GARDEN PLAZA OF AURORA

An administrative relicensure survey was completed on 6/4/26. No deficiencies were cited.

A licensure complaint, prompted by #CO40261, was completed on 4/15/26. No deficiencies were cited.

A revisit survey was completed on 6/16/25 for all previous deficiencies cited on 1/28/25. The facility is in compliance with all deficiencies that were cited.

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

A relicensure survey with complaint #CO35350 was completed on 1/28/25. Deficiencies were cited.

12.2.2 Infection Control Officer (B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following: (2) Completing a minimum of 1.5 hours of continuing education in infection prevention and control on an annual basis from a nationally-recognized provider or the Department's training program sufficient to stay current on changing guidance and requirements in the fieldBased on record review and interview, the residence failed to ensure that the assigned infection control officer completed a minimum of 1.5 hours of continuing education in infection prevention and control on an annual basis from a nationally-recognized provider or the Department's training program, affecting 55 current residents. (Cross-reference B1226)Findings include:On 1/28/25 at 8:10 a.m., the resident care director (RCD) was asked to provide the residence's infection control person's training certificate. On 1/28/25 at approximately 8:00 a.m., the RCD said she was unaware who had taken the required training in infection prevention and control. On 1/28/25 at approximately 4:30 p.m., the administrator said her and the RCD's initial infection prevention and control program training had expired and had not taken the required 1.5 hour continuing education. By the time of the exit on 1/28/25 at approximately 5:00 p.m., the administrator nor the RCD had provided their documentation of 1.5 hours of continuing education in infection prevention and control.

Based on record review and interview, the residence failed to report suspected caretaker neglect to law enforcement within 24 hours of observation or discovery, affecting 55 current residents. Findings include:Former Resident #8 was admitted to the residence on 10/31/24 with diagnoses including respiratory failure with hypoxia, femur and left hip fracture. On 1/28/25 at approximately 8:10 a.m., the resident care director (RCD) was asked to provide the residence's internal investigations on abuse and neglect in the last 90 days. A progress note for Former Resident #8, dated 11/10/24, read in part that Former Resident #8 was required to be repositioned every two hours. On 1/28/25 at 8:38 a.m., the administrator provided a caretaker neglect investigation for Former Resident #8. The investigation notes read in part, on 11/11/24 Former Staff #4 completed no night checks on Former Resident #8 between 10:00 p.m. and 6:00 a.m. Camera footage in Former Resident #8's room confirmed this. The documentation did not indicate whether or not law enforcement was contacted for an allegation of caretaker neglect. On 1/28/25 at 3:57 p.m., the RCD said she was not sure if law enforcement was contacted after the caretaker neglect incident on 11/11/24. She added staff were required to notify law enforcement immediately if they suspected or saw abuse or neglect. On 1/28/25 at approximately 4:30 p.m., the administrator said everyone was a mandated reporter if there was suspected neglect or abuse. She added she was unaware if law enforcement were contacted after the caretaker neglect incident on 11/11/24. At approximately 5:15 p.m., the administrator confirmed she had not contacted law enforcement within 24 hours of the discovery of caretaker neglect on 11/11/24.

Based on record review and interview, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire for two of three sample staff (#1, #2), affecting 55 current residents. Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.b. 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 files for Staff #1 and #2 read the following:Staff #1 was hired on 8/26/22Staff #2 was hired on 12/16/22. The personnel files for Staff #1 and #2 did not contain evidence that the residence received results of a criminal history record check conducted by the CBI.On 1/28/25, the results of CBI criminal history record checks for Staff #1 and #2 were requested but not provided. A review of the January 2025 staff schedules revealed: Staff #1 worked the following dates: 1/2 , 1/7-1/9, 1/12-1/14, 1/19, 1/21-1/23, and 1/26-1/30/25. Staff #2 worked the following: 1/22-1/24 and 1/28-1/30/25. 3. Interview On 1/28/25 at 4:11 p.m., the administrator stated the residence requested a background check; however, she stated she did not receive a final result. The administrator acknowledged the requirement for the results of background checks and follow up were required to be completed prior to hire.

