BONAVENTURE OF THORNTON LLC

A complaint revisit was completed on 11/24/25, for the previous deficiency cited on 3/12/25. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25.

Based on the interview and observation, the residence failed to follow the practitioner's orders, affecting two of 11 sample residents (#29 and #38). This deficiency was cited previously during a state licensure survey on 3/12/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Record Review Resident #38 was admitted to the residence on 4/28/22 with a diagnosis of deep vein thrombosis. TylenolA written practitioner's order, dated 9/17/25, directed the residence to administer two 500 mg tablets by mouth every eight hours. The October 2025 Medication Administration Record (MAR) read the medication was not administered on 10/25/25 at 2:00 p.m. and 8:00 p.m., because it was not available. 2. InterviewsOn 11/24/25 at approximately 4:30 p.m., the administrator stated that she expected that the residence would have the medication available to be administered. She acknowledged that the medication for Resident #38 was not administered because it was not available. The administrator further stated she was unaware why the deficiency had not been corrected. 3. Evidence obtained during the on-site visit revealed that the residence additionally failed to comply with practitioner orders for Resident #29.

A complaint revisit was completed on 11/24/25, for all previous deficiences cited on 4/16/25. Deficiences were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25.

Based on record review and interview, the residence failed to report suspected physical abuse to law enforcement within 24 hours of discovery pursuant to Colorado Revised Statutes (C.R.S.), affecting two of eleven sample residents (#39 and #41). This deficiency was cited previously during a state licensure survey on 4/16/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. References and Policiesa. Chapter VII regulations governing assisted living residences: Part 2.8, defines an "At-risk person" means any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (F) Is mentally impaired.b. Chapter VII regulations governing assisted living residences, part 2.1, defines "Abuse" means subjection to sexual conduct or contact that is classified as a crime.c. The Residences policy on abuse dated, 2/15/21 read in part, any staff member who has reason to suspect an incident of sexual or physical assault has occurred will report to the local law enforcement emergency services number as soon as the resident is protected from further harm. 2. Record Reviewa. Resident #41 was admitted to the residence on 2/14/25 with Alzheimer's Disease. b. A progress note dated, 10/14/25, read in part: During lunch Resident #41 slapped Resident #39 across the face. When asked why by staff, Resident #41 stated Resident #39 touched her breadstick. Resident #39 had no visible marks. The families of the two residents were notified. c. A resident occurrence report, dated 10/14/25, read in part: "An unnamed staff member overheard arguing and looked and saw a resident slapping another resident during lunch." No visible marks were found on Resident #39. The families were notified. However, the box for notifying law enforcement was checked "no."3. InterviewOn 11/24/25 at 3:45 p.m., the administrator acknowledged that the residence did not report the abuse to law enforcement. She acknowledged the deficiency had not been corrected, since she was not aware she needed to report to law enforcement since Resident #39 was not injured.

Based on record review and interview, the residence failed to ensure that the enhanced care plan included a description of how the resident will have continuous independent access to his or her individual room, along with the residence's plan to protect the resident from unwanted visitation by other residents; 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; Documentation describing the resident's behavioral expressions along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact, affecting two of five sample residents who lived in a secure environment (#41 and #42). This deficiency was cited previously during a state licensure survey on 4/16/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. On 11/24/25 at approximately 8:30 a.m., Staff #37 stated Resident #41 and #42 had a tendency to exit-seek, and sometimes escaped the secure environment, into the assisted living section. Staff #37 also stated Resident #41 often wandered throughout the secure environment, including into other resident rooms. She also added that some residents like to keep their doors locked due to Resident #41 and #42's behavior. She stated that all residents in the secure environment had their toiletries locked up. A progress note, dated 9/19/25, read in part: Resident #41 was found in another resident's room with her pants and underwear down, attempting to urinate on the bed. A progress note, dated 11/2/25, read in part: Resident #41 had been aggressive towards staff and trying to escape the secure environment, along with trying to hit staff and throwing things around. On 11/24/25 at approximately 9:30 a.m., a care plan, dated 8/19/25, contained no information regarding Resident #41's wandering patterns, other than she often wandered. It also contained no information with exit-seeking, entering other residents' rooms, or having her toiletries locked up. On 11/24/25 at approximately 3:20 p.m., Resident #41 was observed entering another resident's room. She was observed looking at things in the bathroom before she wandered to the bedroom, where the other resident was sleeping. She then sat in the chair next to the other resident. On 11/24/25 at approximately 3:45 p.m., the administrator stated she was aware of some residents' doors being locked due to the family's request. She stated she was aware of Resident #41's exit-seeking behavior. The administrator also acknowledged the need for an enhanced care plan for residents, which included behavioral expressions along with staff approaches, access to hygiene, and wandering patterns, along with how residents had access to their rooms without unwanted visitation. She acknowledged she is unaware why the deficiency hadn't been corrected. There was similar deficient practice for Resident #42.

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

A relicensure survey and complaint revisit was completed on 11/24/25, for all previous deficiences cited on 3/12/25. Deficiences were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25.

Based on record review and interview, the residence failed to report suspected physical abuse to law enforcement within 24 hours of discovery pursuant to Colorado Revised Statutes (C.R.S.), affecting two of eleven sample residents (#39 and #41). This deficiency was cited previously during a state licensure survey on 4/16/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. References and Policiesa. Chapter VII regulations governing assisted living residences: Part 2.8, defines an "At-risk person" means any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (F) Is mentally impaired.b. Chapter VII regulations governing assisted living residences, part 2.1, defines "Abuse" means subjection to sexual conduct or contact that is classified as a crime.c. The Residences policy on abuse dated, 2/15/21 read in part, any staff member who has reason to suspect an incident of sexual or physical assault has occurred will report to the local law enforcement emergency services number as soon as the resident is protected from further harm. 2. Record Reviewa. Resident #41 was admitted to the residence on 2/14/25 with Alzheimer's Disease. b. A progress note dated, 10/14/25, read in part: During lunch Resident #41 slapped Resident #39 across the face. When asked why by staff, Resident #41 stated Resident #39 touched her breadstick. Resident #39 had no visible marks. The families of the two residents were notified. c. A resident occurrence report, dated 10/14/25, read in part: "An unnamed staff member overheard arguing and looked and saw a resident slapping another resident during lunch." No visible marks were found on Resident #39. The families were notified. However, the box for notifying law enforcement was checked "no."3. InterviewOn 11/24/25 at 3:45 p.m., the administrator acknowledged that the residence did not report the abuse to law enforcement. She acknowledged the deficiency had not been corrected, since she was not aware she needed to report to law enforcement since Resident #39 was not injured.

Based on the interview and observation, the residence failed to follow the practitioner's orders, affecting two of 11 sample residents (#29 and #38). This deficiency was cited previously during a state licensure survey on 3/12/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Record Review Resident #38 was admitted to the residence on 4/28/22 with a diagnosis of deep vein thrombosis. TylenolA written practitioner's order, dated 9/17/25, directed the residence to administer two 500 mg tablets by mouth every eight hours. The October 2025 Medication Administration Record (MAR) read the medication was not administered on 10/25/25 at 2:00 p.m. and 8:00 p.m., because it was not available. 2. InterviewsOn 11/24/25 at approximately 4:30 p.m., the administrator stated that she expected that the residence would have the medication available to be administered. She acknowledged that the medication for Resident #38 was not administered because it was not available. The administrator further stated she was unaware why the deficiency had not been corrected. 3. Evidence obtained during the on-site visit revealed that the residence additionally failed to comply with practitioner orders for Resident #29.

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 88 current residents. This deficiency was cited previously during a complaint investigation on 3/12/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 11/24/25 at 1:45 p.m., the last three quarterly medication audits were provided. However, the medication cart audits revealed no evidence that the investigations and resolutions of irregularities were marked on the audit. On 11/24/25 at 2:25 p.m., the administrator was aware that this deficiency was previously cited. She further stated she had though the deficiency had been corrected; however, she was unaware that the investigation and resolution of medication irregularities needed to be documented on the medication audits.

Based on record review and interview, the residence failed to ensure that the enhanced care plan included a description of how the resident will have continuous independent access to his or her individual room, along with the residence's plan to protect the resident from unwanted visitation by other residents; 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; Documentation describing the resident's behavioral expressions along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact, affecting two of five sample residents who lived in a secure environment (#41 and #42). This deficiency was cited previously during a state licensure survey on 4/16/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. On 11/24/25 at approximately 8:30 a.m., Staff #37 stated Resident #41 and #42 had a tendency to exit-seek, and sometimes escaped the secure environment, into the assisted living section. Staff #37 also stated Resident #41 often wandered throughout the secure environment, including into other resident rooms. She also added that some residents like to keep their doors locked due to Resident #41 and #42's behavior. She stated that all residents in the secure environment had their toiletries locked up. A progress note, dated 9/19/25, read in part: Resident #41 was found in another resident's room with her pants and underwear down, attempting to urinate on the bed. A progress note, dated 11/2/25, read in part: Resident #41 had been aggressive towards staff and trying to escape the secure environment, along with trying to hit staff and throwing things around. On 11/24/25 at approximately 9:30 a.m., a care plan, dated 8/19/25, contained no information regarding Resident #41's wandering patterns, other than she often wandered. It also contained no information with exit-seeking, entering other residents' rooms, or having her toiletries locked up. On 11/24/25 at approximately 3:20 p.m., Resident #41 was observed entering another resident's room. She was observed looking at things in the bathroom before she wandered to the bedroom, where the other resident was sleeping. She then sat in the chair next to the other resident. On 11/24/25 at approximately 3:45 p.m., the administrator stated she was aware of some residents' doors being locked due to the family's request. She stated she was aware of Resident #41's exit-seeking behavior. The administrator also acknowledged the need for an enhanced care plan for residents, which included behavioral expressions along with staff approaches, access to hygiene, and wandering patterns, along with how residents had access to their rooms without unwanted visitation. There was similar deficient practice for Resident #42.

