STONECREEK OF FLYING HORSE

A relicensure survey with complaint #CO37919 and #CO38101 was completed on 11/7/24. Deficiencies were cited. The investigation revealed the residence had four different acting administrators from 10/25/24 through 11/5/24 as follows: On 10/25/24, the wellness director (WD) acted as the administrator until approximately 1:00 p.m. On 10/25/24 at 1:00 p.m., the assistant wellness director (AWD) was the acting administrator. From 10/26/24 to 10/29/24, the WD acted as the administrator. On 10/29/24, the administrator of record acted as the administrator until the residence terminated her at 8:00 p.m. On 10/29/24 at 8:00 p.m., the WD acted as the administrator until 11/4/24 at approximately 11:00 a.m., when the residence suspended her. Despite the suspension, the residence notified the Department that the WD was the administrator of record as of 11/4/24. On 11/4/24 and 11/5/24, the regional vice president of operations acted as the administrator of the residence.

Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting 87 current residents. (Cross-reference S0540, S0640, S0648, S1410, S1412, S2210, S2230 and S3076)Findings include:Chapter VII regulations governing assisted living residences, part 18.8 requires that resident records contain, but not be limited to, the following items: (B) Practitioner order; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. On 10/29/24 at 10:35 a.m., the files for Residents #8, #9, and #12-#15 were requested. The resident files were requested again at 12:35 p.m. and not received until approximately 2:30 p.m. On 10/30/24 at 12:00 p.m., the personnel files for Staff #1, #3, #5-#9 were requested. The files were provided at 1:00 p.m.; however, the files did not contain the required documentation. A second request was made and the rest of the files were provided at 3:00 p.m. On 10/30/24 at 4:00 p.m., the wellness director who was acting as the administrator stated she was aware of the requirement to provide requested documentation to the department upon request. However, with the administrator of record no longer employed at the residence, she could not explain why they did not.

Based on interview and record review, the residence failed to report suspected caretaker neglect to law enforcement within 24 hours of discovery, affecting two of two current residents (#12, #15) for whom abuse was alleged. (Cross-reference S0540, S0640, S1322, S1410, and S1412)Findings include:1. Record ReviewElectronic messages, dated 10/25/24-10/26/24, read that the family member for Resident #12 alleged that the resident was abused by strangulation to the wellness director (WD) and to the assistant wellness director (AWD) and that the family member planned to report the abuse to law enforcement (LE). The WD and AWD responded to the messages; however, they did not respond that the residence planned to contact LE. An electronic communication, dated 10/26/24, sent by the administrator of record, read: "I'm sorry for the late response, I'm out of state on (paid time off). #1 Reported to state, (LE), and APS (adult protective services). #2 Investigation started. This involves suspension, statements, and cameras. This should be concluded in (five) days. I hate not being on-site, and I have full confidence in (WD) and (AWD). I will continue to monitor and record."An incident report, dated 10/25/24 and completed on 10/29/24, read in part that that a family member of Resident #12 reported that the resident had bruises on her eyes and around her neck. The incident report did not read that the residence reported the alleged abuse to LE.A progress note, dated 10/27/24, read that the WD contacted the external service provider (ESP) on 10/26/24 to check on Resident #12. The WD notified the former administrator and the regional health and wellness director (RHWD) of the report. Further, the family member of Resident #12 planned to contact LE to report the incident and that the residence also wanted to make sure that the reporting was completed. The note read that the residence contacted APS and an outside agency representative (OAR); however, the note did not include that staff notified LE. On 10/29/24, the administrator of record was unable to provide evidence that the residence reported the incident to LE. 2. InterviewsOn 10/29/24 at approximately 11:00 a.m., the administrator of record stated that she reported the abuse allegation to APS, an OAR, and the Department on 10/26/24. She acknowledged she did not report it to LE and should have done so on 10/25/24. She added she had not been working on 10/25/24-10/28/24, and she returned to the residence on 10/29/24. She stated she expected the WD and AWD, who were her designees, to have reported the abuse to LE upon discovering the abuse allegations, but they did not do so. On 10/29/24 at approximately 11:00 a.m., the AWD stated that she became aware of the bruising on 10/25/24 at 4:00 p.m. She stated she did not report the abuse allegation to LE. She added that she should have notified LE and that she was aware that she was a mandated reporter. On 10/29/24 at 12:10 p.m., the WD said she was unsure whether the bruising was abuse or neglect. She said she did not report suspected abuse to LE. She stated she was a mandated reporter and she acknowledged that she should have called LE. 3. Evidence obtained during the onsite investigation revealed that the residence additionally failed to report an allegation of abuse of Resident #9 to LE.

Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting three of three sample residents (#9, #12, and #16) (Cross-reference S0540, S0640, S1322, S1410 and S1412)Findings include:A progress note, dated 10/26/24, read in part that Resident #9's family member requested a nurse assessment and stated there were bruises up and down his arms and a scab on his elbow. Resident #9's family member requested that the residence document all of his injuries. The family member stated she thought Resident #9 was being abused and had contacted an outside agency representative (OAR). On 10/29/24 at approximately 12:30 p.m., the wellness director (WD) stated that she should have reported the allegation of abuse of Resident #9 to the Department but did not do so. On 10/29/24-11/5/29, review of the Department database revealed that the residence did not report the abuse allegation as required. Additionally, evidence obtained during the onsite investigation revealed that the residence failed to comply with occurrence reporting required by state law for Residents #12 and #16.