Based on record review and interview, the residence failed to ensure qualified medication administration persons (QMAP) had documentation that the individual ' s name appears on the Department's list of individuals who have successfully completed the medication administration competency evaluation, for three of three staff (#1-#3), affecting 55 current residents. Findings include:1. Record reviewOn 1/28/25, at approximately 2:45 p.m., review of Staff #1-#3's personnel files identified them as QMAPs for the residence. However, none of their files contained documentation showing that the individual's name appeared on the Department's list of individuals who had successfully completed the medication administration competency evaluation, as required. 2. InterviewOn 1/28/25 at approximately 4:15 p.m., the administrator stated that the residence checked the individual ' s training status before they were hired to ensure they had completed the necessary training. She further admitted that she was unaware the residence was required to include QMAP documentation in their personnel files.

Based on interview and record review, the residence failed to have at least one staff member onsite who had certification in first aid from a nationally recognized organization, affecting 55 current residents. Findings include:A review of staff first aid certifications and staff schedules from 1/1/25-1/31/25 revealed the following 28 shifts did not have a person onsite certified in first aid: Day shift 1/3, 1/12, 1/19 and 1/26; afternoon shifts 1/5, 1/6, 1/12, 1/13, 1/19, 1/20, and 1/26; overnight shifts 1/2, 1/5, 1/6, 1/7, 1/9, 1/12, 1/14, 1/16, 1/19, 1/20, 1/21, 1/23, 1/26-1/28 and 1/30 .On 1/29/25 at 4:11 p.m., the administrator stated that she was responsible for reviewing the schedule to ensure there was at least one first aid certified staff member per shift and acknowledged the discrepancies.

Based on record review and interview, the residence failed to ensure there was at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 55 current residents. Findings include:A review of staff CPR certifications and staff schedules from 1/1/25-1/31/25 revealed the following 28 shifts did not have a person onsite certified CPR: Day shift 1/3, 1/12, 1/19 and 1/26; afternoon shifts 1/5, 1/6, 1/12, 1/13, 1/19, 1/20, and 1/26; overnight shifts 1/2, 1/5, 1/6, 1/7, 1/9, 1/12, 1/14, 1/16, 1/19, 1/20, 1/21, 1/23, 1/26, 1/27, 1/28 and 1/30 .On 1/29/25 at 4:11 p.m., the administrator stated that she was responsible for reviewing the schedule to ensure there was at least one CPR certified staff member per shift and acknowledged the discrepancies.

Based on observation and interview, the residence failed to place in a visible location a list of all staff who have current certification in first aid or cardiopulmonary resuscitation (CPR) so that the information is readily available to staff at all times, affecting 55 current residents. During the onsite visit on 1/28/25, the residence placed no list of staff members with current certification in first aid and CPR in a visible location and readily available to staff at all times anywhere throughout the residence. On 1/28/25 at 4:11 p.m., the administrator stated that there was no list of all staff who have current certifications in first aid or CPR posted in a visible location at the residence.

Based on record review and interview the residence failed to define procedures to prevent the spread of influenza from unvaccinated healthcare workers, affecting 55 current residents. Findings include:On 1/28/25 the residence had a posted sign on the entrance door of the residence that indicated the residence was currently in an active influenza outbreak as of 1/21/25. On 1/28/25 at 8:07 a.m., the resident care director (RCD) was asked to provide the residence's influenza policy. On 1/28/25 at approximately 10:30 a.m., the administrator provided a policy, titled Flu Outbreaks, revised 10/1/12. The policy did not define procedures to prevent the spread of influenza from unvaccinated healthcare workers. On 1/28/25 at 11:28 a.m., the administrator was asked a second time to provide the residence's influenza policy according to the regulation. On 1/28/25 at approximately 1:00 p.m., the administrator provided a policy, titled Influenza (Flu) Vaccine, Pneumococcal Vaccine and Flu Outbreak Management, dated May 2015. The policy still did not define procedures to prevent the spread of influenza from unvaccinated healthcare workers. On 1/28/25 at approximately 4:30 p.m., the administrator acknowledged the influenza policy was not accurate and the residence did not have a correct influenza policy as of 5:30 p.m. on 1/28/25.