A licensure revisit was completed on 11/24/25, for the previous deficiency cited on 3/12/25. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25.

Based on the interview and observation, the residence failed to follow the practitioner's orders, affecting two of 11 sample residents (#29 and #38). This deficiency was cited previously during a state licensure survey on 3/12/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Record Review Resident #38 was admitted to the residence on 4/28/22 with a diagnosis of deep vein thrombosis. TylenolA written practitioner's order, dated 9/17/25, directed the residence to administer two 500 mg tablets by mouth every eight hours. The October 2025 Medication Administration Record (MAR) read the medication was not administered on 10/25/25 at 2:00 p.m. and 8:00 p.m., because it was not available. 2. InterviewsOn 11/24/25 at approximately 4:30 p.m., the administrator stated that she expected that the residence would have the medication available to be administered. She acknowledged that the medication for Resident #38 was not administered because it was not available. The administrator further stated she was unaware why the deficiency had not been corrected. 3. Evidence obtained during the on-site visit revealed that the residence additionally failed to comply with practitioner orders for Resident #29.

A revisit survey was completed on 11/24/25 for all previous deficiencies cited on 8/1/23. The facility is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO39577, #CO39796, was completed on 4/16/25. Deficiencies were cited.

Based on record review and interview, the residence failed to report suspected physical abuse to law enforcement (LE) within 24 hours of discovery pursuant to Colorado Revised Statutes (C.R.S.), affecting 25 current residents in the secure environment (SE). (Cross-reference S1410)Findings include:1. References and PoliciesChapter VII regulations governing assisted living residences:Part 2.8, defines an "At-risk person" means any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (F) Is mentally impaired. C.R.S. Section 18-6.5-108, read in part, staff of any care facility who had a reasonable cause to believe that an at-risk elder or an at-risk adult had been mistreated or was at imminent risk of mistreatment was required to report such fact to a LE agency not more than twenty-four hours after making the observation or discovery. A person who willfully violates subsection (1)(a) of this section commits a class 2 misdemeanor. A residence training document, "You Are a Mandated Reporter," dated 2/16/10, read in part that each residence staff was required to immediately report abuse or reasonable cause to believe there was abuse of a resident to LE. The document provided contact information to the entities that the residence required staff to report to; however, none of the entities included LE within the state where the residence was located. The residence was required not to retaliate against any mandated reporter. If residence staff failed to report to LE, then the staff member was not fulfilling their obligation as a mandated reporter under the law. The residence's Occurrence Reporting policy, dated 7/1/23, read in part that the residence was required to notify LE within 24 hours of the residence becoming aware of the incident. Upon completion of the investigation, if the findings were not conclusive, the administrator was required to notify the required agencies for applicable events as per state regulations. All staff members are mandatory reporters and have specific reporting responsibilities as requiredby law. 2. Resident #35 was admitted to the residence on 1/21/25, with a date of birth of 2/13/39, and with a diagnosis of dementia. An investigation of abuse, dated 3/17/25-3/22/25, read that the administrator initiated an investigation of a suspected physical abuse allegation of Resident #35 by Staff #26 to the administrator; however, the investigation failed to include whether the residence contacted LE.3. InterviewsOn 4/15/25, during the onsite visit, Confidential Staff #1-#6 and Former Staff #32-#34 stated that the residence required them to contact their supervisor or another manager at the residence to report all allegations of abuse, and the supervisor notified LE. Confidential Staff #1 and #4 stated that they knew they were mandated reporters, but the residence instructed them to report to a residence manager instead of LE when there was an allegation of abuse of a resident. Confidential Staff #2, #3, #5, and #6 stated that reporting the allegation to a member of the residence's management team satisfied their mandated reporting requirement obligation. Former Staff #33, #34, and Confidential Staff #3 stated that they reported physical abuse allegations regarding Resident #35 and Former Residents #36 and #37 to either the current administrator or former administrator; however, they did not report the allegations to LE directly. They added that, to their knowledge, the residence did not contact LE regarding the abuse allegations. On 4/15/25 at approximately 9:47 a.m., the administrator stated that all residence staff were mandated reporters of abuse of a resident, and she was unaware of the reason that staff members did not report abuse allegations directly to LE. She added that she did not report allegations of suspected abuse when the residence was unable to substantiate them. She added that LE was resistant to taking those reports from the residence. The administrator stated she did not report the specific allegation of suspected abuse of Resident #35 by Staff #26 to LE. On 4/15/25 at approximately 3:30 p.m., the memory care director (MCD) stated that all residence staff were mandated reporters regarding abuse of a resident; however, they had demonstrated that they did not know they were required to report allegations of abuse to LE directly. On 4/16/25 at approximately 10:00 a.m., the health and wellness director (HWD) stated she could not remember the circumstances that the residence was required to report to LE except when a resident sustained an injury. She added that the staff were directed to make reports of suspected abuse to a manager or a manager on-call. She added the staff did not always understand that they were mandated reporters and were required to report to LE instead of reporting to a manager.

Based on interview and record review, the residence failed to thoroughly investigate allegations of abuse in accordance with the residence's written policy, affecting one sample resident (#35) and two former residents (#36, #37). (Cross-reference S0410, S3060) 1. Residence PolicyThe residence's Occurrence Reporting policy, dated 7/1/23, read in part that the residence was required to investigate allegations of suspected abuse. The residence investigated in conjunction with the witness. Administrators reviewed all incident-related documentation and directed the related investigation to determine why the incident occurred and what steps the residence should take to minimize reoccurrence. The investigation process may have included the need to gather witness statements. The residence kept these statements as part of the investigation documentation. The investigation included a description of the occurrence, the resident statement, and immediate action taken. If the investigation was an allegation of abuse, the residence was required to notify the agencies identified in regulatory requirements. The residence notified the resident's practitioner and responsible party during the shift that the residence became aware of the allegation. 2. Record ReviewAll Investigations of abuse for the previous 90 days, and investigations for Former Residents #37 since and including December 2024 were requested. The residence provided two investigations of abuse allegations, one for Resident #35 and one for Former Resident #37. Resident #35 was admitted to the residence on 1/21/25, with a date of birth of 2/13/39, and with a diagnosis of dementia. Documentation of an investigation of physical abuse, dated 3/17/25-3/22/25, read in pertinent part: the residence initiated an investigation of an allegation of suspected abuse or "rough treatment" by Staff #26 toward Resident #35 as reported by Former Staff #33. The administrator contacted all overnight staff to ask if they had any concerns about the mistreatment of residents, and all denied any concerns but reported awareness of Former Staff #33 concerns about Staff #26; however, the residence did not document staff members' names and specific statements with the exception of the alleged assailant, Staff #26, and Former Staff #32. Staff #26 denied the allegations. Former Staff #32 stated she had no concerns and thought the issue was an interpersonal issue between Former Staff #33 and Staff #26. The investigation failed to include:How the residence kept the residents safe while the residence conducted the investigation. A description of any documentation reviewed. The residence's complete documentation of conversations with residents, residents' reactions, and responses to the incident. The residence's complete documentation of staff interviews including names and details such as their definition of rough treatment. Documentation of the interventions that were put in place to ensure there was not a repeated incident. Documentation that the residence contacted all required agencies, such as Adult Protective Services (APS). 3. InterviewsOn 4/15/25, during the onsite visit, Confidential Staff #3 and Former Staff #33-#34 stated that they reported concerns regarding Staff #26 providing rough, possibly physically abusive treatment to Resident #35; however, Former Staff #34 and Confidential Staff #3 added that the residence did not interview them. Confidential Staff #5, #6, and Former Staff #32 stated that they had never witnessed Staff #26 being abusive or rough to residents physically; however, they believed she required some re-training to understand a resident's right to refuse and how to re-approach the residents instead of persistently trying to change them when they did not want to be changed. On 4/15/25 at 7:44 a.m., Resident #35 stated that the staff sometimes got him out of bed when he did not want to get up or moved him around when he did not want to be moved. He added that no one had hurt him but were "bossy."On 4/15/25 at 9:46 a.m., and in a later interview on 4/16/24 at approximately 2:10 p.m., the administrator stated that the requirement for an investigation of abuse was in the residence's policy. She added she could not state verbatim what the residence's investigation of abuse policy contained, but all allegations of abuse required an investigation. She stated that she began an abuse investigation when Former Staff #33 reported suspected abuse/rough treatment of Resident #35 by Staff #26. She stated that she did not know the residence was required to report to APS as a part of the investigation; however, APS contacted the residence within seven days of the investigation, and she shared details of the incident; however, she affirmed the residence did not report the incident to them. The administrator stated the interviews she conducted with staff were not "spelled out" in the investigation, with the exception of Staff #26 and Former Staff #32. She affirmed the residence did not include resident interviews or reactions in the investigation. She added that the residence protected Resident #35 by investigating the allegation prior to Staff #26's return to work; however, she affirmed that the residence did not document the ways the residence protected the resident during the investigation. She stated there were no findings of the investigation, and the abuse was not substantiated. She added that the residence discovered the issues were interpersonal between Former Staff #33 and Staff #26. She stated that Former Staff #33 was attempting to get the residence to terminate Staff #26 due to these interpersonal issues. She affirmed that staff interpersonal issues did not preclude a valid abuse allegation. She affirmed that the investigation could have been more thorough. On 4/15/25 at 10:44 a.m., Staff #26 stated that she did not recall the residence interviewing her regarding Resident #35, for whom she had no concerns. She added he was at times combative during care, and she "pushed through" to get him changed when soiled in order to ensure she did not neglect him. She added the resident's legal representative directed her to change the resident "no matter what." She added that while residents have the right to refuse, she could not neglect them, so she changed Resident #35 when he was resistive; however, she stopped if he appeared to be in pain or called out in pain. She added that she knew abuse meant intentionally hurting someone, and she was not rough but persistent. 4. Additionally, the residence demonstrated similar deficient practice for Former Residents #36 and #37.