Based on observation and interview, 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) and failed to ensure that the administrator ran the day-to-day operations of the residence affecting 87 current residents. (Cross-reference S0410, S0430, S0612, S0640, S0648, S0720, S1322, S1410, S1412, S1522, S1610, S2210, S2230, S3076, B0290)Specifically, Resident #16 tested positive for COVID-19 on 10/31/24. The resident returned to the residence on 11/4/24, and the residence did not isolate the resident for the required five days to protect other residents. On 11/4/24, Resident #16 ate breakfast in the residence's dining room with three residents at the same table, and four additional residents sat at a table within six feet of Resident #16. Staff were aware of the positive test result; however, staff failed to don personal protective equipment (PPE) when providing direct care to the resident, and they failed to don masks throughout the residence. Further, the residence failed to post notification of the positive COVID-19 status at the residence, failed to perform the required reporting of the confirmed COVID-19 positive test result to the Department, and failed to implement testing of staff and residents. This failure created an immediate jeopardy risk to all 87 current residents. On 11/4/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Residence Policya. Assisted Living Residences and and Group Home COVID-19 Mitigation and Outbreak Guidance, dated 10/1/24, required residences to:-Investigate when at least one resident or staff member has a positive COVID-19 test result.-Based on the investigation, follow reporting guidelines to public health.-Identify and test staff and residents who were exposed to COVID-19 using either contact tracing or broad-based testing. Contact tracing is the process of identifying people who have recently been in close contact with someone diagnosed with an infectious disease. Close contact is defined as being within six feet of a person with SARS-CoV-2 infection for a total of 15 minutes or more over a 24-hour period or having unprotected direct contact with infectious secretions or excretions of the person with SARS-CoV-2 infection.-Isolate residents who have respiratory symptoms or have tested positive for COVID-19 for five days, whether asymptomatic or symptomatic. The day of the person's first positive viral test is Day 0.-Consider people with weakened immune systems or severe illness can take longer to recover and may be contagious for a longer period of time. If a resident with suspected or confirmed COVID-19 is immunocompromised or has a severe illness, consider consulting the resident's doctor before ending isolation.-Implement infection prevention and control practices, such as staff providing in-person services for a resident in isolation for COVID-19 to follow recommended IPC practices to protect themselves and others from potential exposures. These measures include hand hygiene, implementation of transmission-based precautions for COVID-19 (with appropriate PPE), and enhanced cleaning and disinfection. The facility should provide the necessary supplies to adhere to recommended IPC practices.-Implement source control among staff and residents. Source control includes high-quality, well-fitting masks or respirators for source control in the facility as follows: Residents who are in isolation for COVID-19 or undiagnosed respiratory illness should wear source control when around others and when leaving their room. All staff and residents identified as close contact with someone with COVID-19 should start wearing source control immediately and continue for 10 days following their last exposure. Everyone is tested for COVID-19 - whether identified through contract tracing or included in broad-based testing.b. The residence's COVID-19 Response Plan, dated 2/17/23, read in part that the administrator and/or wellness director were in charge of the COVID-19 response. The residence quarantined all residents with signs and symptoms of COVID-19 for ten days. Further, the residence required all staff to wear N95 masks, eye protection, gloves, and gowns when interacting with or caring for residents with confirmed or suspected COVID-19. 2. Prevention of the Possible Development and Transmission of COVID-19a. ObservationsOn 11/4/24, from approximately 8:10 a.m. to 10:00 a.m., Staff #1, #4, and #5 donned no PPE while working in direct contact with Resident #16. On 11/4/24, from approximately 8:30 a.m. to 8:45 a.m., Resident #16 sat at a table in the residence's common dining room with three unidentified residents and within six feet of four additional unidentified residents. On 11/4/23 at approximately 10:30 a.m., Resident #16 was within six feet of Resident #9 without a mask. b. Record Review Resident #16 was admitted to the residence on 4/15/22 with a diagnosis of dementia. Post-hospitalization discharge documentation, dated 11/3/24, read in part that Resident #16 tested positive for COVID-19 on 10/31/24 and presented with a high fever, altered mental status, and hypoxia. Progress notes, dated 10/31/24-11/5/24, read in part as follows:On 10/31/24, Resident #16 was hospitalized and tested positive for COVID-19. On 11/4/24, Resident #16 returned to the residence from the hospital in the afternoon. On 11/5/24, late entry: On 11/4/24 at 12:00 p.m., the resident was placed in isolation after a positive COVID-19 test at the hospital. Signage and an isolation cart were placed outside her door. c. InterviewsOn 11/4/23 at approximately 8:30 a.m., Staff #5 stated that Resident #16 returned to the residence on 11/3/24, and she was aware that the resident returned after testing positive for COVID-19; however, the residence had not directed the staff to ensure isolation precautions were in place despite the resident having tested positive within the previous four days. She added that she believed the resident ate dinner in the common dining room with other residents on 11/3/24, and she acknowledged that Resident #16 was currently seated in the common dining room within six feet of seven other residents. On 11/4/24 at 10:13 a.m., the wellness director (WD) stated that Resident #16 returned to the residence before dinner on 11/3/24. She stated she did not direct staff to place the resident on isolation precautions because a family member of Resident #16 stated that the resident had a false positive test result. She added that she should have confirmed that before integrating the resident back into the residence without isolating and masking. The WD affirmed she should have directed the staff to implement isolation precautions and don masks since there was no evidence of a false positive test result. On 11/4/24 at 10:16 a.m., the practitioner's nurse for Resident #16 stated that Resident #16 had a confirmed positive test result for COVID-19 as of 10/31/24 and should have been isolated away from other residents. He added that he checked with the resident's team of practitioners, and there was no evidence that there was a false positive test result for COVID-19. On 11/4/24 at approximately 10:45 a.m., the regional vice president of operations (RVPO) stated that the residence suspended the WD due to concerns regarding her mishandling of COVID-19 protocols. On 11/4/24 at 12:30 p.m., a family member of Resident #16 stated that Resident #16 had a confirmed positive test result for COVID-19 as of 10/31/24. On 11/4/24 at 1:08 p.m., the infectious disease practitioner for Resident #16 stated that he could not confirm that the resident had a false positive test result for COVID-19.d. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed 15 current residents in the secure environment (SE) at immediate jeopardy risk for COVID-19 exposure. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 11/4/24 at 2:13 p.m., the RVPO submitted written evidence that read in pertinent part: "1. Action: On 11/4/24, resident (#16) was immediately placed on isolation to mitigate potential exposure to other residents. PPE box was placed outside of resident's apartment and signage posted on (the resident's) apartment door. Completion Date: 11/4/24 Completed by: (Assistant Wellness Director [AWD]) 2. Action: On 11/4/24, staff were informed of Resident (#16) COVID-19 positive status and provided with updated protocols regarding resident isolation and use of personal protective equipment. Completion Date: 11/4/24 Completed by: (AWD) 3. Action: Starting on 11/4/24, the (RVPO) began inservice for all staff on infection control protocols. All staff not in-serviced have been removed from the schedule until they have been in-serviced. Completion Date: 11/4/24 Completed by: (RVPO) 4. Action: On 11/4/24, families and responsible parties of other residents in the (SE) were informed of the exposure risk and measures being taken to ensure resident safety. Start Date: 11/4/24 Completion Date: 11/4/24 Completed by: (RVPO). 5. Action: On 11/4/24, all residents residing in the (SE) were tested for COVID 19 except for (two) residents that refused. All residents tested have tested negative at this time. Completion Date: 11/4/24 Completed by: (AWD) 6. Action: On 11/4/24, (RVPO) contacted local public health department and the Department. Completion Date: 11/4/24 Completed by: (RVPO)."However, the written evidence did not indicate the risk had been removed because it did not include how the residence ensured that staff understood the protocols in the event another resident had a positive COVID-19 test. The RVPO was directed to submit additional written evidence. On 11/4/24 at 4:46 p.m., the RVPO submitted additional written evidence that read in pertinent part: "7. Action: On 11/4/24, (RVPO) will conduct an in-service for all staff COVID-19 positive residents returning from the hospital, including proper PPE to be utilized. All staff not in-serviced have been removed from the schedule until they have been in-service. Communication will be via verbal during shift change, progress note, or via phone call if resident is being readmitted from hospital."2. Administrator Overseeing Day-to-Day Operationsa. Reference Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management and maintenance of the assisted living residence.b. Administrator of Record and Administrator DesigneesOn 10/24/24 through 10/25/24, the administrator of record was on leave and not working at the residence until 10/29/24. The administrator appointed the WD to manage the day to day operations during her approved leave. The WD was acting as the administrator until approximately 3:00 p.m. on 10/25/24. On 10/25/24 at 1:00 p.m., the assistant wellness director (AWD) was acting as the administrator. On 10/26/24 until approximately 10/29/24, the WD returned and was acting as the administrator. On approximately 10/29/24, the administrator of record returned to the administrator role until the residence terminated her at 8:00 p.m. On 10/29/24 at 8:00 p.m., the WD acted as the administrator until 11/4/24 at approximately 11:00 a.m., when the residence suspended her. On 11/4/24 and 11/5/24, the RVPO acted as the administrator. On 11/4/24, despite the residence's suspension of the WD, the residence notified the Department that the WD was the administrator of record as of 11/4/24. c. Record ReviewOn 10/29/24, investigations of injuries of unknown origin and abuse for Resident #12 were requested; however, the administrator of record, the WD, and the AWD could not provide any documentation because the residence had not started an investigation.d. InterviewsOn 10/29/24 at approximately 12:00 p.m., a family member of Resident #12 stated that she reported bruising around the resident's neck and eye due to possible strangulation on 10/25/24 to WD and AWD; however, the WD was ill and not working at the residence, and the AWD left the residence and failed to start investigating the bruises or the allegation of abuse. On 10/29/24, at approximately 12:00 p.m., the AWD stated that on 10/25/24, a family member of Resident #12 reported bruising and possible strangulation around the resident's neck and eye. She stated that she was done working for the day and she left the residence without starting an investigation of the bruises and possible strangulation. On 10/29/24, at approximately 12:00 p.m., the WD stated that on 10/25/24 she was out sick and not working at the residence; the AWD was the acting administrator and assumed the duties of the day to day operations. The WD added that she returned to the residence on 10/26/24, and resumed managing the day to day operations of the residence. She stated that the family member of Resident #12 reported that the resident had bruises to her neck, eye, and face, and she contacted the administrator of record. She added that on 10/26/24, the administrator of record instructed the WD and the AWD to start an investigation of injuries sustained by alleged abuse and collect statements from staff who provided care to Resident #12. On 10/30/24 at approximately 10:00 a.m.,the RHWD stated that the administrator of record was terminated and that the WD had completed the administrator training and would be the acting administrator. On 11/4/24 at approximately 10:00 a.m., the RVPO stated that WD was suspended as of 11/4/24 and that she and the RHWD would alternate weeks as the acting administrator until they found a replacement.

Based on observation, record review, and interview, the residence failed to ensure applicants complied with Colorado Adult Protective Service Data Systems (CAPS) requirements prior to hiring staff who provided care to the residents for one of seven sample staff (#8), affecting 87 current residents. (Cross-reference S0540, S1322 and B0290)Chapter VII regulations governing assisted living residences, part 2.8, defines "At-risk person" as any person who is 70 years of age or older. Resident records revealed that Residents #8, #9, #12, and #14-#19 were 70 years of age or older. The personnel file for Staff #8 revealed a hire date 9/19/24; however, the file contained no CAPS check for Staff #8. Staff #8 provided care and services to residents who were at-risk adults. The staff timesheet, dated 10/20/24-11/3/24, revealed that Staff #8 provided care and services to residents as follows: 10/20/24, 10/22/24, 10/24/24-10/28/24, and 11/1/24-11/3/24. On 11/05/24 at 1:35 p.m., the regional vice president of operation said the residence did not complete a CAPS check for Staff #8. She said the residence should have requested a CAPS check before the staff worked with residents.

Based on interview and record review, the residence failed to ensure each staff member received orientation and training prior to providing any care services to a resident for seven of seven sample staff (#1, #3, #5-#9), affecting 87 current residents. (Cross-reference S0410, S0430, S0540, S0648, and B0290)Findings include: On 10/29/24 and 10/30/24 from 7:00 a.m. to 2:00 p.m., Staff #3 provided personal care services to residents. Personnel files for Staff #1, #3, and #5-#9 contained documentation that they had completed initial orientation; however, their initial orientation did not include the following required elements: training on the care and services provided by the assisted living residence, assignment of duties and responsibilities specific to the staff member, reporting requirements, including occurrence reporting procedures, house rules, where to immediately locate a resident's advance directive, nor an overview of the assisted living residence's policies and procedures and how to access them for reference. The October 2024 staff schedule revealed that Staff #3 worked on 10/1, 10/3, 10/5-10/8, 10/10, 10/15, 10/19-10/21, 10/25, and 10/26/24. Further, the staff schedule revealed Staff #1 and Staff #5-#9 worked in the residence providing personal care services to residents. On 11/5/24 at 1:35 p.m., the regional vice president of operations stated she was unaware that the initial staff orientation that the residence provided to all newly hired staff did not meet all of the requirements.

Based on observation, interview, and record review, the residence failed to ensure each staff member completed training relevant to their specific duties and responsibilities prior to working independently for seven of seven sample staff (#1, #3, #5-#9), affecting 87 current residents. (Cross-reference S0540, S0640 and B0290)Findings include: On 10/29/24 and on 10/30/24 from 7:00 a.m. to 2:00 p.m., Staff #3 provided personal care services to residents. Personnel files for Staff #1, #3, and #5-#9 revealed that the residence failed to ensure that the staff received all required training prior to providing personal care to residents. The October 2024 staff schedule revealed that Staff #3 worked on 10/1, 10/3, 10/5-10/8, 10/10, 10/15, 10/19-10/21, 10/25, and 10/26/24. Further, the staff schedule revealed that Staff #1, and #5-#9 worked in the residence providing personal care services to residents. On 11/5/24 at 1:35 p.m., the regional vice president of operations stated she was aware that staff were required to complete training prior to providing care to residents. However, she was unaware the training did not meet all of the requirements per state regulations.