Based on record review, observation and interview, the residence failed to comply with practitioners orders associated with medication administration, affecting three out of six sample residents (#2-#4). Findings include:1. Record reviewA physician order dated 1/9/25, read that the residence was required to administer prednisone 30 mg (3 tablets) three times daily for three days. The order was prescribed for a pruritic rash on his upper back. 2. ObservationOn 1/28/25, at 3:09 p.m., Resident #2 was observed with multiple red, open sores on his upper back. On 1/28/25, at approximately 3:45 p.m., a medication cart audit revealed that a blister pack containing prednisone 30 mg (3 tabs) medication had not been administered as prescribed by the physician. Only one dose had been given to Resident #2, despite a three-day prescription. 3. InterviewsOn 1/28/25, at approximately 3:15 p.m., Resident #2 reported that the medication he had received for the rash on his back was not effective. On 1/28/25, at 3:51 p.m., the resident care director stated there was a med error with Resident #2 ' s prednisone and that staff used the wrong blister back with the wrong dosage. She further stated that Resident #2 missed two days of his medication or was given the incorrect dose. On 1/28/25, at 4:11 p.m., the administrator stated that her expectation was for all residents to receive medication exactly as prescribed by their physician. She also acknowledged that this was not being consistently followed in the residence. 4. Similar deficient practice was also found for Resident #3 and Resident #4.

Based on record review and interview, the residence failed to have the administrator and the QMAP (qualified medication administration person) supervisor, on a quarterly basis, audit the accuracy and completeness of the medication administration records, affecting 55 current residents. Findings include:1. Record reviewA weekly medication audit dated 1/7/25, revealed the medication audit forms did not focus on auditing the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Additionally, the medication audit was not signed by the administrator. This was consistent with other weekly medication audits from 1/12 and 1/14/25.2. InterviewOn 1/28/25, at 3:50 p.m., the Resident Care Director (RCD) explained that she and the Resident Care Coordinator (RCC) conducted the medication audits. She clarified that no one else reviewed the audits. Additionally, the RCD mentioned that the local pharmacy handled the quarterly audits and that the administrator was not involved in the medication audit process. The RCC acknowledged that the residence had not met the required regulation.

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:(C) Personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or on-going monitoring and possible re-assessment. 13.1 The assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items:(D) The right to choice and personal involvement regarding care and services, including:(4) The right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services which are made available by the assisted living residence. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner.(D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.