Based on record review and interview, the residence failed to ensure resident care plans contained documentation of residents' wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident, affecting two of two sample residents (#28, #35) and two former residents (#36-#37). (Cross-reference S1410)Findings include:1. Resident #35 was admitted to the residence on 1/21/25, with a date of birth of 2/13/39, and with a diagnosis of dementia. Progress notes, dated 3/4/25-4/14/25, read in part:On 3/4: The resident wandered out of the secure environment (SE) into the assisted living (AL) area of the residence and was redirected by staff. On 3/5, the resident was angry and was resistant to care. On 3/6 and 3/7, the resident was resistant to care. On 3/12, the resident refused care, directed staff to leave his room, and used "slurs" when addressing staff. On 3/13, the resident was in a "bad mood."On 3/15, staff attempted to assist the resident out of bed, but he refused. Staff attempted to assist the resident out of bed a second time, but the resident became agitated, struck the staff, and called staff names using "foul language."On 3/31, the resident refused care and directed staff to leave his room. On 4/1, the staff reported that the resident had agitation with the resident's external service provider (ESP). On 4/1, the resident was "still refusing to go to bed."On 4/2, the resident expressed aggression toward the ESP.On 4/14, the resident was resistant to care and refused to allow staff to assist him with dress assistance and incontinence care. A care plan, dated 1/9/25, read in part that the resident became easily angered and required intervention to prevent harm to others, was resistant to care, and had a behavioral expression of agitation. However, the care plan did not include individualized approaches to be implemented by staff to protect the resident and other residents with whom he had contact. Further, despite the resident's history of wandering out of the SE, the care plan read that he had no risk of elopement and failed to contain his wandering patterns, and staff approaches to address his wandering and keep him safe. 2. InterviewsOn 4/15/25, during the onsite visit, Confidential Staff #1, #2, and #4 stated that Resident #35 required time and a later approach when he was resistant to care and became physically agitated. They said the resident became agitated when staff assisted him with incontinence care, administering medications, checking vital signs, or assisting him with transfers. Confidential Staff #6 stated that it was essential to provide care with a second person to reduce agitation for Resident #35. Confidential Staff #5 and Staff #26 stated that to address behavioral expressions; the staff attempted to talk with him and perform tasks quickly. Staff #26 stated that she had to often "push through" to get him changed despite his behavioral expressions of verbal and physical aggression towards her. On 4/15/25 at approximately 3:30 p.m., the memory care director (MCD) stated she began working as the MCD approximately two months prior to the onsite visit and was responsible for updating resident care plans. She added she was working on updating them; however, she had no updates for Resident #35 or Former Residents #36 and #37. She added she was unable to state what elements were required in an enhanced care plan as she was still learning. On 4/16/25, at approximately 10:15 a.m., the health and wellness director (HWD) stated that she and the administrator were responsible for updating care plans in addition to the MCD. She added that the enhanced care plan had to have elopement risk in addition to the general care plan requirements for all residents. On 4/16/25 at approximately 2:30 p.m., the administrator stated that the MCD was responsible for updating residents' care plans. She added that behavioral expressions and wandering patterns were required in the enhanced care plans and the residence had updated many care plans with those expressions; however, she affirmed that the staff approaches to address behavioral expressions were often not included in care plans. 3. Additionally, the residence failed to document descriptions of behavioral expressions, along with individualized approaches to be implemented, as well as document wandering patterns for Resident #18 and Former Residents #36 and #37.

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 7.14.44 The assisted living residence shall have policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and/or expired medications which are not returned to the resident or legal representative. At a minimum, the policies and procedures shall include the following requirements:(A) Outdated, discontinued, and/or expired medications shall be destroyed in accordance with federal, state, and local regulations within thirty (30) days.(1) Medication shall be destroyed in the presence of two individuals, each of whom are either a qualified medication administration person, nurse, or practitioner;(2) All medications shall be destroyed in a manner that renders the substances totally non-retrievable to prevent diversion of the medication; and(3) There shall be documentation which identifies the medications, the date, and the method of destruction, and the signatures of the witnesses performing the medication destruction.(B) All destroyed medications shall be disposed of in compliance with Parts 24.2 and 24.3 regarding medical waste disposal.

A licensure revisit was completed on 3/12/25 for the previous deficiency cited on 8/1/23. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/24.

Based on record review and interview the residence failed to comply with authorized practitioner orders, affecting two of seven sample residents (#29, #30). This deficiency was cited previously during a complaint investigation 8/1/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Resident #29 was admitted to the residence on 10/1/24 with a diagnosis of dementia. a. AcetaminophenA written practitioner order, dated 2/10/25, directed the residence to administer acetaminophen 650 mg three times daily. The March 2025 medication administration record (MAR), indicated the residence failed to administer the medication on 3/1/25 and the morning of 3/2/35 due to the medication being out of stock. b. MetoprololA written practitioner order, dated 10/1/24, directed the residence to administer metoprolol 25 mg twice daily. The March 2025 MAR, indicated the residence failed to administer the evening dose on 3/1 and 3/3/25 and the morning and evening dose on 3/2/25 due to the medication being out of stock. On 3/11/25 at approximately 1:30 p.m., Staff #18 confirmed the medications were out of stock and the residence was waiting on them to be delivered. On 3/12/25 at approximately 12:30 p.m., the administrator stated that she expected all medications to be administered as directed by the practitioner's order. Similar deficient practice was found for Resident #30.

A relicensure survey with complaints #CO35459, #CO37315, #CO38765 and #CO39399 were completed on 3/12/25. Deficiencies were cited.

Based on record review and interview, the residence failed to identify the highest potential risk and hold routine drills to facilitate staff and resident response to that risk, affecting 82 current residents. Findings include:The residence's fire drill log book read the last fire drills were completed on 9/11, 8/27, 7/24, 6/28 and 5/27/24. On 3/11/25 at 8:20 a.m., the administrator identified the residence's highest potential risk were fires. On 3/11/25 at 10:38 a.m., Staff #20 and #21 acknowledged that the last fire drill held at the residence was "a while ago."On 3/12/25 at 8:51 a.m., Staff #23 said since she started working in July 2024 she had not been involved in any fire drills. On 3/12/25 at approximately 12:30 p.m., the administrator acknowledged the residence was not conducting routine fire drills, as required.

Based on observation, interview and record review, the residence failed to develop and implement a fall management program detailing in each resident care plan the individualized approach necessary to address fall risks related to deficits in strength and balance and provide staff with training related to fall prevention affecting one of five sample residents (#27). Specifically, Resident #27 fell four times from January 2025 to March 2025. Resident #27 fell on 1/13/25 and broke his ribs. On 1/18/25 Resident #27 fell and received stitches in his elbow. On 3/10/25, Resident #27 fell and had a bloody nose and redness on his face. The residence failed to update the care plan after the fall on 1/18/25. Additionally the only staff intervention put in place for Resident #27 was to remind the resident to use his walker. Findings include:1. Resident #27 was admitted to the residence on 5/18/24 with diagnoses including Parkinson's disease. Progress notes in Resident #27's record for January and March 2025 revealed the following:On 1/13/25 Resident #27 fell in the dining room and complained of pain in his back and ribs. On 1/13/25 an intervention was added by staff to remind Resident #27 to pull his chair out. On 1/14/25 Resident #27 was diagnosed with multiple rib fractures. On 1/18/25 Resident #27 fell in his bedroom, cut his elbow, went to the emergency department and received six stitches. On 1/28/25 Resident #27 fell on the ground in the common area. No pain or injury. On 3/10/25 Resident #27 was found on the floor with a bloody nose and redness all over his face. The care plan in Resident #27's record, dated 12/26/24 read Resident #27 required the use of a four wheeled walker when he was ambulating. The care plan did not detail the individualized approaches necessary to address fall risk related deficits in strength, balance and eyesight, or effects of medication. There were no other care plans in Resident #27's record. 2. InterviewsOn 3/11/25 at 8:31 a.m., Staff #20 said after Residents #27's multiple falls she was educated to remind him to use his walker. On 3/12/25 at 8:51 a.m., Staff #23 said the caregivers tracked meal attendance and attendance was not tracked consistently. She added she was not trained on what to do, other than document, if a resident did not attend a meal. On 3/11/25 at 3:16 p.m., Staff #22 said she was educated to ensure Resident #27 was using his walker to mitigate falls. On 3/12/25 at approximately 1:15 p.m., the administrator said she expected the care plan for Resident #27 to include fall interventions and for staff to be aware of what staff interventions were in place. She added she was not sure why the care plan was not updated nor why staff were not educated and trained on interventions, as required.