Based on record review and interview, the residence failed to ensure that staff were sufficient in number considering the acuity and needs of the residents, the services outlined in the care plan, and services set forth in the resident agreement, affecting 87 current residents. (Cross-reference S0540)Findings include:1. Residence PolicyThe residence's undated staffing policy read in part that the residence provided staff sufficient in number to meet the care needs of the residents and maintain a safe and clean environment. The residence based their staffing needs on the acuity of residents, the services outlined in the resident care plans, and the services set forth in the resident agreement. The residence reviewed staffing needs monthly. 2. Record ReviewFamily council minutes, dated 8/21/24, read in part that resident family members had safety concerns related to insufficient staffing. There was constant staff turnover. The residence pulled staff from the secure environment (SE) to cover the assisted living. The lack of consistency in staffing affected the quality of care of the residents. Family council minutes, dated 9/5/24, read in part that the family members of residents in the SE were concerned that staff were not showering the residents. The family members stated that external service providers (ESP) were not responsible for showering the residents. Family council minutes, dated 10/3/24, read in part that family members voiced concern that multiple residents had urinary tract infections and this was an ongoing concern. The family members were concerned that not all staff did a good job with the care they gave the residents, that residents spent too much time in soiled incontinence products, that the family members themselves changed resident incontinence products since the staff were too busy, and that the staff did not encourage the residents to drink water. The family members wanted staffing numbers based on assessment scores and the needs of the residents. The family members were concerned that staff often did not show up to work. The family members voiced that the SE frequently had only two staff to care for 15 residents from 2:00 p.m. to 10:00 p.m. The family members added that the SE was frequently short staffed on weekends. The residence's staff schedule, dated 10/16/24-11/2/24 revealed 11 staff worked double shifts at the residence with 33 total double shifts. Timesheets for the entire residence, dated 10/26/24-11/2/24, read the following:Two staff worked on 10/26/24 worked from 6:00 a.m. to 10:00 a.m. Three Staff worked on 10/27/24 from 6:00 a.m. to 10:00 a.m. Two staff worked on 10/28/24 from 6:00 a.m. to 2:00 p.m. Two Staff worked on 10/29/24 from 7:00 a.m. to 2:00 p.m. and two staff started at 10:00 a.m., Three staff worked on 10/30/24 from 6:00 a.m. to 2:00 p.m. Three staff worked on 11/2/24 from 6:00 a.m. to 7:00 a.m. and two staff worked until 2:00 a.m. 3. InterviewsOn 10/29/24 at approximately 8:30 a.m., Staff #1 said when the SE had three staff they were able to complete their duties. Staff #1 said they often had only two staff in the SE. Staff #1 said staff did not assist the residents with needed showers or incontinence care when the residence was short staffed. On 10/29/24 at approximately 8:45 a.m., Staff #5 said that the SE was often understaffed. Staff #5 said the staff could not provide residents with shower assistance due to insufficient staffing. On 10/29/24 at approximately 8:45 a.m., Staff #4 said she felt comfortable when there were three staff in the SE; however, the SE often had only two staff working. She said that residents went without required line-of-sight supervision due to staffing. Staff #4 added that the lack of supervision resulted in increased resident falls and staff being unable to intervene with behavioral issues. On 11/5/24 at 7:30 a.m., Staff #12 stated that she often administered medications to residents "later" than the residents wanted in the mornings because she also had to help get the residents up and provide personal care. Additionally, she stated due to the lack of staff in the dining room, care staff were often pulled away from care tasks to assist with serving food and drinks to the residents. On 11/5/24 at at approximately 7:45 a.m., Staff #20 stated when care staff served in the dining room because there was not enough staff, they did not assist residents with showers because they ran out of time. Further, Staff #20 stated that if the residence required an evacuation, staff would not be able to get all of the residents out promptly due to the lack of sufficient staffing. She stated three residents required two-person assistance with transfers and mobility, and multiple residents who resided on the second floor required walkers or wheelchairs. On 11/5/24 at approximately 1:15 p.m. Staff #3 said she was required to work double shifts. She said she did two double shifts weekly. Staff #3 said working double shifts specifically during the night shift was difficult. She said after working the night shift, she had to work short-staffed, adding that staff was unable to complete all care tasks due to staffing concerns. She said staff frequently were unable to assist residents with showers or ensure resident safety due to lack of staffing and lack of supervision of residents who expressed behaviors in the SE.On 11/5/24 at 9:15 a.m., Staff #9 said the residence was often understaffed. She said she often had to work twice as hard in the mornings to meet resident care needs because the residence did not have enough staff. Staff #9 said the SE often only had two staff members in the mornings. She said she felt extremely tired and that it was hard to keep up with resident needs and provide quality care when staff were tired and working understaffed. Staff #9 said the result was that residents often went without showers. On 11/5/24 at 9:20 a.m., Staff #10 said the residence was under-staffed which made it difficult. She said she worked double shifts regularly. Staff #10 said that in the mornings there were often two staff members working. She said because she was exhausted and the residence was understaffed it made it difficult to ensure all resident needs were met. Staff #10 said meals would be served late and residents often were not assisted with showers. On 11/5/24 at 9:28 a.m., Confidential Staff #15 said there was not enough staff in the SE. She said there often were only two staff so staff would often not respond to residents' call lights in a timely manner. She said they were unable to provide assistance to residents with showering, housekeeping and changing them when soiled due to being short staffed. On 11/5/24 at 9:30 a.m., Staff #11 said the residence was often understaffed. He said it made it difficult to take care of the residents adequately; staff were not able to help residents with changing their incontinence products and toileting because there were too many residents to assist and too few staff. On 11/5/24 at 9:35 a.m., Staff #7 said the SE was often short staffed. She said the staff were required to leave the SE to go to the kitchen to retrieve meals, which took away from the residents who needed assistance. Staff #7 said the staff was unable to consistently meet the needs of the residents due to being tired and understaffed. On 11/5/24 at 9:58 a.m., Resident #20 said the residence was often understaffed. He said staff had to help in the kitchen and help residents. Resident #20 said staff would help in the kitchen which left residents without getting the help they needed. He said staff could not help him when he needed it because they were helping other residents. On 11/4/24 at 1:20 p.m. an external agency representative (EAR) said the secure environment never had sufficient staff. She said that residents often asked her for help. The EAR said that residents had behavioral expressions that the staff could not handle due to insufficient staffing. On 11/4/24 at approximately 3:00 p.m., a family member of an unknown resident who resided in the SE said the residence was often short staffed. She said staff were unable to help residents with changing their briefs when soiled and would often ask family members to do so. On 11/5/24 at approximately 1:45 p.m., the regional vice president of operations, acting as the administrator, said the residence added staff according to the needs of the residents. She said double shifts were not the standard because it could make the staff tired, resulting in staff not doing their jobs well.

Based on interview and record review, the residence failed to ensure staff observed a resident's right to be free from physical abuse, affecting one resident (#12). (Cross-reference S0410, S0430, S0612, S1410)Specifically, on 10/25/24, Resident #12 presented with bruising of the eye and bruising that appeared to be finger marks around the neck. The resident was then transported to the emergency department and a forensic examination nurse provider determined possible physical abuse as the cause. Subsequently, a law enforcement (LE) report read in part that the offenses committed against Resident #12 were second-degree assault, strangulation causing bodily injury and crime against an at-risk adult. 1. Residence Agreement and Policya. The residence's undated Resident Rights policy read in part: Residents had the right to be free from physical and emotional abuse.b. The residence's undated Abuse Prohibition and Prevention policy, read in part that it was the residence's responsibility to prohibit and prevent abuse, neglect, and exploitation of residents. The policy further read: "Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish."2. Record ReviewResident #12 was admitted to the residence on 6/18/21 with diagnoses including depression and dementia. Photographs provided by an external service provider (ESP), dated 10/26/24, revealed Resident #12 had swollen eyes with deep gray and red marks measuring three to four centimeters around them. There was a bruise that measured approximately five by five centimeters on the upper right side of her forehead and several small bruises on the left side of her forehead. There was a line of bruises that resembled a thumb print and fingers on her neck and similar lines of bruises behind both ears. There were multiple bruises on the back of her head and on her left hip. An ESP note, dated 10/25/24, read in part that Resident #12 had a reddish purple area around her left eye and purple discoloration to her back, left side of her neck, right side of her neck, and under her ear. An incident report, dated 10/25/24 and finalized on 10/29/24, read in part that that a family member of Resident #12 reported to staff that the resident had bruises on her eyes and around her neck. An electronic message, dated 10/25/24 from a family member of Resident #12 to the wellness director (WD), alleged that the resident had been abused by strangulation. A hospital note, dated 10/26/24, read in part that Resident #12 had a large hematoma on the back of her skull along with multiple acute and sub-acute rib fractures. It further read that the resident sustained potential elder abuse. An ESP note, dated 10/26/24, read in part that the ESP received multiple calls regarding possible strangulation of Resident #12. The ESP conducted a skin assessment and found bruising to the eye and other areas of the body including the resident's neck. The bruising to the resident's neck was consistent with the potential of physical abuse. A law enforcement report, dated 10/26/24, read in part that the offenses committed against Resident #12 included second-degree assault, strangulation causing bodily injury, and crime against an at-risk adult. A progress note, dated 10/27/24, read in part that a family member reported to the WD and assistant wellness director (AWD) that Resident #12 had bruises around her eye and neck. Written statements, dated 10/29/24, read in part as follows:Staff #9: "While I was walking with her to the table, I was trying to tidy her hair and noticed a red circle around her eye."Staff #3: "On Friday, October 26th (sic 25th) around (1:00) p.m., (Resident #12) came out of her room and myself and another caregiver saw that she had a bruised eye ..."Written statements, dated 11/3/24, read as follows: Staff #8: "(Resident #12's) eye was not black until the next day." The statement did not specify a date. Staff #10: "(Staff #10) worked on Friday, 10/25/24. I noticed (Resident #12's) black eye ..."An ESP note, dated 11/7/24, read that Resident #12 passed away. The ESP contacted the coroner. The death was a case for the coroner's office as LE was investigating the abuse and assault of Resident #12. 3. InterviewsOn 10/29/24, a family member of Resident #12 stated she discovered the resident with a black eye and significant bruising with finger-like markings around her neck and behind her ears. She stated that on 10/25/26 she requested guidance from the WD as to when to call LE and APS. The family member added that hospital staff advised her to call LE and make other living arrangements for the resident. On 10/29/24 at approximately 8:30 a.m., during the onsite investigation, Staff #5 stated that Resident #12 "looked beat up." She added that she reported to AWD that Resident #12 looked abused due to the bruises on her face and neck. On 10/29/24 at approximately 12:30 p.m., the WD stated that she was not sure if it was abuse or neglect that resulted in bruises on Resident #12's face. On 10/29/24 at approximately 2:30 p.m., Confidential Staff #15 stated that they communicated to the AWD that on 10/26/24, Resident #12 "looked bad and abused."