A revisit survey was completed on 6/26/24 for all previous deficiencies cited on 3/4/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 4/16/24 for all previous deficiencies cited on 12/12/22. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO35159 was completed on 3/4/24. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure that all residence personnel engaged in the care and treatment of at-risk persons, affecting 43 current residents. (Cross-Reference S640)Findings include:1. Residence Policiesa. The residence's Resident Abuse Policy, dated 1/4/22, read in part that each of the residence's staff was a mandated reporter and had the duty as an individual to report any actual/known, alleged, suspected incident of physical abuse, neglect, exploitation, financial abuse, abandonment, or isolation to local law enforcement within 24 hours of suspicion or allegation. b. The residence's Staff Training Policy, dated 8/25/22, read in part that staff training on abuse, neglect, exploitation, and reporting requirements were included during orientation and ongoing in-services. 2. InterviewsOn 3/4/24 at 7:43 a.m., Staff #6 stated her understanding of being a mandatory reporter was that she needed to report any suspicions of resident abuse or neglect to the resident care coordinator (RCC) or the resident care director (RCD). On 3/4/24 at 8:05 a.m., Staff #2 stated she had completed training, and the day of the onsite investigation was her first day providing care and services to residents. She stated she would report suspicions of resident abuse or neglect to the resident care director, the RCC, or the business office director, adding that she would only call law enforcement herself if none of the three did anything about her report. She stated she was not trained to notify law enforcement herself when she suspected resident abuse or neglect. On 3/4/23 at 3:40 p.m., Staff #8 stated that if she suspected resident abuse or neglect, she would notify the RCC or the RCD. She stated they would take over from there. On 3/4/24 at 3:45 p.m., Staff #9 stated that for suspicions of resident abuse or neglect, she was trained to report it to a supervisor (the administrator, RCC, or RCD) and document it in the staff's care communication log. Staff #9 stated she would then discuss it with the care team during a meeting at the change of shift. On 3/4/24 at 3:45 p.m., Staff #10 stated she would document suspected resident abuse or neglect in both an incident report and in the care communication log. On 3/4/24 at 4:32 p.m., the administrator stated that staff were trained on mandatory reporting for suspected resident abuse and neglect during staff orientation. She stated that she trained staff to report any allegation of abuse or neglect to herself, the RSC, or the RCC within 24 hours of discovery. The administrator stated she then would take over the investigation. She stated staff were trained to contact emergency services only when abuse or neglect resulted in an injury; otherwise, they reported it to her.

Based on observation, interview, and record review, the residence failed to ensure that each staff member received initial orientation prior to providing any care or services to a resident, affecting five of five sample staff (#1-#5). (Cross-Reference S410)Findings include:Residence PolicyThe residence's Staff Training Policy, dated 8/25/22, read in part that the residence provided initial orientation to staff based on state regulations and the needs of the residents being served in the residence. All training was documented and retained in the staff files. ObservationOn 3/4/24, from approximately 7:15 a.m. to approximately 2:00 p.m., Staff #2 was observed providing care and services to residents. Record ReviewOn 3/4/24 at 9:07 a.m., personnel files for Staff #1-#5 were requested. The files provided did not include any documentation that the residence provided orientation for Staff #1-#5 prior to providing any care or services to a resident. A staff roster, provided by the administrator on 3/4/24, revealed the following:Staff #1 had a hire date of 1/18/24;Staff #2 had a hire date of 2/13/24;Staff #3 had a hire date of 12/20/23;Staff #4 had a hire date of 11/29/23;Staff #5 had a hire date of 11/17/23. The February and March 2024 staff schedules revealed the following:Staff #1 provided care and services to residents on 2/4, 2/5, 2/7, 2/8, 2/11, 2/13, 2/15, 2/18, 2/20, 2/22, 2/25, 2/26, 2/28, 3/1, and 3/3/24. Staff #2 provided care and services to residents on 2/27, 2/19, and 3/3/24. Staff #3 provided care and services to residents on 2/3, 2/4, 2/7, 2/8, 2/10, 2/11, 2/18, and 2/19/24. Staff #4 provided care and services to residents on 2/3, 2/6-2/14, 2/16, 2/17, 2/20-2/24, 2/28, 2/29, 3/1, and 3/2/24. Staff #5 provided care and services to residents on 2/3, 2/7, 2/12, 2/14, 2/17, 2/19, 2/21, 2/23, and 3/2/24. InterviewOn 3/4/24 at 3:11 p.m., the administrator stated that sometimes they did not complete orientation with new staff prior to allowing them to provide care and services to the residents. She stated, "We're not documenting it (orientation), and they're not getting it." She stated the residence had not provided the five sample staff (#1-#5) orientation, but she acknowledged that they were currently on the residence's schedule. The administrator stated that all five sample staff were the most recently hired staff, so they had not completed orientation yet.