Based on record review and interview the residence failed to comply with authorized practitioner orders, affecting two of seven sample residents (#29, #30). Resident #29 was admitted to the residence on 10/1/24 with a diagnosis of dementia. a. AcetaminophenA written practitioner order, dated 2/10/25, directed the residence to administer acetaminophen 650 mg three times daily. The March 2025 medication administration record (MAR), indicated the residence failed to administer the medication on 3/1/25 and the morning of 3/2/35 due to the medication being out of stock. b. MetoprololA written practitioner order, dated 10/1/24, directed the residence to administer metoprolol 25 mg twice daily. The March 2025 MAR, indicated the residence failed to administer the evening dose on 3/1 and 3/3/25 and the morning and evening dose on 3/2/25 due to the medication being out of stock. On 3/11/25 at approximately 1:30 p.m., Staff #18 confirmed the medications were out of stock and the residence was waiting on them to be delivered. On 3/12/25 at approximately 12:30 p.m., the administrator stated that she expected all medications to be administered as directed by the practitioner's order. Similar deficient practice was found for Resident #30.

Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting six unknown residents out of 22 residents in the secure environment. Findings include:On 3/11/25 at approximately 8:30 a.m. to 9:00 a.m., Staff #18 walked over to the medication cart and unlocked it, touching the cart, the keys and the computer with her hands. Without sanitizing her hands or washing, Staff #18 touched each resident's medication cups, their medication packs and administered medication to six different unknown residents within the secured environment. It was also observed that Staff #18 was not sanitizing their hands at the time. On 3/12/25 at 2:00 p.m., the administrator stated she expected staff to wash or sanitize their hands between filling and administering medications for its residents.

Based on interview and records review, the administrator and qualified medication administration persons (QMAP) supervisor failed to routinely complete and document audits of the accuracy and completeness of medication administration records (MARs), controlled substance lists, and medication disposal records, affecting 82 current residents. Findings include:On 3/11/25 at approximately 8:18 a.m., documentation of medication audits was requested. The residence provided documentation as requested but it did not include an audit of the controlled substance lists, and medication disposal records. On 3/12/25 at approximately 1:30 p.m., an additional request was made to the residence to provide the missing documentation. On 3/11/25 at approximately 1:00 p.m., the administrator stated the residence had not completed audits of the controlled substance list and medication disposal records.

Based on interview and record review, the residence failed to observe food consumption on a regular basis in order to detect unplanned changes, affecting 82 current residents. Findings include:The administrator provided the residence's meal roster for the assisted living. The meal roster listed each resident's name and indicated breakfast, lunch and dinner. One form was used for each day. Meal rosters were reviewed for February and March 2025. The meal rosters for this time were incomplete and not consistently documented. On 3/12/25 at 8:51 a.m., Staff #23 said caregivers were responsible for tracking resident meal attendance. Staff #23 acknowledged that the meal attendance records are not filled out consistently, as required. She added she had no formal training from management on what to do if a resident did not attend a meal. On 3/12/25 at 11:13 a.m., Staff #24 said caregivers were responsible for filling out the resident meal attendance records and she would help as the qualified medication administration person if caregivers could not. She added sometimes the resident meal attendance records were not completely filled out, as required. On 3/12/25 at 11:18 p.m., Staff #14 said staff tracked resident meal attendance. She added it was hard for staff to completely fill out the meal attendance forms because they were busy doing other caregiving duties. Staff #14 said she was taught only to track resident meal attendance and was provided no other direction or training on what to do if a resident did not show up for a meal. On 3/12/25 at 1:15 p.m., the administrator stated the residence did not observe resident meal consumption but had a tracker for staff to fill out for each resident at each meal. She added the office manager (OM) was responsible for updating the meal attendance records. The administrator said she was not sure how often the OM checked the attendance records and expected staff to fill out the attendance record for each resident for each meal.

Based on observation and interview the residence failed to keep grounds maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction in the secure environment outdoor courtyard, affecting 22 residents in the secure environment. Findings include:During an environmental tour on 3/11 and 3/12/25 in the outdoor courtyard of the secure environment there was a three and a half inch drop along the paved sidewalk. On 3/12/25 at approximately 12:30 p.m., the administrator acknowledged the drop off on the walkway and agreed that it could be a potential hazard for the residents residing in the secure environment.

Based on record review and interview, the residence failed to re-assess residents every six months for the need of a secure environment, affecting two of three sample residents in the secure environment (#28, #30). Findings include:1. Resident #28 was admitted to the residence on 3/16/24 with a diagnosis of Alzheimer's. The record for Resident #28 contained an evaluation for the secure environment, dated 4/18/24. However, the record contained no further evidence that the residence re-assessed the resident every six months for the need of a secure environment. On 3/12/25 at approximately 12:30 p.m., the administrator said she did not know the residence was required to assess residents in the secure environment every six months to determine their continued need for a secure environment. 2. Similar deficient practice was found for Residents #30

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents:(D) Protective oversight including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach.

A licensure revisit was completed on 3/15/25 for the previous deficiency cited on 8/1/23. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/24.

Based on record review and interview the residence failed to comply with authorized practitioner orders, affecting two of seven sample residents (#29, #30). This deficiency was cited previously during a relicensure revisit 8/1/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Resident #29 was admitted to the residence on 10/1/24 with a diagnosis of dementia. a. AcetaminophenA written practitioner order, dated 2/10/25, directed the residence to administer acetaminophen 650 mg three times daily. The March 2025 medication administration record (MAR), indicated the residence failed to administer the medication on 3/1/25 and the morning of 3/2/35 due to the medication being out of stock. b. MetoprololA written practitioner order, dated 10/1/24, directed the residence to administer metoprolol 25 mg twice daily. The March 2025 MAR, indicated the residence failed to administer the evening dose on 3/1 and 3/3/25 and the morning and evening dose on 3/2/25 due to the medication being out of stock. On 3/11/25 at approximately 1:30 p.m., Staff #18 confirmed the medications were out of stock and the residence was waiting on them to be delivered. On 3/12/25 at approximately 12:30 p.m., the administrator stated that she expected all medications to be administered as directed by the practitioner's order. Similar deficient practice was found for Resident #30.

A licensure complaint revisit was completed on 3/12/25 for all previous deficiencies cited on 8/1/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/24.

Based on record review and interview the residence failed to comply with authorized practitioner orders, affecting two of seven sample residents (#29, #30). This deficiency was cited previously during a complaint investigation 8/1/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Resident #29 was admitted to the residence on 10/1/24 with a diagnosis of dementia. a. AcetaminophenA written practitioner order, dated 2/10/25, directed the residence to administer acetaminophen 650 mg three times daily. The March 2025 medication administration record (MAR), indicated the residence failed to administer the medication on 3/1/25 and the morning of 3/2/35 due to the medication being out of stock. b. MetoprololA written practitioner order, dated 10/1/24, directed the residence to administer metoprolol 25 mg twice daily. The March 2025 MAR, indicated the residence failed to administer the evening dose on 3/1 and 3/3/25 and the morning and evening dose on 3/2/25 due to the medication being out of stock. On 3/11/25 at approximately 1:30 p.m., Staff #18 confirmed the medications were out of stock and the residence was waiting on them to be delivered. On 3/12/25 at approximately 12:30 p.m., the administrator stated that she expected all medications to be administered as directed by the practitioner's order. Similar deficient practice was found for Resident #30.

A licensure revisit was completed on 8/1/23 for all previous deficiencies cited on 3/30/22. The residence is in compliance with all regulations surveyed.

A licensure revisit was completed on 8/1/23 for all previous deficiencies cited on 1/12/23. No deficiencies were cited given that on 8/1/23, the residence was operating under the terms of an intermediate condition imposed by the department.

The department was unable to determine if the residence demonstrated an understanding of regulatoruy requirements for fall management, as the residence was operating under the terms of an intermediate condition imposed by the department at the time of the 8/1/23 onsite revisit.