Based on observation, interview, and record review, the residence failed to thoroughly investigate all allegations of abuse of residents in accordance with its written policy, affecting 87 current residents. (Cross-reference S0540, S0410, S0430, S1322, S1412)Specifically, on 10/25/24 and 10/26/24, a family member of Resident #12 reported to the wellness director (WD), assistant wellness director (AWD), and an external service provider (ESP) that Resident #12 sustained bruising caused by possible strangulation. The family member of Resident #12 reported to the WD that the alleged abuse occurred between 10/23/24-10/25/24 and the WD agreed. On 10/26/24, the administrator of record communicated to the family member of Resident #12 that the residence began taking steps to investigate abuse. Resident #12 was admitted to the hospital on 10/26/24 wherein a forensic nurse examiner (FNE) determined that the resident sustained possible physical abuse which resulted in bruising to the resident's eye and fingermark bruises around her neck. On 10/25/24-10/29/24, the residence failed to thoroughly investigate the alleged physical abuse of Resident #12 including how the residence would protect residents during the investigation. During the onsite survey, on 10/29/24, the residence provided three written staff statements, dated 10/29/24, as the residence's investigation of abuse. However, the residence failed to interview all of the staff, residents, and family members who were at the residence during the time period that the abuse was alleged. The residence suspended one staff member (#9); however, the residence could not provide evidence that Staff #9 was the alleged assailant. On 11/3/24, the residence provided three additional written staff statements, dated 11/3/24. However, the residence failed to interview all of the staff, residents, and family members who were at the residence during the time period that the abuse was alleged. On 11/4/24, the residence could not provide evidence that the staff (#1-#8, #10, #11, #13, and #14) who worked during the timeframe of the alleged abuse were not the alleged assailant. Staff #1-#8, #10, #11, #13, and #14 continued to independently provide care and services to the residents. The residence's failure to investigate alleged abuse created an immediate jeopardy risk of physical abuse to 87 current residents. On 11/4/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Residence PolicyThe residence's undated Abuse and Neglect Allegation Reporting Checklist policy read in part that the residence was required to investigate all allegations of abuse, conduct documented interviews with staff and residents, write a narrative of summary of the events, report the incident to the Department and LE, and document all actions taken to ensure the safety of residents to prevent additional incidents from happening. 2. Record ReviewResident #12 was admitted to the residence on 6/18/21 with diagnoses including depression and dementia. An ESP note, dated 10/22/24, read in part that the resident had no skin abnormalities, including bruising. Electronic messages, dated 10/25/24-10/26/24, read as follows:On 10/25, the family member of Resident #12 alleged that the resident had been abused by strangulation to the WD. The WD responded to the messages; however, she did not affirm what steps the residence was going to take other than contact the resident's ESP. The family member communicated the incident occurred between 10/23/24- 10/25/24, and the WD responded that she agreed. On 10/26, the AWD responded to the family member of Resident #12 that she reviewed video footage and planned to discipline Staff #1, #4, and #9 by writing them up; however, the residence did not provide the specifics of what Staff #1, #4, or #9 did, nor provide documentation of how the disciplinary actions protected residents from abuse during the investigation. A staff schedule for theSE, for the period that the alleged abuse occurred, 10/23/24-10/25/24, read that Staff #1-#11, #13, and #14 worked directly with residents providing care and services. An incident report for Resident #12, dated 10/25/24 and finalized on 10/29/24, read in part that that a family member of Resident #12 reported to the residence that the resident had bruises on her eyes and around her neck. The incident report did not include any documentation of an investigation into abuse nor what actions the residence took to protect the residents from future abuse. An electronic communication, dated 10/26/24, sent by the administrator of record to the family member of Resident #12 communicated that she was currently out of the residence and that the WD and AWD began an investigation. However, there was no evidence that they initiated an investigation into the allegation of abuse until 10/29/24, the date of the onsite investigation. ESP notes, dated 10/25/24-10/26/24, read in part:On 10/25, Resident #12 had a reddish purple area around her left eye, and purple discoloration to the back and left side of her neck, the right side of her neck, and under her ear. The bruising appeared to be fairly new and fresh. On 10/26, the ESP received multiple calls regarding possible strangulation of Resident #12. The ESP conducted a skin assessment and found bruising to the eye and other areas of the body including the resident's neck. The bruising to the resident's neck was consistent with the potential of physical abuse. The ESP met with the family member of Resident #12. The family member stated that she reported the concern to the WD on 10/25; however, the WD stated to the family member that she was leaving the residence at that time and would write a report about the incident the following day. Further, the family member stated that when she reported to the WD and administrator that she contacted LE, the residence still did not take action. The LE report, dated 10/26/24, read that the offenses committed against Resident #12 included second-degree assault, strangulation causing bodily injury, and crime against an at-risk adult. A progress note, dated 10/27/24, read that the WD contacted the ESP on 10/26/24 to check on Resident #12. The WD notified the former administrator and the regional health and wellness director (RHWD) of the report. The family member of Resident #12 planned to contact LE and APS to report abuse sustained by Resident #12. The administrator of record was not working as she was taking time off; however the WD notified her, and reportedly the administrator of record directed the WD and AWD to take staff statements regarding when the bruising was noticed by staff and to review video footage. Resident #12 was admitted to the hospital on 10/26/24. An electronic communication, dated 10/29/24, read that the family member of Resident #12, received a telephone call from the WD which communicated that from her experience, LE did not conduct investigations of abuse once they found out residents lived in the SE.On 10/29/24 (four days after the family member alleged abuse of Resident #12), all investigations of abuse and neglect were requested for September and October 2024; however, the residence failed to provide full investigation documentation and instead provided incident reports. None of the incident reports listed the incident as an abuse investigation or contained a thorough investigation including how the residence planned to protect residents during the investigation. On 10/29/24 during the onsite investigation, the residence provided three written staff statements by Staff #3, #4, and #9. However, the staff statements did not include information regarding an investigation of the alleged abuse that caused the bruising. No written statements or documented interviews were provided for Staff #1, #5-#8, #10, #11, #13, and #14 who worked in the SE during the time period that the alleged abuse occurred. Additionally, no documentation was provided addressing how the residence protected the residents from future abuse. On 11/4/24 (ten days after the family member alleged abuse of Resident #12), the residence provided additional statements written by Staff #8, #10, and a second written statement from Staff #3. However, the staff statements did not include information regarding investigation of the alleged abuse that caused the bruising. No statements were provided for Staff #1, #5-#7, #11, #13, and #14 who worked in the SE during the time period that the alleged abuse occurred. Additionally, no documentation was provided addressing how the residence protected the residents from future abuse. 3. ObservationsOn 10/29/24 and 10/30/24, throughout the onsite investigation, Staff #1-#7 was observed providing care and services to residents independently without additional supervision. On 11/4/24 and 11/5/24, throughout the onsite investigation, Staff #1-#5 was observed providing care and services to residents independently without additional supervision. 3. InterviewsOn 10/29/24 at approximately 8:30 a.m., Staff #5 stated that she told the AWD on 10/26/24, during the 6:00 a.m. to 2:00 p.m. shift, that Resident #12 looked abused due to bruises on her face and neck. On 10/29/24 at approximately 11:00 a.m., the administrator of record stated that she had not been working on 10/25/24-10/28/24, and she returned to the residence on 10/29/24. In a later interview at 12:30 p.m., the administrator of record stated she failed to ensure the residence initiated an abuse investigation on 10/25/24, when the abuse allegation was made, and she instead initiated the investigation of alleged abuse on the date of the onsite investigation on 10/29/24. On 10/29/24 at approximately 11:00 a.m., the AWD stated that she became aware of bruising sustained by Resident #12 on 10/25/24 at 3:45 p.m. She did not initiate an investigation of the incident that led to the bruising on 10/25/24 because she had finished working for the day. She stated she became aware that the family member of Resident #12 planned to call LE due to alleged strangulation on 10/26/24. The AWD added that she should have investigated the allegation of abuse; however, she instead reported the allegation to the administrator of record and the WD. She added that they did not direct her to collect any statements nor advise her how to protect residents from abuse during the investigation. On 10/29/24 at approximately 2:30 p.m., Confidential Staff #15 stated that the family member of Resident #12 alleged abuse of Resident #12 on 10/26/24 to the AWD. She added that the resident looked very bruised. On 11/4/24 at approximately 3:30 p.m., the regional vice president of operations (RVPO) stated that the written statements provided for Staff #3, #4, and #8-#10 were the documented evidence of the residence's investigation of abuse. She added that Staff #9 was suspended during the investigation due to suspicion from the family, but no other direct-care staff were suspended. She affirmed she had access to the electronic communication on 10/26/24 from the administrator of record to the family member of Resident #12 that read that the former administrator began an investigation of abuse for Resident #12. The RVPO stated that the former administrator had not completed getting all resident, resident family members, and staff statements, and the former administrator did not direct staff on the process of protecting other residents during the investigation. The RVPO affirmed that the residence had not officially cleared any staff that had worked during the time period when the incident that led to bruising may have occurred, and that Staff #4, #6, #7 and several other staff continued to work independently with residents. She affirmed that the residence did not put measures in place to ensure all residents were protected from staff that were not cleared as possible assailants of the abuse allegation. 4. Evidence obtained during the onsite investigation revealed that the residence additionally failed to thoroughly investigate allegations of abuse or neglect for Residents #9 and #16. 5. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed 87 current residents at immediate jeopardy risk for potential physical abuse due to the failure of the residence to thoroughly investigate allegations of abuse. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 11/4/24 at 5:07 p.m., the RVPO submitted written evidence that read in pertinent part: "The (residence) must ensure that allegations of abuse, neglect, and exploitation are thoroughly investigated and residents are protected during the investigation. Staff must be educated on policies related to reporting, investigating, and documenting injuries of unknown origin to prevent recurrence and ensure residents' safety. Immediate Interventions: 1. Suspension of (former administrator) (WD) (Staff #9) ... pending an investigation by (regional health and wellness director [RHWD]) regarding the delay in investigating and reporting injuries. Additional retraining, and disciplinary actions, including potential termination, will be determined based on the findings. 2. Resident Assessment and Safety Review Action: All residents in (secure environment [SE]) will be assessed to evaluate for any signs or symptoms of potential abuse or neglect. This included skin assessments to be completed by one of the following: (RHWD) or Corporate Wellness Specialist (CWP). Any findings requiring follow-up will be reported immediately. 3. Re-Education of Department Managers on Reporting and Investigation Procedures. Action: (RHWD) to re-educate (WD) and Other Managers on reporting, documenting, and investigating injuries, Including requirements for notifying oversight and implementing resident safety protocols. Completion Date: Mandatory staff training by Thursday 11.05.24. Completed By: (RHWD). 4. Re-Education of All Staff on Abuse and Neglect Reporting and Investigation. Procedures and Mandatory Reporting. Action: (RVPO and RHWD) conduct mandatory re-education sessions for all staff on site on reporting, documenting, and investigating injuries, including requirements for notifying oversight and implementing resident safety protocols. All staff not on site will complete the re-education before their next shift. Completion Date: Mandatory staff training by Thursday 11.05.24 5. Re-Education of All Staff that care for the Vulnerable Residents should be completed by two care staff at a time. Action: (RVPO and RHWD) to conduct mandatory re-education sessions on care requirements, including requirements for notifying oversight and implementing resident safety protocols. Completion Date: Mandatory staff training by Thursday 11.05.24."However, the written evidence did not indicate the risk had been removed because the residence incorrectly identified the risk as the residence's lack of investigation of injury of unknown origin instead of the correct risk as the residence's lack of investigation of abuse. Additionally, the plan did not include the process of completing the investigation of abuse interviews with residents' families and by whom. The RVPO was directed to submit additional written evidence. On 11/4/24 at 5:17 p.m., the RVPO submitted a corrected plan that identified the correct risk of investigation of abuse and removed the incorrect risk of investigation of unknown origin. Further, the residence added that, with the assistance of a contracted consultant, the residence began the process of contacting all SE residents' families for interviews with a completion date of 11/8/24.