Based on interview and record review, the residence failed to update a comprehensive assessment whenever a resident's condition changed from baseline status, affecting one of four current sample residents (#3). Findings include:Residence policyThe residence's Evaluations policy, dated 8/25/22, read in part that the residence reviewed and updated comprehensive assessments every six months or as needed for changes in baseline status. Record ReviewA comprehensive assessment, dated 12/18/23, read in part that the resident required stand-by assistance with mobility and transfers and reminders to use her ambulatory device. It read that Resident #3 had sustained two falls: on 12/11/24 and 12/14/24. The assessment read that a medicated lotion was to be applied to the resident's legs twice daily due to Resident #3 scratching at her skin. The assessment indicated that a goal for Resident #3 was to have no complications resulting from cellulitis or edema and to maintain clean and intact skin. A care communication note, dated 1/4/24, read that staff noted "leakage" on Resident #3's lower legs. A care communication note, dated 1/10/24, read in part that Resident #3's left leg was "leaking water."A care communication note, dated 1/27/24 read in part that Resident #3 used a wheelchair that day because her feet were swollen and she could barely walk. A progress note, dated 1/29/24, read in part that the administrator, a nurse, and the practitioner discussed Resident #3's recent consistent decline both physically and mentally. The practitioner reviewed Resident #3's test results, which showed multiple mini strokes. It appeared that Resident #3's vascular dementia was progressing and decline would continue. A progress note, dated 2/8/24, read in part Resident #3 weighed 126.8 pounds in January 2024. Her weight was currently 121.3 pounds. The weight difference could have been from the excess fluid that had been "removed."A care communication note, dated 2/11/24 read in part that the resident was in her room all day. She did not feel good and was weak. A care communication note, dated 2/14/24, read in part hat Resident #3 was really weak, had a bad cough, was in bed all day and required two staff to assist her with care. A progress note, dated 2/15/24, read in part: Resident #3 was admitted for services with an external service provider (ESP), who will deliver a hospital bed. A progress note, dated 2/21/24, read in part: Resident #3 was weaker and was no longer ambulatory. A progress note, dated 2/28/24, read in part: A specialty wheelchair was ordered by the ESP and delivered to the residence. Resident #3 was anxious and restless, requiring one on one oversight. New medication orders were placed for anxiety and restlessness. The comprehensive assessment was not updated after Resident #3 experienced changes in the condition of her lower legs, sustained multiple mini-strokes, increased falls, weight loss, or as Resident #3 experienced a steady decline in both her physical and mental baseline status. InterviewsOn 3/4/24 at 3:20 p.m., the practitioner for Resident #3 stated that over approximately the two months prior to the on site investigation, Resident #3 had declined and was no longer able to coordinate movement or communicate. The practitioner stated that Resident #3 started using a specialized wheelchair one week prior to the onsite investigation due to an increase in the number of falls that Resident #3 had sustained. On 3/4/24 at 4:15 p.m., the resident care director acknowledged that Resident #3 had experienced multiple changes from her baseline status, especially since the practitioner discontinued her heart medications on 2/13/24. She acknowledged that she had not updated the comprehensive assessment with these changes as required. On 3/4/24 at 4:15 p.m., the administrator stated that the residence did not update a comprehensive assessment when there was a change in a resident's baseline status, unless there was a change in that resident'scare level.