A licensure revisit was completed on 8/1/23 for all previous deficiencies cited on 3/31/23. A deficiency was cited.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting three of six sample residents (#3, #6, #23) and one former resident (#1). This deficiency was cited previously during a state licensure survey on 1/12/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with regulatory requirements. Findings include:1. Residence PolicyThe residence's Medication System Summary, dated 5/1/23, read in part that staff were timely to provide medication administration according to practitioner's orders. 2. Resident #23 was admitted to the residence on 11/28/23 with diagnoses including pain, depression, and skin irritation.a. SeroquelA written practitioner's order, dated 5/5/23, directed the residence to administer Seroquel 25 mg daily. However, the July 2023 medication administration record (MAR) revealed the residence failed to administer the medication on 7/12-7/17/23 because the medication was not in stock.b. AtorvastatinA written practitioner's order, dated 5/5/23, directed the residence to administer atorvastatin 20 mg daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/10/23 because the medication was not in stock.c. HydroseptineA written practitioner's order, dated 5/5/23, directed the residence to administer hydroseptine 0.44-20.6% twice daily . However, the July 2023 MAR revealed the residence failed to administer the medication on 7/16/23 and 7/17/23 because the medication was not in stock.d. Potassium ChlorideA written practitioner's order, dated 5/5/23, directed the residence to administer potassium chloride 10 mEq daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/16/23 and 7/17/23 because the medication was not in stock.e. DuloxetineA written practitioner's order, dated 5/5/23, directed the residence to administer Duloxetine 120 mg daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/16/23 and 7/17/23 because the medication was not in stock.f. AcetaminophenA written practitioner's order, dated 5/5/23, directed the residence to administer acetaminophen 650 mg twice daily. However, the July 2023 MAR revealed the residence failed to administer the medication for one dose on 7/12/23 because the medication was not in stock. 3. Resident #6 was admitted to the residence on 7/24/21.a. Tacrolimus A written practitioner's order, dated 12/17/21, directed the residence to administer tacrolimus 0.1% OINT apply to affected areas daily in small amounts. However, the July 2023 MAR revealed the residence failed to administer the medication from 7/2 to 7/6/23 because the medication was not in stock.b. OxycodoneA written practitioner's order, dated 7/25/21, directed the residence to administer oxycodone 5 mg one tablet at bedtime and two tablets every morning . However, the July 2023 MAR revealed the residence failed to administer the medication on 7/13/23 and 7/14/23 because the medication was not in stock.c. MiralaxA written practitioner's order, dated 7/16/2023 , directed the residence to administer Miralax 17 gm, three capfuls every Monday, Wednesday, and Friday. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/3, 7/5, 7/10, and 7/12/23 because medication was not in stock. 4. Resident #3 was admitted to the residence on 5/11/19 with diagnoses including glaucoma.a. LovastatinA written practitioner's order, dated 5/19/22, directed the residence to administer Lovastatin 10 mg every evening. However the July 2023 MAR revealed the residence failed to administer the medication on 7/1/23 because it was not in stock. b. LatanoprostA written practitioner's order, dated 3/16/23, directed the residence to administer latanoprost 0.005% one drop eacheye at bedtime. However, the July 2023 MAR revealed the residence failed to administer the medication from 7/6 to 7/12/23, because medication was not in stock. 5. Former Resident #1 was admitted to the residence on 1/1/20 with diagnoses including hypertension, depression, and hypocalcemia.a. DiltiazemA written practitioner's order, dated 4/21/23, directed the residence to administer diltiazam 180 mg daily. However, the April 2023 MAR revealed the residence failed to administer the medication until 4/26/23, five days after the date of the order because the medication was not in stock. Additionally, the May and June 2023 MARs revealed the residence failed to administer the medication on 5/30/23, 5/31/23, 6/2/23 because the medication was not in stock. On 7/25/23 at 1:32 p.m., a family member for Resident #1 stated the resident was discharged from the hospital on 4/21/23 with a prescription for diltiazem. She stated she received a telephone call from an unknown staff at the residence on 4/26/23, five days after the medication was ordered, that they had not administered the medication because the family member needed to pick the prescription from the hospital. b. AdvairA written practitioner's order, dated 12/21/22, directed the residence to administer Advair 115/21 mcg one puff twice daily. However, the April-June 2023 MARs revealed the residence failed to administer the medication for two doses on 4/29/23, 5/1/23 and 5/2/23 one dose on 4/30/23, 5/3/23, and 6/19/23 because the medication was not in stock.c. BuspironeA written practitioner's order, dated 4/21/21, directed the residence to administer buspirone 5 mg twice daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 because the medication was not in stock.d. CalciumA written practitioner's order, dated 12/21/22, directed the residence to administer calcium 325 mg/500 unit two tablets daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 6/2/23, 6/9-6/16/23, and 6/19/232 because the medication was not in stock.e. EscitalopramA written practitioner's order, dated 4/21/23, directed the residence to administer escitalopram 10 mg daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 and 6/18/23 because the medication was not in stock.f. LevothyroxineA written practitioner's order, dated 4/21/23, directed the residence to administer levothyroxine 75 mcg daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 and 6/25/23 because the medication was not in stock.g. Vitamin B-12A written practitioner's order, dated 12/21/22, directed the residence to administer vitamin B12 1000 mcg daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 because the medication was not in stock. On 7/24/23 at 4:30 p.m., the regional director of operations (RDO) stated the residence was required to administer medications according to practitioner orders. She stated when the residence received a new written order for a medication, her expectation was that the residence administered the medication within 24 hours of receiving the order. She acknowledged that the residence received a written practitioner's order for diltiazem for Former Resident #1 on 4/21/23; she also acknowledged that the residence did not administer the first dose of the medication until 4/26/23 (5 days after the date of the written practitioner's order). The RDO stated there was no reason that Former Resident #1 should have gone that long without being administered diltiazemOn 7/24/23 at 6:14 p.m., the regional nurse consultant (RNC) stated the residence was required to follow practitioner's orders. She stated that this deficiency that was previously cited was not corrected because the residence staff was working on ensuring that medications were in stock at all times. The RNC stated the expectation was for the staff to reorder all medications seven to 10 days prior to running out of medications. 6

A licensure revisit was completed on 7/27/23 for all previous deficiencies cited on 11/23/21. The residence is in compliance with all regulations surveyed.

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 revisit was completed on 8/1/23 for all previous deficiencies cited on 11/23/21. A deficiencies was cited.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting three of six sample residents (#9, #22, #23) and one former resident (#26). This deficiency was cited previously during a state licensure survey on 1/12/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with regulatory requirements. Findings include:1. Residence PolicyThe residence's Medication System Summary, dated 5/1/23, read in part that staff were timely to provide medication administration according to practitioner's orders. 2. Resident #23 was admitted to the residence on 11/28/23 with diagnoses including pain, depression, and skin irritation.a. SeroquelA written practitioner's order, dated 5/5/23, directed the residence to administer Seroquel 25 mg daily. However, the July 2023 medication administration record (MAR) revealed the residence failed to administer the medication on 7/12-7/17/23 because the medication was not in stock.b. AtorvastatinA written practitioner's order, dated 5/5/23, directed the residence to administer atorvastatin 20 mg daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/10/23 because the medication was not in stock.c. HydroseptineA written practitioner's order, dated 5/5/23, directed the residence to administer hydroseptine 0.44-20.6% twice daily . However, the July 2023 MAR revealed the residence failed to administer the medication on 7/16/23 and 7/17/23 because the medication was not in stock.d. Potassium ChlorideA written practitioner's order, dated 5/5/23, directed the residence to administer potassium chloride 10 mEq daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/16/23 and 7/17/23 because the medication was not in stock.e. DuloxetineA written practitioner's order, dated 5/5/23, directed the residence to administer Duloxetine 120 mg daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/16/23 and 7/17/23 because the medication was not in stock.f. AcetaminophenA written practitioner's order, dated 5/5/23, directed the residence to administer acetaminophen 650 mg twice daily. However, the July 2023 MAR revealed the residence failed to administer the medication for one dose on 7/12/23 because the medication was not in stock. 3. Resident #9 was admitted to the residence on 7/24/21.a. Tacrolimus A written practitioner's order, dated 12/17/21, directed the residence to administer tacrolimus 0.1% OINT apply to affected areas daily in small amounts. However, the July 2023 MAR revealed the residence failed to administer the medication from 7/2 to 7/6/23 because the medication was not in stock.b. OxycodoneA written practitioner's order, dated 7/25/21, directed the residence to administer oxycodone 5 mg one tablet at bedtime and two tablets every morning . However, the July 2023 MAR revealed the residence failed to administer the medication on 7/13/23 and 7/14/23 because the medication was not in stock.c. MiralaxA written practitioner's order, dated 7/16/2023 , directed the residence to administer Miralax 17 gm, three capfuls every Monday, Wednesday, and Friday. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/3, 7/5, 7/10, and 7/12/23 because medication was not in stock. 4. Resident #22 was admitted to the residence on 5/11/19 with diagnoses including glaucoma.a. LovastatinA written practitioner's order, dated 5/19/22, directed the residence to administer Lovastatin 10 mg every evening. However the July 2023 MAR revealed the residence failed to administer the medication on 7/1/23 because it was not in stock. b. LatanoprostA written practitioner's order, dated 3/16/23, directed the residence to administer latanoprost 0.005% one drop each eye at bedtime. However, the July 2023 MAR revealed the residence failed to administer the medication from 7/6 to 7/12/23, because medication was not in stock. 5. Former Resident #26 was admitted to the residence on 1/1/20 with diagnoses including hypertension, hypothyroidism, dementia, depression, and hypocalcemia.a. DiltiazemA written practitioner's order, dated 4/21/23, directed the residence to administer diltiazam 180 mg daily. However, the April 2023 MAR revealed the residence failed to administer the medication until 4/26/23, five days after the date of the order because the medication was not in stock. Additionally, the May and June 2023 MARs revealed the residence failed to administer the medication on 5/30/23, 5/31/23, 6/2/23 because the medication was not in stock. On 7/25/23 at 1:32 p.m., a family member for Resident #26 stated the resident was discharged from the hospital on 4/21/23 with a prescription for diltiazem. She stated she received a telephone call from an unknown staff at the residence on 4/26/23, five days after the medication was ordered, that they had not administered the medication because the family member needed to pick the prescription from the hospital. b. AdvairA written practitioner's order, dated 12/21/22, directed the residence to administer Advair 115/21 mcg one puff twice daily. However, the April-June 2023 MARs revealed the residence failed to administer the medication for two doses on 4/29/23, 5/1/23 and 5/2/23 one dose on 4/30/23, 5/3/23, and 6/19/23 because the medication was not in stock.c. BuspironeA written practitioner's order, dated 4/21/21, directed the residence to administer buspirone 5 mg twice daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 because the medication was not in stock.d. CalciumA written practitioner's order, dated 12/21/22, directed the residence to administer calcium 325 mg/500 unit two tablets daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 6/2/23, 6/9-6/16/23, and 6/19/232 because the medication was not in stock.e. EscitalopramA written practitioner's order, dated 4/21/23, directed the residence to administer escitalopram 10 mg daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 and 6/18/23 because the medication was not in stock.f. LevothyroxineA written practitioner's order, dated 4/21/23, directed the residence to administer levothyroxine 75 mcg daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 and 6/25/23 because the medication was not in stock.g. Vitamin B-12A written practitioner's order, dated 12/21/22, directed the residence to administer vitamin B12 1000 mcg daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 because the medication was not in stock. On 7/24/23 at 4:30 p.m., the regional director of operations (RDO) stated the residence was required to administer medications according to practitioner orders. She stated when the residence received a new written order for a medication, her expectation was that the residence administered the medication within 24 hours of receiving the order. She acknowledged that the residence received a written practitioner's order for diltiazem for Former Resident #26 on 4/21/23; she also acknowledged that the residence did not administer the first dose of the medication until 4/26/23 (5 days after the date of the written practitioner's order). The RDO stated there was no reason that Former Resident #26 should have gone that long without being administered diltiazemOn 7/24/23 at 6:14 p.m., the regional nurse consultant (RNC) stated the residence was required to follow practitioner's orders. She stated that this deficiency that was previously cited was not corrected because the residence staff was working on ensuring that medications were in stock at all times. The RNC stated the expectation was for the staff to reorder all medications seven to 10 days prior to running out of medications.