Based on observation, record review, and interview, the residence failed to investigate injuries of unknown origin, affecting 87 current residents. (Cross-reference S0540, S1410, S2230)Specifically, on 9/9/24, a family member for Resident #9 and residence staff reported bruising to the arm of Resident #9 to the assistant wellness director (AWD). The residence failed to investigate the injury of unknown origin. The AWD acknowledged that she should have investigated the injury of unknown origin for Resident #9. On 10/25/24, Resident #12 sustained bruising to her eye, face, and neck, and the residence failed to investigate the cause of the unknown injury until the date of the onsite survey. Subsequently, on 10/26/24, Resident #9 sustained additional bruising. The residence failed to investigate the cause of the unknown injury. The residence demonstrated a pattern of failure to investigate injuries of unknown origin. These failures placed Resident #9 and #12 at risk, along with the 85 other current residents, at immediate jeopardy for serious continued injuries for failing to investigate injuries of unknown origin. On 10/29/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Investigations of Unknown Origin On 10/29/24 at 8:30 a.m., documentation of investigations of injuries of unknown origin for September and October 2024 were requested; none were provided. 2. Resident #9 was admitted to the secure environment (SE) on 12/13/23 with a diagnosis of dementia. a. ObservationsOn 10/29/24 at 9:45 a.m., there were two bruises on Resident #9's left hand and forearm, as well as a bruise and a skin tear on his elbow. Additionally, there were two bruises on Resident #9's right hand and forearm. b. Record ReviewOctober 2024 progress notes did not contain any documentation of the bruises, including an investigation. An external service provider (ESP) note, dated 10/26/24, read in part, "The family member called and stated the resident had bruises up and down his arms today as well as a scab to the left elbow which was bleeding ... The family member stated she was very shaken about the new bruises ..."c. InterviewsOn 10/29/24 at 9:45 a.m., Resident #9's family member stated she noticed new bruises on both of the resident's arms on 10/26/24. She stated she visited the resident daily so she knew the bruises were fresh and she was "horrified" when she saw them. Additionally, the family member stated the first bruise occurred on 9/9/24 and the bruise looked like a large thumbprint. She stated she notified staff and the AWD but was unsure whether the residence investigated it. Further, the family member stated she had reported it to an ESP. On 10/29/24 at 9:00 a.m., Staff #5 stated she noticed bruises on Resident #9's arms and hands and reported it to the AWD on 10/26/24. On 10/29/24 at 12:30 p.m., the AWD said, "I was notified of the bruises on Resident #9's arms and hands by staff and the resident's family member on 10/26/24; however, I did not look into it because I was busy doing other things." The AWD acknowledged that she should have investigated the bruises on Resident #9's hands and arms. On 10/29/24 at 12:30 p.m., the wellness director (WD) acknowledged that the residence should have investigated the bruises on Resident 9's hands and arms, but they failed to do so. On 12/29/24 at 12:00 p.m., the former administrator stated she expected staff to report all injuries of unknown origin to her and that she took appropriate action, contrary to the record review. 3. Additionally, the residence failed to investigate injuries of unknown origin for Resident #12.4. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed Resident #9 and #12, along with the 85 other current residents at immediate jeopardy risk of serious injury for failing to investigate injuries of unknown origin. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 10/29/24 at 5:30 p.m., the regional health and wellness director (RHWD), acting as the administrator, submitted written evidence that read in pertinent part: "On 10/26/2024, it was noted that the (AWD) failed to initiate an investigation into an injury of unknown origin for Resident (#9), despite family and staff reports of bruising. Additionally, similar concerns were raised for Resident #12, reported by staff and family on 10/25/2024, but the investigation was delayed until 10/29/2024, the date of the onsite survey. This pattern of noncompliance has been identified as likely to cause serious injury or harm to residents, warranting Immediate Jeopardy designation. The facility must ensure that residents ... Staff must be educated on policies related to reporting, investigating, and documenting injuries of unknown origin to prevent recurrence and ensure residents' safety ... Immediate interventions include suspension off the (AWD) and the (administrator of record) effective 10/29/24, pending an investigation by the (RDHW) regarding the delay in investigating and reporting injuries. Additional retraining, and disciplinary actions, including potential termination, will be determined based on the findings ... All residents in (SE) will be assessed to for any signs or symptoms of potential abuse or neglect. Any findings requiring follow-up will be reported immediately and will be documented in the chart notes and will follow incident reporting guidelines ... The (RDHW) to re-educate (WD) and Other Managers on reporting, documenting, and investigating injuries, including requirements for notifying oversight and implementing resident safety protocols. Notifications include Family, Physician ... and Corporate Office ... The (RDHW) and (WD) will conduct mandatory re-education sessions for all staff on site on reporting, documenting, and investigating injuries, including requirements for notifying oversight and implementing resident safety protocols. All staff not on site will complete the re-education before their next shift starting on 10/29/24 ... An in person Inservice with attendance sheet will be added to their personal chart ..."

Based on record review and interview, the residence failed to ensure each resident received proper monitoring of medications, affecting two of 10 sample residents (#12 and #15). Findings include: Resident #12 was admitted to the residence on 6/18/21 with diagnoses including depression and dementia. Video footage provided by Resident #12's family revealed that on 10/24/24 at 11:29 a.m., Staff #1 placed a crushed substance using a spoon into Resident #12's mouth while the resident laid on her bed. Staff #1 then walked out of Resident #12's room. An electronic message from Resident #12's family member to the wellness director (WD) and assistant wellness director (AWD), dated 10/26/24 at 7:26 a.m., revealed that Resident #12's family member expressed concerns about the staff placing medication in the resident's mouth while she was asleep. On 10/29/24 at approximately 12:30 p.m., the AWD stated that Resident #12's family member informed her that staff placed the crushed medications in the resident's mouth while the resident was asleep. She added that she herself was providing care and services to residents that morning and did not investigate Resident #12's family concern. On 10/29/24 at approximately 12:45 p.m., the WD stated that she was not aware that staff placed medications in Resident #12's mouth while the resident was asleep. She expected the qualified medication administration person to stay with the resident and monitor the ingestion of medications. The WD stated that she expected staff to follow the care plan for Resident #12. Evidence obtained during the onsite investigation revealed that staff also failed to ensure that Resident #15 received proper monitoring of medications.

