Resident Rights policy read in part, "The right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services which are made available by the assisted living residence." 2. ObservationsOn 8/29/23 at 7:30 a.m., the residence had two elevators. One of the elevators, located on the east side of the residence, provided elevator service to residents who resided on the second floor to the main level. The east elevator was out of order. The residence's only dining room and resident engagement area for activities were located on the main level. There was no information in the residence's second floor, to include the adjacent east elevator area, on the elevator doors, the stairway door or in the hallways, that the east elevator was out of order. On 8/29/23 at 7:30 a.m., an unidentified resident was observed ambulating down the second floor stairs and stated out loud, "I am so tired of taking these stairs, when will they fix it already." On 8/29/23 at 7:35 a.m., the second floor contained a separate area utilized for the residence's church services and activities. There was a temporary folding table with a tablecloth located in the middle of the area. 3. Resident #10 was admitted to the residence on 1/8/19. The resident resided on the second floor. A care plan for Resident #10, dated 8/2/23, revealed that she required an assistive device with ambulation. Resident #10 utilized a front wheeled walker. On 8/29/23 at 7:37 a.m., Resident #10 stated the second floor east elevator had been out of order for over two weeks and the staff had not provided a definitive timeframe of when the elevator would be repaired. Additionally, Resident #10 stated she had required staff assistance to ambulate the second floor stairs. Resident #8 stated, "I had to go down and up those stairs because I had an appointment (outside of the residence). I don't want to go down or up those stairs again. I was exhausted." 4. Resident #9 was admitted to the residence on 2/10/22 with diagnosis including cerebrovascular accident (CVA). The resident resided on the second floor. A care plan for Resident #9, dated 6/13/23, read she required one person assistance for all transfers to and from her chair related to a history of CVA and paralysis. Resident #9 utilized an electric scooter. On 8/29/23 at approximately 7:45 a.m., Resident #9 stated the east elevator had not been working since 8/16/23 and staff had told her the elevator parts were delivered and the repairs were under contract. Additionally, Resident #9 stated, "Typically I go downstairs (via the east elevator) to the (only) dining room for my meals. It's been a pain. I had to cancel a dentist appointment. My tooth is better but I haven't rescheduled. I don't have any idea about activities. I'm not a joiner."5. Resident #8 was admitted to the residence on 2/26/18 with diagnosis including stroke. The resident resided on the second floor. A care plan, dated 7/6/23, for Resident #8 revealed that she required max assistance with one person for all transfers in and out of her wheelchair related to a history of stroke and right-sided weakness. Resident #8 utilized an electric scooter and wheelchair as a primary mode of transportation. On 8/29/23 at 8:12 a.m., Resident #8 stated she did not know how long the East elevator had been not working. She stated the staff had not communicated when the elevator was expected to be repaired and had not received any updated information from staff. She further stated, "I'm stuck up here." 6. InterviewsOn 8/29/23 at approximately 7:00 a.m., Staff #5 stated the residence's second floor East elevator had been down for two weeks and that the second floor residents were unable to come down. She was unaware when the elevator would be fixed. On 8/29/23 at 3:13 p.m., the administrator confirmed the East elevator had not been working since 8/16/23. She stated the last communication with the residents on the status of the East elevator was the day prior to the onsite visit and was held in the residence's only dining room located on the first floor. She acknowledged she was not aware of Resident #8-#10's voiced concerns related to the elevator or for the lack of staff communication.

A licensure revisit was completed on 8/29/23 for all previous deficiencies cited on 3/28/23. A deficiency was cited.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of five sample residents (#3). This deficiency was cited previously during a state licensure complaint survey 3/28/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's Medication Administration Policy, dated 4/30/19, read in part: Medications shall be administered to each resident in accordance with a practitioner's written order. Resident #3 was admitted to the residence on 10/24/14. A written practitioner's order, dated 2/24/23, directed the residence to administer Nystatin 100,000 IU twice daily. However, the July 2023 electronic medication administration record (eMAR) for Resident #3 had circled staff initials and read no exception/nurse notified on 7/1, 7/2, 7/3 morning dose, 7/4 morning dose, 7/5, 7/6 morning dose, 7/7, 7/8 morning dose, 7/9, 7/10 morning dose, 7/18, 7/20 morning dose, and 7/24/23 morning dose, for a total of 19 missed doses. On 8/29/23 at 11:52 a.m., the administrator from a sister residence and the administrator stated when the eMAR read "no exception/nurse notified" that it meant there was an issue with the medication. Both stated that the qualified medication administration person (QMAP) was to notify the nurse whenever there was an issue with the medications not in stock or unavailable. They further stated that the nurse notified should follow up on the issue and document in the progress notes. They confirmed circled staff initials on the MAR meant the medication was not administered. On 8/29/23 at 4:14 p.m., the administrator stated she would expect that medications were in stock and administered as ordered. She said the reason the deficiency was recited was due to the documentation being insufficient. On 8/29/23 at 4:14 p.m., the regional healthcare specialist confirmed the medications were not administered for Resident #3.

A licensure revisit was completed on 5/15/23 for all previous deficiencies cited on 11/29/22. The residence is in compliance with all regulations surveyed.