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 #CO32801 and #CO32946 was completed on 8/1/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure applicants completed the Colorado Adult Protective Data Systems (CAPS) requirements prior to hiring staff who provide care to the residents, affecting one out of five sample staff (#1). Findings include:1. ReferencesAccording to the Colorado Revised Statutes (2020) Title 26 Human Services Code, "... individuals receiving care and exercises 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 case of mistreatment of an at-risk adult. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado adult protective data system pursuant to section 26-3.1-111. Chapter VII regulations governing assisted living residences, part 2.7, defines an "At-risk person" as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (D) Is a person with an intellectual and developmental disability as defined in Section 25.5-10-202, C.R.S.; (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.2. Record ReviewThe personnel file for Staff #1 revealed a hire date of 9/16/20. The July 2023 schedule revealed that Staff #1 worked on 7/4-7/7/23 and 7/11-7/14/23. However, the personnel file revealed that a CAPS check had been completed on 7/17/23.3. InterviewOn 7/24/23 at approximately 5:15 p.m., the regional director of operations acknowledged that the personnel file for Staff #1 did not include documentation that a CAPS check was requested prior to her hire date of 9/16/20. She stated she had recently completed the CAPS check for Staff #1 (on 7/17/23) due to the former assistant executive director's failure to complete to request the CAPS check prior to Staff #1's date of hire.

Based on interview and record review the residence failed to obtain a name-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for staff prior to their hire, affecting one of five sample staff (#1). Findings include:1. References a. Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include written documentation regarding the following items:(E) Results of background checks and follow up, as applicable. 2. Record Review The personnel file for Staff #1 revealed a hire date of 9/16/20. The July 2023 schedule revealed that Staff #1 worked on 7/4-7/7/23 and 7/11-7/14/23. However, the personnel file revealed that the residence received results from a criminal history check conducted by the CBI on 7/20/23.3. InterviewOn 7/24/23 at approximately 5:55 p.m., the operations director acknowledged that the personnel file for Staff #1 did not include documentation of a criminal history check conducted by the CBI prior to her hire date. She stated she had recently requested the CBI background check (on 7/20/23) due to the former assistant executive director's failure to complete to request the CBI prior to Staff #1's date of hire.

Based on observation, record review and interview, the residence failed to ensure that each resident's care plan promoted resident choice, independence, and safety; detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs; and identified all external service providers (ESP) along with care coordination arrangements affecting one former resident (#26). Findings include:1. Residence PolicyThe residence's care plan policy, dated July 2023, read in part that the care plan identified resident care needs, how staff monitored and observed them, and interventions for each resident that staff can apply when necessary. 2. Former Resident #26 was admitted to the residence on 01/20/20 with diagnosis including anxiety, gait instability, and a history of left femoral neck fracture.a. Record ReviewA progress note, dated 4/23/23 read in part that Former Resident #26 was more confused than normal, and she was not doing basic tasks such as changing her clothes independently. A care plan, dated 6/2/23, read that Former Resident #26 required physical assistance with bathing and dressing. The care plan further read that the resident was not incontinent and did not require assistance with toileting. The care plan did not detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs nor identify all external service providers (ESP) along with care coordination arrangements.b. InterviewsOn 7/24/23 at 7:49 a.m., Staff #16 stated Former Resident #26 had been receiving services from an ESP while she lived in the unsecure environment (prior to her admission into the secure environment on approximately 6/17/23). She stated the former resident sustained a fall when Staff #15 assisted the former resident with bathing within seven days after her admission to the secure environment, which resulted in a broken hip. On 7/24/23 at 8:14 a.m., Staff #17 stated that Staff #16 assisted Former Resident #26 with a shower on the evening of 6/22/23. She stated the external service provider was scheduled to provide shower assistance twice weekly. Staff #17 stated that the former resident had declined within approximately two months and required more assistance with care and redirection due to increased confusion. On 7/24/23 at 11:06 a.m., a former assistant executive director (AED) stated that Former Resident #26 received services from an ESP, and contrary to the record review, she added she updated the former resident's care plan. On 7/24/23 at 5:32 p.m., the regional director of operations (RDO) stated it was the responsibility of the former AED to ensure Resident #26's care plan was updated with her service needs and preferences along with the staff tasks necessary to meet those needs. The RDO acknowledged that the former AED failed to update the care plan as required. On 7/25/23 at 1:32 p.m., a family member for Former Resident #26 stated Staff #16 provided the former resident with shower assistance on the evening of 6/22/23. She stated that Staff #16 attempted to provide assistance in the shower while the former resident was standing up, despite a shower chair being present. The family member stated the service plan was not updated to include detailed service needs and preferences along with the staff tasks necessary to meet those needs. She stated that Former Resident #26 had been receiving services from an ESP since the day after she sustained a fall on 6/15/23. On 7/27/23 at 3:05 p.m., an ESP representative stated that an unknown new staff member attempted to assist Former Resident #26 with a shower (on 6/22/23), and the resident slipped and fell. The ESP representative stated she did not understand why the new staff member attempted to assist the former resident with a shower that evening because the external service provider was scheduled to provide bathing assistance the very next day. She stated the resident was incontinent and required assistance with peri care and changing her clothing and sheets when she had incontinence episodes.