Based on interview and record review, the residence failed to implement a fall management program which included providing fall management education and materials to residence and family members, detailing in the resident's care plan the individualized approaches necessary to address fall risk, and providing staff training related to fall prevention, affecting 43 current residents. (Cross-Reference S1146)Findings Include: 1. References and Residence Policya. The residence's undated fall management policy read in part that residence staff reviewed the Fall Intervention sheet and the Environmental Screen: Resident Room section for interventions, and added the interventions to the care plan for the staff to follow. 2. Failure to develop a policy and procedure that included all required elementsOn 3/4/24 at at 8:20 a.m., the administrator was asked to provide the residence's current fall policy. The provided policy was untitled and undated. The policy was missing the following elements:(A) Providing fall management education and materials to residents and family members; and(E) Providing staff training related to fall prevention as specified in Part 7.8(B)(6). No additional policies related to the residence's fall management program were provided. 3. Resident #3 was admitted to the residence on 11/21/22 with diagnoses including chronic pain and osteoporosis. Record ReviewA care plan, dated 12/24/23, read that the residence's goals for Resident #3 were to maintain her current level of ambulation, minimize fall risk, and reduce the number of avoidable falls. The following interventions were listed to achieve these goals:Encouraged participation in activities to increase strength and mobilityEncouraged Resident #3 to walk to meals and activities. Ensure appropriate fitting clothing and footwearKeep room clear from clutter and hazardsMake staff aware that resident was at risk for fallsProvide escort to meals and activitiesProvide evening safety checks or monitoringProvide stand-by assistance with mobilityRemind resident to use assistive devices at all times (walker)Remind resident to use call light when needing assistanceKeep call light and most frequently used personal items within reachAssist with toileting every two hours when awakeAn incident report, dated 1/19/24, read that Resident #3 was transported to the emergency department. There was no other information on the report that indicated the reason for the transport. A hospital discharge note, dated 1/19/24, read in part that the resident had sustained an unwitnessed fall at the residence at 1:30 p.m. on 1/19/24. The resident had increased falls in the last six months. The last known fall, according to the emergency responders, was 12/14/24 but before that was unknown. A care communication note, dated 1/19/24 read in part that Resident #3 returned from the hospital; she had a fall and needed night checks. A progress note, dated 1/23/24, read in part: Another resident found Resident #3 lying on the floor of a doorway. Resident #3 was transported to the emergency department and returned to the residence that day. A progress note, dated 2/12/24, read in part: Staff found Resident #3 lying on the floor asleep. The resident was unable to explain how she ended up on the floor, due to cognitive impairment. An incident report, dated 2/21/24 at 1:30 p.m., read in part that the resident was found on the floor of her living room asking for help. An incident report, dated 2/21/24 at 10:54 p.m., read in part that staff found Resident #3 on the floor of her bathroom. A progress note, dated 2/22/24, read in part: Staff found the resident on the floor of her bathroom. Resident #3 had poor safety awareness and attempted to ambulate independently. A progress note, dated 2/25/24, read in part: Staff found Resident #3 in her bathroom lying on her back calling for help. The resident was placed in her wheelchair in a place where staff could see and monitor her. The care plan, updated on 2/25/24, read in part that Resident #3 had multiple falls during that month. She required monitoring for safety. "Do not leave her in her room during the daytime." This was the only fall intervention that the residence added to the care plan between 12/24/23 and 3/4/24. The care plan further read that the resident fell once on 2/12/24, twice on 2/21/24, once on 2/25/24 and twice on 2/28/24. An incident report, dated 2/28/24 at 2:09 a.m., read in part that the resident had pressed her call pendant. Staff found her sitting down on the floor yelling for help. An incident report, dated 2/28/24 at 2:50 p.m., read in part: Staff found Resident #3 lying on the floor in front of her wheelchair. A progress note, dated 2/28/24 at 4:37 p.m., read in part: A specialty wheelchair was ordered by the ESP and delivered to the residence. A progress note, dated 3/2/24, read in part: Resident #3 was found on the floor in the hallway. A care communication note, dated 3/3/24, read in part to watch Resident #3. She kept trying to get up and she fell. The residence documented that Resident #3 fell seven times from 1/19/24 to 2/25/24. The residence added one fall intervention to the care plan on 2/25/24, and the resident sustained five additional falls within a seven day period, from 2/26/24 to 3/3/24. The residence failed to subsequently address additional fall prevention interventions in the care plan. InterviewsOn 3/4/24 at 7:43 a.m., Staff #6 stated that Resident #3 fell frequently. She stated she checked on her frequently, assisted her with her walker, and encouraged her to notify staff for help. She stated, however, that Resident #3 continued to fall. On 3/4/23 at 12:03 p.m., Staff #7 stated Resident #3 fell frequently. She stated that she now used a specialized wheelchair to prevent her from falling forward out of her wheelchair. Staff #7 stated that approximately one week prior to the onsite investigation, the resident still got up from the wheelchair and fell. Staff #7 stated Resident #3 liked to walk, adding that she herself felt that she needed to check the resident every 10 minutes to prevent her from falling. On 3/4/24 at 3:20 p.m., the practitioner for Resident #3 stated that over approximately the two months prior to the on site investigation, Resident #3 had declined and was no longer able to coordinate movement or communicate. She stated the resident was admitted for external services approximately one month prior to the on site investigation, but she had continued to fall since then. The practitioner stated that Resident #3 started using a specialized wheelchair one week prior to the onsite investigation, but again, the resident continued to fall. On 3/4/23 at 3:40 p.m., Staff #8 stated she did not remember getting any training on fall management. She stated that it was likely because "I don't think there's a lot of falls here."On 3/4/34 at 3:45 p.m., Staff #10 stated she did not recall receiving training regarding fall management. On 3/4/24 at 4:06 p.m., the administrator stated the residence provided fall prevention materials to the residents upon admission during a resident orientation but no other time. She stated that the residence did not provide any fall prevention materials to family members, adding "our fall policy needs work."On 3/4/24 at 4:15 p.m., the resident care director stated she had not completed any fall management training with the staff since she started working at the residence (on 11/6/23). She stated the care plan for Resident #3 was updated to reflect some of the dates that she sustained a fall, adding that she had added new fall interventions but the care plan did not indicate the dates that she added them.