Based on interview and record review, the residence failed to implement policies and procedures for documenting, investigating, reporting, and responding to any errors related to accurate accounting of controlled substances and/or medication administration, affecting one of 10 sample residents (#12). (Cross-reference S2210) 1. Residence PolicyThe residence's undated Resident Rights policy read in part that the residence promptly notified the resident's responsible party and practitioner of any medication errors that affect the resident. 2. Resident #12 was admitted to the residence on 6/18/21 with diagnoses including depression and dementia. A practitioner's order, dated 9/5/24, directed the residence to administer lorazepam 0.5 mg at bedtime. On 10/30/24 at approximately 8:00 a.m., a photograph provided by Staff #5, dated 10/21/24 revealed that Resident #12's controlled substance medication pack and the residence controlled substance sheet had a discrepancy in accounting of the controlled substance. Electronic messages sent between Staff #5 and the wellness director (WD), dated 10/21/24, read in part that Resident #12's controlled medication count was off by one. The WD directed Staff #1 and #5 to call the external service provider (ESP), check the counts on previous dates in the controlled substance count sheet, and sign the controlled substance sheet. Another message from the WD directed Staff #5 to search for the medication that could have fallen in the medication cart drawers. On 10/30/24 at approximately 3:00 p.m., the missing controlled substance investigation was requested but not provided. Resident #12's October 2024 progress notes did not include documentation of investigation, reporting, nor responding to errors related to accurate accounting of controlled substances. Resident #12 The October 2024 electronic medication administration record (eMAR) revealed that the residence administered lorazepam from 10/21 through 10/25/24. 3. Interviews On 10/30/24 at approximately 8:30 a.m., Staff #5 stated that no one at the residence asked her questions that indicated they were conducting an investigation into errors related to accurate accounting of controlled substances. On 10/30/24 at approximately 3:00 p.m., the WD stated that she was aware of the error in the accounting of Resident #12's controlled substance. She acknowledged that she did not investigate the error that occurred on 10/21/24.

Based on record review and interview, the residence failed to ensure a confidential health information record for each resident was maintained for accuracy of information affecting two (#12, #19) of 10 sample residents whose medication administration records were reviewed. (Cross-reference S1610, S2230) 1. Residence PolicyThe residence's undated Resident Rights policy read in part: Resident health records were confidential and would not be released without the written consent of authorization of the resident or their responsible party. 2. Record ReviewResident #12 was admitted to the residence on 6/18/21 with diagnoses including depression and dementia. A photo of Resident #12's controlled substance medication pack with medical information and the residence controlled substance sheet were stored on Staff #12's personal phone. 3. Interviews On 10/30/24 at approximately 7:30 a.m., Staff #5 stated that she utilized her personal phone to communicate to the wellness director (WD) regarding the inconsistency in the controlled substance count sheet. She stated that on 10/21/24, she took a photo of Resident #12's medication packet with medical information along with the controlled substance count sheet to report medication count inconsistencies. She revealed that her phone had multiple reciprocal electronic messages from the WD. She added that she had utilized this form of communication since she was hired on 7/31/23. On 10/30/24 at approximately 3:00 p.m., the regional health and wellness director (RHWD) acknowledged that the Staff #12 violated confidentiality of health information. 4. Evidence obtained during the onsite investigation revealed that the residence also failed to maintain the health record of Resident #19 in a confidential manner.

Based on record review and interview, the residence failed to complete progress notes at the end of each shift, which included documentation regarding any out-of-the-ordinary event or issue that affected the resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address that resident's changing needs, affecting three of 10 sample residents (#9, #12 and #15) who experienced out of the ordinary events. (Cross-reference S0540, S1412, S1610)Findings include:1. ObservationsOn 10/29/24 at 9:45 a.m., there were two bruises on Resident #9's left hand and forearm, as well as a bruise and a skin tear on his elbow. Additionally, there were two bruises on Resident #9's right hand and forearm. 2. Record ReviewResident #9 was admitted to the residence on 12/13/23 with a diagnosis of dementia. Progress notes for October 2024 failed to contain bruising sustained by Resident #9. On 10/29/24 at approximately 12:00 p.m., the administrator of record stated that staff should have documented any out-of-the-ordinary events for residents. On 10/29/24 at approximately 12:30 p.m., the wellness director (WD) and assistant wellness director (AWD) acknowledged that staff had not completed progress notes at the end of their shifts, as required. The AWD added that she did not complete a progress note regarding Resident #9's injuries because she was busy doing other things. The WD stated that staff should have documented Resident #9's bruises in a progress note, but did not. On 10/29/24 at approximately 1:30 p.m., Staff #4 and #5 stated that staff did not complete progress notes on out of the ordinary events or issues. Staff #4 added that staff communicated resident issues verbally to AWD and WD.On 10/29/24 at approximately 3:30 p.m., the regional health and wellness director (RHWD) stated that staff were not required to complete daily progress notes but required to document out-of-the-ordinary events or issues in the residence 24-hour report form. She added that staff should have documented Resident #9's bruises. 3. Evidence obtained during the onsite investigation revealed that the residence failed to document out-of-the-ordinary events at the end of each shift in progress notes for Residents #12 and #15.

Based on record review and interview, the residence failed to provide, within 60 days, a minimum of six (6) hours of general training and education on providing care and services for residents with dementia/cognitive impairment with training content provided or recognized by an academic institution, a recognized state or national organization or association, or an independent contractor or group that emphasizes dementia/cognitive impairment care, affecting 15 current residents residing in the secure environment. Findings include: The personnel file for Staff #3 revealed a hire date of 6/28/24. However, the personnel file did not contain the documentation that the residence provided Staff #3 with the required six-hour dementia training. Personnel files for Staff #1 and #5-#9 revealed no documentation that the residence provided the required six-hour dementia training within 60 days of hire. The secure environment staff schedule, dated October 2024, revealed that Staff #3 worked on 10/1, 10/3, 10/5, 10/6, 10/8, 10/10, 10/15, 10/19, 10/25, and 10/26/24. Further, the October 2024 staff schedule revealed Staff #1 and #5-#9 had also worked in the secure environment. On 11/5/24 at 1:35 p.m., the regional vice president of operations stated she was aware that the residence was required to provide all staff who provided care services to residents in the secure environment a six-hour dementia training within 60 days of hire. She stated, however, that she was unaware that the residence did not provide this required training to the above staff within 60 days of their hire dates.

A licensure complaint, prompted by #CO34772, #CO34803, and #CO37323 was completed on 9/18/2024. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure the resident's right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence, affecting two of ten sample residents (#5, #6). Findings include:Resident #6 was admitted to the residence on 7/17/23. The September 2024 Resident Event Report documented for Resident #6 read that he pressed his call pendant 18 times with a wait time longer than 25 minutes as follows:On 9/1/24 at 6:04 a.m., for 29 minutes, and at 5:57 p.m., for 27 minutes. On 9/8/24 at 3:37 p.m., for 34 minutes. On 9/9/24 at 6:47 p.m., for 26 minutes. On 9/10/24 at 3:34 a.m., for 29 minutes, at 5:29 a.m., for 33 minutes, and at 10:41 a.m., for 38 minutes. On 9/12/24 at 4:57 a.m., for 29 minutes. On 9/13/24 at 4:30 a.m., for 29 minutes, and at 11:02 a.m., for 29 minutes. On 9/14/24 at 9:24 a.m., for 32 minutes. On 9/15/24 at 3:47 a.m., for 27 minutes, and at 6: 42 p.m., for 36 minutes. On 9/16/24 at 6:19 a.m., for 28 minutes and at 2:06 p.m., for 30 minutes. On 9/17/24 at 3:41 a.m., for 32 minutes, at 7:41 a.m., for 39 minutes, and at 4:17 p.m.. for 29 minutes. On 9/18/24 at 12:21 p.m., the wellness director stated staff should answer the call pendant in five minutes. She further explained that 25 to 30 minutes is too long. On 9/18/24 at 12:42 p.m., the administrator stated her expectation for call pendant response time was under 10 minutes and that 25 to 30 minutes was too long for someone to wait. Additionally, the residence failed to ensure Resident #6's right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence.

Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and identification of injuries of unknown origin, affecting 96 current residents. Findings include 1. ReferenceChapter VII regulations governing assisted living residences, part 13.11, requires the residence to investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following: (A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; (C) The process for investigating such allegations; (D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; (E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted; (F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; (G) and A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. 2. Residence Policy and Incident Report ExampleThe residence's Incident Reports policy dated 12/20/22 was provided as the policy for investigation of identification, reporting, and investigation of injury of unknown origin. The policy read in part that an incident report must be completed when any of the following are reported or witnessed: abuse, misappropriation, or exploitation allegations; resident to resident or resident to staff; elopement; alleged, reported, observed fall, witnessed fall, found on floor; lowered resident to the ground; skin injuries, abrasion, burn, discoloration, laceration, skin tear; new pressure ulcer. The Policy also included instructions to contact the resident's legal representative, the wellness director, or their designee to review and investigate and for the administrator to review the report's results. The policy failed to include several required elements such as the requirements of 13.11. A-G should the investigation determine the origin of the injury be related to abuse and neglect, the implementation of steps taken to prevent or mitigate future injuries of like nature for all residents. The policy also failed to include steps to be taken to monitor the resident to prevent similar injuries. Additionally, the policy failed to include the requirement for the residence to retain all documentation of the investigation, interviews, outcomes, and steps taken for review by the Department. Finally, the policy failed to include the requirement for the results of the investigation to be communicated to the resident's legal representative. An incident report dated 8/22/24 was provided as an example of an investigation that did not include areas to document several elements of investigation of injury of unknown origin, such as an area to include details of any interviews or records used in the investigation, related staff training, or any required modification of the resident's policies, or a summary of the investigation and the steps taken to prevent future injuries. 3. Record ReviewResident #8 was admitted to the residence on 3/9/21 with a diagnosis of Alzheimer's Disease. A progress note for Resident #8, dated 8/22/24 read in part the external hospice nurse reported another resident's family member was holding Resident #8's right hand on top of a table. The note included a description of the discoloration of the skin and an explanation that the administrator had reported the occurrence to the Department and that a meeting with the legal representative was scheduled for that evening. 4. InterviewsOn 9/17/24 at 7:20 a.m., Staff #4 stated that Resident #8 had bruises on her hands that no one saw her receive and they assumed it was from hand rubbing. On 9/17/24 at 7:35 a.m., Staff #5 stated that Resident #8 had bruises on her hands before it was progress noted on 8/22/24. On 9/17/24 at 10:28 a.m., Resident #8's legal representative stated the resident routinely had bruises on her hands, and the residence thought it was from rubbing her hands together but they did not investigate formally. On 9/17/24 at 11:15 a.m., the administrator stated that they did not investigate the bruises on Resident #8's hands as they had no confirmed origin and that the residence should have investigated the bruising.

Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) had completed a competency assessment with direct observation of all medication administration tasks the QMAPs were assigned to perform and assigned additional medication administration tasks for two of the three sample staff (#1, #3) affecting six of ten sample residents. (Cross-reference S1600)Findings include:The residence's resident agreement, undated, read in part, through its qualified staff, the residence would assist, or supervise, as appropriate, residents with storage and administration of medications and assistance in taking self-administered medications, as directed by the resident's practitioner. Personnel files for Staff #1 and #3 read that both staff members were QMAPs. However, the QMAP competency completed for both staff was incomplete. Staff #1's QMAP checkoff dated 4/8/23, was incomplete with one blank page and the QMAP supervisor also failed to sign indicating completion of the competency. Staff #3's QMAP checkoff dated 7/13/24 was also incomplete, missing the second page of the document. Resident #8 was admitted to the residence on 3/9/21 with a diagnosis of Alzheimer's Disease. The September 2024 Medication Administration Record (MAR) for Resident #8 indicated that Staff #1 on 9/2, 9/8, 9/9, and 9/16 administered medications. The MAR also indicated that Staff #3 on 9/2, 9/3, 9/5, 9/12, and 9/17 administered medications. On 9/18/24 at approximately 12:45 p.m., the wellness director agreed that all QMAP tasks and competencies training should be completed and signed off by the qualified trainer. The wellness director acknowledged that staff tasks and competencies training were not signed off as of 9/18/24 and staff had been working with residents. The wellness director agreed that if staff had a medication error the tasks and competencies training should be revisited. On 9/18/24 at approximately 12:45 p.m., the assistant wellness director agreed that all QMAP tasks and competencies training should be completed and signed off by the qualified trainer. The wellness director acknowledged that staff tasks and competencies training were not signed off as of 9/18/24 and staff had been working with residents. The wellness director agreed that if staff had a medication error the tasks and competencies training should be revisited. On 9/18/24 at approximately 12:45 p.m., the executive director agreed that all QMAP tasks and competencies should be completed and signed off by the trainer. The executive director agreed that if staff had a medication error the tasks and competencies training should be revisited.

Based on record review and interview the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting one of the ten sample residents (#2). Findings Include:1. References and Residence PolicyChapter VII regulations governing assisted living residences, part 2.35, defines "Medication administration" as a means of assisting a person in the ingestion, application, inhalation, or, using universal precautions, rectal or vaginal insertion of medication, including prescription drugs, according to the legibly written or printed directions of the attending physician or other authorized practitioner, or as written on the prescription label, and making a written record thereof with regard to each medication administered, including the time and the amount taken. The residence's residency agreement read in part, "through its qualified staff, the community will assist, or supervise as appropriate, Resident with storage and administration of medication and assistance in taking self-administered medications as direct by Resident's Physician and as permitted under the Community's assessment test."2. Resident # 2 was admitted to the residence on 6/19/23 with a diagnosis of emphysema, cor pulmonale, chronic respiratory failure with hypoxia, and supplemental oxygen dependence.a. Albuterol HFA inhalerA written practitioner's order, dated 7/26/24, directed the residence to administer albuterol HFA inhaler to be administered two puffs by mouth every six hours for emphysema rinse mouth after use at 6:00 a.m., 12:00 p.m., and 6:00 p.m. to Resident #2; however, the residence failed to add the medication to the medication administration record and administer the medication to Resident #2 from 8/1-8/31/24. The residence failed to provide a discontinued order for the medication to no longer be administered to Resident #2.b. Fluticasone propionateA written practitioner's order, dated 8/27/24, directed the residence to administer fluticasone propionate 50 MCG/ACT to be administered via suspension two sprays in each nostril nasally once a day to Resident #2. However, the residence failed to add the medication to the medication administration record and administer the medication to Resident #2 from 9/1- 9/18/24. The residence failed to provide a discontinued order for the medication to no longer be administered to Resident #2.3. InterviewOn 8/18/2024 at approximately 12:30 p.m., the wellness director stated that they were not complying with the practitioner's medication orders if they did not have a discontinuation order for the medication and the residence stopped administering the medication. On 8/18/2024 at approximately 12:30 p.m., the assistant wellness director stated that they were not complying with the practitioner's medication orders if they did not have a discontinuation order for the medication and the residence stopped administering the medication. On 8/18/2024 at approximately 12:45 p.m., the administrator stated that they were not complying with the practitioner's medication orders if they did not have a discontinuation order for the medication and the residence stopped administering the medication. The administrator reported they would expect the medication to be taken off the medication administration record.

Based on interviews and record review, the residence failed to ensure the medication administration record (MAR) contained accurate information, affecting three of six sample residents (#3-#5). Findings include:Resident #4 was admitted to the residence on 5/25/23 with a diagnosis of hypertension and chronic respiratory failure with hypoxia. A written practitioner order dated 9/10/24 directed the residence to administer empagliflozin 10 mg one tab daily. The September 2024 MAR indicated the empagliflozin was administered twice 9/10-9/14 for a total of five extra doses. On 9/18/24 at approximately 10:00 a.m., Resident #4 stated he always counted his meds and has never been administered an extra dose of medications. On 9/18/24 at 12:21 p.m., the wellness director confirmed that Resident #11 was diligent about his medications and would have noticed a double dose missing. She also explained that due to the electronic MAR system, new orders were entered twice. When this occurred the qualified medication administration person was instructed to indicate this as an exception, noting duplicated orders. She agreed that without exceptions being indicated 9/10-9/14, the MAR was inaccurate. On 9/18/24 at 12:42 p.m., the administrator stated that 9/10-9/14 did indicate the medication was administered twice and that the MAR was inaccurate. Additionally, the residence failed to ensure the medication administration record (MAR) contained accurate information for Residents #3 and #5.

Based on interview and record review, the residence failed to document routinely completed audits of the accuracy and completeness of medication administration records (MARs), medication error reports, and medication disposal records affecting six of six sample residents (#1-3, #5, #6, #8). Findings include:The residence's MARs audit tool failed to include a complete audit of the accuracy and completeness of the MARs, medication error reports, and review of the disposal of medications. The report also failed to indicate the administrator and the qualified medication administration person supervisor had completed the audits quarterly. On 9/18/24 at 12:21 p.m., the wellness director stated the MARs audit did not capture the completeness of the MARs and was missing the medication error reports. She also acknowledged that the audits did not indicate who completed the audits. She further stated that if the audit were complete, more medication errors would be caught. On 9/18/24 at 12:42 p.m., the administrator stated the MARs audit did not capture the completeness of the MARs, expanding that if the audits were complete they would have been able to catch previous medication errors. She also acknowledged that she was not always the one completing the audits and that there was no place on the form to indicate who had completed the audit.

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: (B) 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.

A revisit survey was completed on 2/27/24 for all previous deficiencies cited on 11/1/23. No deficiencies 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 complaints #CO29997, #CO30268, #CO33874, #CO34049 was completed on 11/1/23. Deficiencies were cited.

Based on interviews and record review, the residence failed to provide, upon request, access to staff records, affecting 71 current residents. Findings include:Chapter VII regulations governing assisted living residences, part 8.7, requires that each assisted living residence shall have at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization such as the American Red Cross, the American Heart Association, the National Safety Council or the American Safety and Health Institute. The certification shall either be in Adult CPR or include Adult CPR.Chapter VII regulations governing assisted living residences, part 7.12, requires that each assisted living residence shall maintain a personnel file for each of its employees that includes written documentation of CPR certification. The residence's undated Personnel Files policy read in part: "Each employee will have a personnel file which may include the following ... Copy of license or certificates."On 11/1/23 at 8:20 a.m., CPR certifications for all residence staff were requested. On 11/1/23 at 11:30 a.m., CPR certifications for all residence staff were requested. On 11/1/23 at 1:00 p.m., CPR certifications for all residence staff were requested. On 11/1/23 at approximately 1:33 p.m., CPR certifications were provided for staff. On 11/1/23 at approximately 1:40 p.m., the wellness director stated that the residence was required to maintain staff CPR certification and provide them as requested. She added that the residence had not maintained staff CPR certifications and they were not readily available for review. On 11/1/23 at approximately 1:45 p.m., the regional director of wellness stated that the residence was expected to maintain and provide staff CPR certifications.

Based on record review and interview, the residence failed to have a quality management program (QMP) designed to improve client safety and well-being, affecting 71 current residents. Findings include:The residence's undated Quality Assurance Process Improvement (QAPI) policy read in part: "QAPI is the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement. The committee will meet quarterly. More frequent meetings may be necessary based on identification of problems or issues. The committee includes the Executive Director (Chairperson), Business Office Manager, Wellness Director, and a minimum of three other Community team members."On 11/1/23 at 8:20 a.m., the residence's QMP was requested from the administrator. On 11/1/23 at 2:10 p.m., the residence's QMP was requested from the regional director of wellness (RWD). On 11/1/23 at 2:45 p.m., the RWD stated that the residence had not been cited for QMP before; therefore, the residence did not have a current QMP. On 11/1/12 at approximately 5:50 p.m., the administrator stated that she became aware during the onsite survey that a QMP was required. She added that the residence had yet to initiate or participate in any QMP activities since she began employment, approximately three months prior to the onsite survey.