Based on observation, record review, and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting 73 current residents. Findings include:1. Reference and Residence Policy a. Chapter VII regulations governing assisted living residences, requires in part 13.12, that the assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements:- the residence must identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either the resident cannot explain how the injury occurred, or the resident can explain the source of the injury, but the source could be addressed to prevent future injuries.- the residence is required to document the following: The investigation and identification of any injury identified above. The implementation and outcome of the following for injuries for which the investigation determines the source/origin.- when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; the residence is required to take steps to prevent or mitigate future injuries of like nature. Such steps were to include, but not limited to: Staff or volunteer corrective action and/or additional training. Modification of the residence's policies, procedures or physical environment. - if the source of the injuries is undetermined, the residence is required to take steps to monitor the resident in an effort to prevent similar injuries. - all documentation of the investigation, outcomes and steps taken are to be retained by the residence to include, but not limited to, details of any interviews and/or records used in the investigation. - the documentation has to be made available for review at the Department ' s request. - the documentation may be maintained separately and not in the resident's record, but the summary of the investigation must be in the resident's care plan and progress notes- the residence is required to notify the resident ' s representative of the outcome of the investigation and steps taken.b. According to Intermountain Health care, "A skin tear is a wound that happens when the layers of skin separate or peel back. They can happen as a result of bumping something, dressing changes, or washing or drying the skin harshly. They most often happen on the arms or legs. Skin tears are most common in ... the elderly and people who are chronically ill." Intermountain Healthcare (2018) Skin Tears, retrieved from:https://intermountainhealthcare.org/services/wound-care/wound-care/conditions/skin-tears/#:~:text=A%20skin%20tear%20is%20a,on%20the%20arms%20or%20legs. 2. Failure to develop a policy and procedure that included the required elementsOn 7/24/23 at 8:44 a.m., the regional director of operations (RDO) was asked to provide the residence's policy for the identification, reporting, and investigation of injuries of unknown origin. The provided policy was titled Occurrence Reporting Policy and was dated 7/17/23. The policy read in part: "Administrators report suspected cases of ... injury of unknown origin ... in a timely manner to ... state agencies in accordance with state regulations."The policy was missing the following required elements:- the residence must identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either the resident cannot explain how the injury occurred, or the resident can explain the source of the injury, but the source could be addressed to prevent future injuries.- the residence is required to document the following: The investigation and identification of any injury identified above. The implementation and outcome of thefollowing for injuries for which the investigation determines the source/origin.- when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; the residence is required to take steps to prevent or mitigate future injuries of like nature. Such steps were to include, but not limited to: Staff or volunteer corrective action and/or additional training. Modification of the residence's policies, procedures or physical environment. - if the source of the injuries is undetermined, the residence is required to take steps to monitor the resident in an effort to prevent similar injuries. - all documentation of the investigation, outcomes and steps taken are to be retained by the residence to include, but not limited to, details of any interviews and/or records used in the investigation. - the documentation has to be made available for review at the Department ' s request. - the documentation may be maintained separately and not in the resident's record, but the summary of the investigation must be in the resident's care plan and progress notes- the residence is required to notify the resident ' s representative of the outcome of the investigation and steps taken. No additional policies related to the identification, reporting, and investigation of injuries of unknown origin were provided. 3. Resident #13A progress note, dated 6/22/23, read in part: "(Staff) went to check the resident after (staff) put her to bed and noticed a skin tear on her top right leg. Could not talk to (staff) about it because she left early."A progress note, dated 7/7/23, read in part that staff noticed bruising on Resident #13's upper buttocks; they appeared old as they were green and yellow. There was no evidence that investigations into the above injuries of unknown origin were completed nor documented. On 7/24/23 at 4:30 p.m., the RDO acknowledged that the residence policy she provided directed the residence to report and investigate injuries of unknown origin in accordance with the department's regulations, but did not include the above listed required elements. She stated she was not familiar with the regulatory requirements. She stated Resident #13's injuries of unknown origin should have been investigated, and she was not able to answer as to why they were not.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting three of six sample residents (#9, #22, #23) and one former resident (#26). Findings include:1. Residence PolicyThe residence's Medication System Summary, dated 5/1/23, read in part that staff were timely to provide medication administration according to practitioner's orders. 2. Resident #23 was admitted to the residence on 11/28/23 with diagnoses including pain, depression, and skin irritation.a. SeroquelA written practitioner's order, dated 5/5/23, directed the residence to administer Seroquel 25 mg daily. However, the July 2023 medication administration record (MAR) revealed the residence failed to administer the medication on 7/12-7/17/23 because the medication was not in stock.b. AtorvastatinA written practitioner's order, dated 5/5/23, directed the residence to administer atorvastatin 20 mg daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/10/23 because the medication was not in stock.c. HydroseptineA written practitioner's order, dated 5/5/23, directed the residence to administer hydroseptine 0.44-20.6% twice daily . However, the July 2023 MAR revealed the residence failed to administer the medication on 7/16/23 and 7/17/23 because the medication was not in stock.d. Potassium ChlorideA written practitioner's order, dated 5/5/23, directed the residence to administer potassium chloride 10 mEq daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/16/23 and 7/17/23 because the medication was not in stock.e. DuloxetineA written practitioner's order, dated 5/5/23, directed the residence to administer Duloxetine 120 mg daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/16/23 and 7/17/23 because the medication was not in stock.f. AcetaminophenA written practitioner's order, dated 5/5/23, directed the residence to administer acetaminophen 650 mg twice daily. However, the July 2023 MAR revealed the residence failed to administer the medication for one dose on 7/12/23 because the medication was not in stock. 3. Resident #9 was admitted to the residence on 7/24/21.a. Tacrolimus A written practitioner's order, dated 12/17/21, directed the residence to administer tacrolimus 0.1% OINT apply to affected areas daily in small amounts. However, the July 2023 MAR revealed the residence failed to administer the medication from 7/2 to 7/6/23 because the medication was not in stock.b. OxycodoneA written practitioner's order, dated 7/25/21, directed the residence to administer oxycodone 5 mg one tablet at bedtime and two tablets every morning. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/13/23 and 7/14/23 because the medication was not in stock.c. MiralaxA written practitioner's order, dated 7/16/2023 , directed the residence to administer Miralax 17 gm, three capfuls every Monday, Wednesday, and Friday. However, the July 2023 MAR revealed the residence failed to administer the medication on 7/3, 7/5, 7/10, and 7/12/23 because medication was not in stock. 4. Resident #22 was admitted to the residence on 5/11/19 with diagnoses including glaucoma.a. LovastatinA written practitioner's order, dated 5/19/22, directed the residence to administer Lovastatin 10 mg every evening. However the July 2023 MAR revealed the residence failed to administer the medication on 7/1/23 because it was not in stock. b. LatanoprostA written practitioner's order, dated 3/16/23, directed the residence to administer latanoprost 0.005% one drop each eye at bedtime. However, the July 2023 MAR revealed the residence failed to administer the medication from 7/6 to 7/12/23, because medication was not in stock. 5. Former Resident #26 was admitted to the residence on 1/1/20 with diagnoses including hypertension.a. DiltiazemA written practitioner's order, dated 4/21/23, directed the residence to administer diltiazam 180 mg daily. However, the April 2023 MAR revealed the residence failed to administer the medication until 4/26/23, five days after the date of the order because the medication was not in stock. Additionally, the May and June 2023 MARs revealed the residence failed to administer the medication on 5/30/23, 5/31/23, 6/2/23 because the medication was not in stock. On 7/25/23 at 1:32 p.m., a family member for Resident #26 stated the resident was discharged from the hospital on 4/21/23 with a prescription for Diltiazem. She stated she received a telephone call from an unknown staff at the residence on 4/26/23, five days after the medication was ordered, that they had not administered the medication because the family member needed to pick the prescription from the hospital. b. AdvairA written practitioner's order, dated 12/21/22, directed the residence to administer Advair 115/21 mcg one puff twice daily. However, the April-June 2023 MARs revealed the residence failed to administer the medication for two doses on 4/29/23, 5/1/23 and 5/2/23 one dose on 4/30/23, 5/3/23, and 6/19/23 because the medication was not in stock.c. BuspironeA written practitioner's order, dated 4/21/21, directed the residence to administer buspirone 5 mg twice daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 because the medication was not in stock.d. CalciumA written practitioner's order, dated 12/21/22, directed the residence to administer calcium 325 mg/500 unit two tablets daily. However, the July 2023 MAR revealed the residence failed to administer the medication on 6/2/23, 6/9-6/16/23, and 6/19/232 because the medication was not in stock.e. EscitalopramA written practitioner's order, dated 4/21/23, directed the residence to administer escitalopram 10 mg daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 and 6/18/23 because the medication was not in stock.f. LevothyroxineA written practitioner's order, dated 4/21/23, directed the residence to administer levothyroxine 75 mcg daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 and 6/25/23 because the medication was not in stock.g. Vitamin B-12A written practitioner's order, dated 12/21/22, directed the residence to administer vitamin B12 1000 mcg daily. However, the June 2023 MAR revealed the residence failed to administer the medication on 6/2/23 because the medication was not in stock.h. MorphineA written practitioner's order, dated 6/22/23, directed the residence to administer morphine sulfate 20 mg/mL 0.5 mg every six hours. A pharmacy delivery manifest read the medication was delivered to the residence on 6/23/23 at 1:38 a.m. However, the June 2023 MAR revealed the residence failed to administer the medication until approximately 2:00 p.m. on 6/23/23, over 12 hours after the medication was delivered. On 7/24/23 at 11:06 a.m., the former assistant executive director (AED) stated that a practitioner had placed the order for Morphine on 6/22/23. She stated that the pharmacy delievered it in the early morning of 6/23/23. The former AED stated that although the medication was in stock, the residence failed to administer the medication within receipt of the medication because the residence did not have the staff on duty to input the medication on the June 2023 MAR until the next day. On 7/25/23 at 1:32 p.m. a family member for Former Resident #26 stated a practitioner called in an order for Morphine at approximately 8:00 p.m. on 6/22/23. She stated the staff were instructed to administer the medication as soon as it was delivered. The family member stated she expected the pharmacy to deliver the medication at aproximately 11:00 p.m. on 6/22/23, adding that she expected the residence to administer it upon delivery. She stated the residence did not administer the medication until the afternoon of 6/23/23. On 7/24/23 at 4:30 p.m., the regional director of operations (RDO) stated the residence was required to administer medications according to practitioner orders. She stated when the residence received a new written order for a medication, her expectation was that the residence administered the medication within 24 hours of receiving the order. She acknowledged that the residence received a written practitioner's order for diltiazem for Former Resident #26 on 4/21/23; she also acknowledged that the residence did not administer the first dose of the medication until 4/26/23 (5 days after the date of the written practitioner's order). The RDO stated there was no reason that Former Resident #26 should have gone that long without being administered diltiazem. On 7/24/23 at 6:14 p.m., the regional nurse consultant (RNC) stated the residence was required to follow practitioner's orders. She stated that the residence staff was working on ensuring that medications were in stock at all times. The RNC stated the expectation was for the staff to reorder all medications seven to 10 days prior to running out of medications.

A licensure complaint, prompted by complaints #CO30498 and #CO30554, was completed on 1/12/23. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 63 current residents. Findings include:The Ninth Amended Public Health Order, dated 10/11/22, required residences to implement the COVID-19 infection prevention and management strategies as outlined in Assisted Living and Group Home COVID-19 Mitigation and Outbreak Guidance. The Assisted Living Residences and Group Homes Mitigation and Outbreak Guidance, updated 11/3/22, required residences to:- Assign at least one staff member to complete training in IPC (Infection Prevention and Control) and provide on-site management of infectious disease prevention and response activities and general infection prevention duties. The designated person must have completed the Colorado RCF (residential care facility) Infection Prevention Training within two weeks of the assignment of duties. The information must be reported in EMResource and remain updated. The EMResource database, updated 9/15/22, read the former regional nurse was designated to complete IPC training and provide on-site management of infectious disease prevention and response activities and general infection prevention duties. On 1/12/13 at 10:33 a.m., the residence's sales specialist stated the former regional nurse no longer worked for the residence. Additionally, she stated she was unaware who the residence's new infection prevention and control staff member was. On 1/12/23 at 10:40 a.m., the regional director of operations stated the administrator would be the replacement for the infection prevention and control staff member role but stated she had not taken the course so at the time of the onsite visit, no one was trained. On 1/12/23 at 2:29 p.m., the divisional director of operations stated he was aware during the onsite visit, the residence was not in compliance with having a designated infection prevention and control staff member.