Based on interview and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed or was reported to them, affecting two of four current sample residents (#3, #4). Findings include:Residence PolicyThe residence's Progress Notes policy, dated 8/22/22, read in part that staff recorded observations and changes regarding a resident in the progress notes of the residence's electronic information management system. Designated individuals, including qualified medication administration persons and care staff, documented in the progress notes. The policy further read that progress notes should include significant changes in mood, attitude, or behavior; changes of condition, new medical symptoms, special concerns, clinical follow up, and the resident's responses to their medical plan of care. Record ReviewA care communication note, dated 3/3/24, read (with regard to Resident #3): "Please watch her. She keeps trying to get up and she fell." There was no corresponding progress note with more information about the resident's status or well-being or how the fall affected her physical, behavioral, or functional condition. Additionally, there was not note addressing the action taken by staff to address Resident's #3's changing needs. InterviewsOn 3/4/24 at 10:00 a.m., the administrator stated that staff informed the resident care director (RCD) and the resident care coordinator (RCC) about the residents' status and well-being or any out of the ordinary event or issue that affected the residents' physical, behavioral, cognitive and/or functional condition. She added that the RCC and/or the RCD would then document a progress note. On 3/4/24 at 1:47 p.m., the RCD stated that when a resident fell, the staff documented in an incident report on the date that the fall occurred. She stated, however, that the incident report was not considered a progress note. She stated she (not the staff) entered a progress note after reviewing the incident report (not consistently before the end of each staff's shift), which could be up to three days after the incident. She stated Resident #3 sustained a fall on 3/3/24, but she had not completed the incident report, and therefore there was no progress note. On 3/4/23 at 3:40 p.m., Staff #8 stated when a resident sustained a fall, she documented the incident in an incident report and the RCD then reviewed it. She stated that in the staff's care communication log, she documented that the resident fell and what their vital signs were. Staff #8 stated that she did not document any details about the incident nor the actions she took to address the resident's changing needs in a progress note. Evidence obtained during the onsite investigation revealed that the residence additionally failed to require staff members to enter progress notes before the end of their shift for Resident #4.