Based on record review and interview, the residence failed to ensure direct care staff demonstrated competency to safely and effectively provide care services, affecting 63 current residents. Findings include: The residence's staff list read Staff #3 was a caregiver at the residence. The residence's staff schedule for January 2023 read Staff #3 worked at the residence on 1/3-1/7/23. The personnel file for Staff #3 read a hire date of 10/11/22. Staff #3 completed orientation for the residence on 10/11/22. However, the personnel file for Staff #3 did not reveal Staff #3 had demonstrated competency to safely and effectively provide care services. On 1/15/23 2:29 p.m., the administrator and the divisional director of operations acknowledged competency checks were required for direct care staff. The administrator stated she was not aware Staff #3 did not have documentation that she demonstrated competency to safely and effectively provide care and services.

Based on record review and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting one sample resident (#4). Specifically, Resident #4 was admitted to the residence on 5/1/22 with diagnoses which included bone fractures. Resident #4 sustained a fall on 10/15/22 without injury. The residence had not updated Resident #4's care plan to include the individualized approach necessary to address Resident #4's fall risks. Subsequently, Resident #4 sustained five falls that resulted in injury on 10/21/22, 11/24/22, 11/30/22, 12/14/22 and 12/31/22. Additionally, Resident #4 sustained two falls, on 12/2/22 and 12/26/22, that resulted in increased lethargy and a change in baseline status. Furthermore, Resident #4 sustained four falls, on 11/26/22, 12/23/22 and two on 12/25/22, that resulted in no injury. The residence had not updated Resident #4's care plan to include individualized approaches necessary to prevent additional falls after the 11 additionally documented falls. This failure created an immediate jeopardy risk of injury from falls to Resident #4. On 1/12/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include: 1. Residence Policy The residence's Safe Resident Handling/Evaluating Residents Fall Potential policy, dated 8/27/20, read in part: "The Community shall provide initial and ongoing evaluations of each resident's mobility needs as well as seek to minimize risk of injury from falls while promoting resident independence and safety. Toward that objective, residents and their environments will be evaluated to identify those at risk for falling, and interventions that might reduce that potential. After any resident falls, staff will review specific care coordination needs and seek to minimize recurrence." 2. Resident #4 was admitted to the residence on 5/1/22 with diagnosis including osteoporosis, restless leg syndrome and bone fracture. The residence's progress notes for Resident #4, dated 10/15/22-1/11/23, read:On 10/15/22: "(Resident #4) fell trying to get in her chair in a dark room". On 10/17/22: Resident #4 experienced a fall on 10/15/22. No injuries were noted. "Resident (#4) and (Resident #3) do not use call system consistently. Frequent checks are not effective because she falls at different times." On 10/21/22: Resident #4 was placed on alert charting after a she sustained a fall with injury. "Resident fell again today in her bathroom and reported to the care giver that she had hit her head, Paramedics were called and they determined that she did not need to go to the hospital." On 11/25/22: "Resident experienced a fall yesterday in her kitchen. Initially c/o (complained of) hip pain and head pain ..."On 11/26/22: Resident #4 fell on 11/24/22 in the kitchen and hit her head and right hip. "Resident on alert charting for multiple falls. Resident fell again today at around (11:00 a.m.) today, no injuries detected this time and resident not complaining to staff or (Resident #3) of any pain."On 11/30/22: "Resident on alert charting for multiple falls. Resident had another one today at around 3:30 (p.m.), resident appears to be favoring her right arm and has not vocally complained of any pain."On 12/2/22: "Resident experienced another fall this morning. No injuries noted but resident is more lethargic and slower to respond than usual." On 12/14/22: "Resident fell out of her recliner today at around 10:20 (a.m.). Resident managed to get herself up off the floor and she sustained a cut on her right elbow and an abrasion on her lower back as well as some pain in her right arm." On 12/22/22: "Resident frequently falls in the middle of the night. The sum total of (seven) falls in the past 90 days. Resident is attempting to take herself to the bathroom and has very limited ability to speak."On 12/23/22: "Resident was found on her bottom by the toilet. Caregiver was able to pick her up off of the floor without my assistance and resident was not reacting as if she was in pain."On 12/25/22: "Resident had another fall at 2:45 a.m." On 12/26/22: "Resident had two falls yesterday and will continue to fall in her current condition and living situation. Resident has dementia unsteady on her feet and does not ask for help and cannot be supervised at all times by staff in assisted living. Resident does not appear to be injured but is more lethargic than usual."On 12/31/22: "Resident's latest fall happened yesterday evening cuts on both hands and a scratch on her face resulted from the fall. Cuts are no longer bandaged but not needing band aides at this time and resident not complaining of any pain and does seem tired and did not want to eat her breakfast this morning." On 12/31/22: "Resident not complaining of any pain but does have a big bruise on her tailbone, bruise was reported to me by a caregiver while she was showering resident." On 1/5/23: "Resident presenting with ongoing falls and poor safety awareness ... She does not remember to lock the brakes on her walker, rather tries to pull on it to get herself up ... Review of call lights for this (apartment) for month of (December), there was a total of 153 calls with an avg response time of 5m:23s (five minutes and 23 seconds). Staff report that (Resident #3) consistently calls after the resident has fallen and not prior to her getting up. (resident) does not have the cognition to remember to call for assistance."On 1/11/23: "Put assisted resident to bed at approximately 8:30 (p.m.). When I went back to put trash bags in the apartment at 9:00 (p.m.) (Resident #3) was yelling at (Resident #4) to get back into bed. She was up trying to put her headphones on the charger and almost fell. I had to catch her because she spun around so fast. She would have fallen had I not been there to catch her." The residence's assessment for Resident #4, dated 6/28/22, read she did not have a history of falls in the past twelve months and there was no pattern of falls for her. The assessment read Resident #4 used a walker to ambulate and read interventions for fall trends were located on the resident's care plan. The residence's care plan for Resident #4, dated 8/24/22, read Resident #4 had frequent falls, including a fall before being admitted to the residence, which resulted in a broken neck. The care plan read Resident #3 was expected to support Resident #4's needs and her use of her walker. The care plan identified Resident #4 as being at risk for falls or having a pattern of falls. The care plan for Resident #4 was not updated to include individualized approaches necessary to address fall risks after Resident #4's falls on 10/15/22, 10/21/22, 11/24/22, 11/26/22, 11/30/22, 12/2/22, 12/14/22, 12/23/22, 12/25/22, 12/26/22, and 12/31/22. 3. InterviewsOn 1/12/23 at 12:39 p.m., Staff #4 stated Resident #4 had fallen in her bathroom approximately two weeks prior to the onsite visit. She stated Resident #4 attempted to go to the restroom alone and stated Resident #3 was present however; he was unable to help. Staff #4 stated Resident #4 did not want help with care and tried to be independent, which resulted in her becoming agitated. 1/12/23 at 12:44 p.m., Resident #4's family member stated Resident #4 told Resident #3 she needed to use the restroom but instead of waiting for staff to come assist after Resident #4 pressed his call button, Resident #3 got up on her own and fell. The family member stated Resident #4's equilibrium was off, which resulted in her falls. In addition, the family members stated Resident #4 got frustrated and decided to do things on her own, which resulted in falls. The family member added the falls led to bruising on Resident #4's body and stated Resident #4 was admitted to the residence due to all of the broken bones she sustained from falling priorto admission. Resident #4's family member stated the resident's falls were mainly in her restroom or getting out of her chair. On 1/12/23 at approximately 1:15 p.m., the administrator stated she was aware of Resident #4's falls. The administrator added a conversation with Resident #3 occurred the week of the onsite visit to remind Resident #3 he needed to press his call button. Further, the administrator stated Resident #4 was independent and more frequent checks were in place since Resident #4 had a tendency to get up frequently. The administrator stated training in regards to fall management at the residence was lacking. On 1/12/23 at 2:22 p.m., a second family member for Resident #4 stated Resident #4 fell all of the time. She stated Resident #3 would press the call button however; Resident #4 got concerned staff would not come in time and attempted to get up on her own, resulting in her numerous falls. The family member stated when they moved Resident #4 into the residence, they informed the residence staff that Resident #4 would fall unless she had someone with her at all times. 4. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the one current resident at immediate jeopardy risk for injury in the event of additional falls. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 1/12/23 at 2:35 p.m., the administrator submitted written evidence that read in pertinent part: ""... The (administrator) or designee will be assigned to review resident services plan after each fall to review individualized approach updates as needed. The completed reviews will be documented `biweekly for a period of 90 days. The assisted living residence shall further expand policies and procedures to establish a clear definition of our fall management system. All staff will receive training regarding this definition effective immediately dated 1/12/23. A review of all resident's care plans to be completed by 1/14/2023 for individualized response to fall management. Affected residents care plan updated 1/12/2023 with the following interventions- Staff will assist with toileting (four times) per shift, Staff will be assisting with one person transfers with all mobility needs, eight checks to be conducted per shift to offer assistance until PT eval completed. Checks to be reevaluated after PT (physical therapy) eval (evaluation), Faxing (practitioner) for PT eval."

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 7.7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer. (A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the assisted living residence shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI). (B) If the applicant has lived in Colorado for three years or less at the time of application, the assisted living residence shall obtain a name-based criminal history report for each state in which the applicant has lived for the past three years, conducted by the respective states' bureaus of investigation or equivalent state-level law enforcement agency or other name-based report as determined by the Department. 12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status.