Based on observation, interview and record review the residence failed to have sufficient staff to meet the needs of the residents affecting 11 current residents residing in the secure environment. (Cross-reference Q1110, Q1190, Q2960)Findings include:1. Resident AgreementThe residence ' s undated agreement read in part: "The community, through its staff, regularly observes resident health status and food consumption to identify observable change. Residents have been allowed as much freedom and independence as possible but will be supervised to the extent necessary to avoid negative outcomes. Staffing levels at the community are adjusted at the sole discretion of the community to ensure adequate personnel are available to meet the needs of every resident as required by law. Staffing levels and qualifications vary based on the number and care needs of residents at the community."2. Staff Schedule for the Secure Environment, dated 10/29-11/4/23 read in part:The residence had three shifts, first shift 6:00 a.m. to 2:00 p.m., second shift from 2:00 p.m. to 10:00 p.m. and third shift from 10:00 p.m. to 6:00 a.m. 10/29- fist shift two staff, second shift two staff and third shift one staff was scheduled. 10/30- first, second and third shift two staff were scheduled. 10/31-first shift one staff, second and third shift had two staff scheduled. 11/1 and 11/2- first, second and third shift two staff were scheduled. 11/3 and 11/4/23- first shift one staff, second and third two staff. 3. Resident #4 was admitted to the residence on 8/4/23 with diagnoses including Vertigo and repeated falls. A progress note for Resident #4, dated 10/20/23, read in part: Resident #4 required three to four staff to assist on and off the toilet, in and out of bed. On 11/1/23 at 12:11 p.m., Resident #4 was observed slipping out of wheelchair while trying to eat lunch, the resident was unable to reach the plate and therefore could not eat independently. Staff #4 was feeding other residents, and Staff #1 was serving food to all residents. All staff members were either serving food or feeding other residents. On 11/1/23 at 12:20 p.m., Resident #4 was repositioned back in the wheelchair by two staff members. On 11/1/23 at 8:36 a.m., Staff #1 stated Resident #4 require three staff for transfer assistance. She stated during the overnight shift the residence usually staffed the memory care with two staff. Staff #1 stated if Resident #4 required transfer assistance they would notify assisted living staff they needed help with transferring the resident. However, Staff #1 stated sometimes the assisted living staff were unable to provide assistance and staff had to transfer the resident with less people than was safe. She further stated the residence did not allow mechanical lifts and therefore needed three staff at all times. On 11/1/23 at 5:09 p.m., the wellness director stated she had staffing concerns brought to her attention. She stated managers often had to work the floors to assist with caregiving and answering call lights. The wellness director stated during the day the residence staff the secure environment with three staff and two staff during the overnight shift. She confirmed that Resident #4 required two to three person assistance with transfers depending on the time of day. The wellness director further stated when there was not enough staff in the secure environment staff were able to notify the assisted living and obtain staff assistance. The wellness director further stated she was aware Resident #4 required a high level of assistance and stated he was at the point where he needed a higher level of care. 4. Resident #5 was admitted to the residence on 1/12/21 with a diagnosis of Alzheimer's disease. On 11/1/23 at 7:13 a.m., upon entrance to the secure environment there was one resident seated at the dining room table and no staff were visible from the common areas. On 11/1/23 at 7:17 a.m., Staff #1 came out of a resident room into the common areas. On 11/1/23 at 7:53 a.m., Resident #5 paced the hallways and attempted to open other resident rooms; however, all other resident rooms were locked. On 11/1/23 at 9:44 a.m., Staff #4 stated that there were usually two or three staff members in memory care at a time; however, she stated they required more staff for the amount of oversight residents requiredOn 11/1/23 at 3:35 p.m., the family member for Resident #1 stated she visited the residence on a daily basis. She stated Resident #5 wandered throughout the secure environment consistently. She stated approximately one year prior to the onsite investigation, Resident #5 had wandered into Resident #1's room and urinated on her chair. The family member stated the residents in the secure environment required too much assistance from staff and other residents' needs were lacking as a result. The family member stated there was a resident that required transfer assistance of three staff, a second resident that was bed bound, a third resident (Resident #5) that wandered into other resident rooms, one resident that "escaped through a window" one night twice. She stated staff were leaving the secure environment to find the resident that escaped leaving not enough staff to care for the residents. She stated when staff had to care for the resident that required three people for assistance, then no one was in the common areas assisting residents or providing supervision. The family member further stated, the mixture of behavioral residents with high care residents caused a high enough acuity that there was not sufficient staff to meet the needs. The family member added she had seen residents fall and had to use her personal telephone to notify the assisted living to obtain staff assistance. She stated her concerns had been expressed to the residence's corporate office. On 11/1/23 at 4:16 p.m., the responsible party for Resident #5 stated the resident approximately a year prior to the onsite investigation, the resident went into another resident's room, sat on their chair and urinated on the chair. The responsible party stated staff was not around to prevent this incident. On 11/1/23 at 5:50 p.m., the administrator stated the residence currently staffed the secure environment with two staff overnight and three staff during the day. She confirmed the residents that resided in the secure environment were a higher acuity. The administrator further stated she tried her best to ensure there was enough staff to meet the needs of the residents; however, she stated that approximately 80 percent of the residents in the memory care required higher levels of care for items such as: assistance, with eating, transfers, supervision for wandering etc.

Based on record review and interview, the residence failed to have a readily available roster of current residents that included emergency contact information, along with a residence diagram showing room locations, affecting 71 current residents. Findings include: The residence's undated Evacuation of Residents policy read in part: "Use a resident roster to assure that all residents are accounted for."On 11/1/23 at 7:17 a.m., Staff #1 stated that 11 residents resided in the secure environment. On 11/1/23 at 7:29 a.m., a current resident roster was requested from Staff #6. Staff #6 was unable to provide a resident roster upon request. On 11/1/23 at 7:29 a.m., Staff #6 stated that the receptionist or management at the residence could print the resident roster; however, the receptionist and management team arrived after 8:30 a.m. at the residence. On 11/1/23 at approximately 9:00 a.m., the residence provided the resident roster; however, it was not readily available prior to the arrival of management staff and failed to include a diagram showing the room locations. Further, the roster read that 14 residents resided in the secure environment. On 11/1/23 at 9:20 a.m., the regional director of wellness (RDW) stated that the roster provided was the residence's official roster. On 11/1/23 at approximately 5:09 p.m., the wellness director (WD) stated that a resident's date of birth, allergies, religion, diagnoses, and insurance should be on the resident roster; however, she failed to include the required residents' emergency contact information. She added that she was unaware that an attached residence diagram was a requirement for the resident roster. She stated once a resident was completely discharged, the resident's name was removed from the roster. She stated that the secure environment staff was likely correct when they stated that 11 residents resided in the secure environment despite the roster reading a higher number of residents. On 11/1/23 at approximately 5:50 p.m., the administrator stated that residence staff should have a resident roster readily available at all times. She added the roster did not contain a residence diagram and was not up-to-date. She added she was unaware it was not readily available to staff. She stated that 73 residents were listed instead of the actual 71 residents. She added it was essential to have an accurate resident roster readily available for the local fire authority to avoid looking for absent residents.

Based on interview and record review, the residence failed to either directly or indirectly provide personal services, affecting one current resident (#4). (Cross-reference Q0744)Findings include:The residence's Resident Agreement, dated 5/19/23, read in part, "The community, through its staff, will regularly observe a Resident's health status and food consumption to identify observable changes in physical, mental, emotional and social functioning and will help Resident respond to dietary and health needs, including needs for special services to approve admission for future residents and ensure that the services we provide can meet the needs of the potential resident. For current residents, the assessment tool is required every quarter or upon a change in condition."Resident #4 was admitted to the residence on 8/4/23 with diagnoses including hypertension,vertigo, hearing loss, hyperlipidemia and repeated falls. On 11/1/23 at 12:11 p.m., Resident #4 was observed slipping out of his wheelchair while trying to eat lunch, the resident was unable to reach the plate and therefore could not eat independently. On 11/1/23 at 4:46 p.m., Resident #4 was observed trying to eat dinner independently, Resident #4 could not reach the plate and food kept slipping out of utensils before the resident could put the food in their mouth. An assessment for Resident #4, dated 8/2/23, read in part: Resident #4 required complete assistance and supervision for eating. Additionally, the assessment read Resident #4 required assistive or adaptive devices for eating. On 11/1/23 at 10:28 a.m., Staff #1 confirmed Resident #4 was not provided with eating assistance as required in the resident assessment dated 8/2/23. On 11/1/23 at 4:00 p.m., the memory care coordinator stated Resident #4 had not previously required assistance with eating; however, recently required assistance. She stated Resident #4 had declined and required a higher level of care than the number of staff available could handle. On 11/1/23 at 5:09 p.m., the wellness director stated Resident #4 did not routinely require assistance with eating; however, Resident #4 had an infection and required increased assistance during the onsite survey.

Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated for a resident whenever the residents' condition changed from baseline status, affecting two of three sample residents (#4 and #8) who experienced a change in condition. (Cross-reference Q1180)Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 12.7, requires residences to complete a comprehensive assessment that reflects information requested and received from the resident, the resident's representative, if requested by the resident, and a practitioner. The comprehensive assessment shall include the following:(B) Information regarding the resident's overall health and physical functioning ability;(F) Food and dining preferences, unique needs and restrictions;;(J) History and circumstances of recent falls and any known approaches to prevent future falls;(K) Safety awareness; andThe residence ' s undated Comprehensive Assessment policy read in part: "For current residents, the assessment tool is required every quarter or upon a change in condition."2. Resident #4 was admitted to the residence on 8/4/23 with diagnoses including vertigo and repeated falls. The progress notes for Resident #4 read that the resident had fallen on the following dates, 8/8/23, 8/12/23, 8/17/23, 8/20/23, 8/29/23, 9/4/23, and 9/25/23. Incident reports identified by the residence, as assessments read the following:An incident report dated 8/8/23 read in part: Staff heard Resident #4 yell out and then heard a thud. Staff subsequently rounded the corner to find him on the floor with a wheel chair beside him. An incident report dated 8/12/23 read in part: Staff saw Resident #4 sitting on the ground beside a wheelchair. An incident report dated 8/17/23 read in part: Staff heard a crash down the hall. Staff found the resident on the floor outside his apartment with his wheelchair behind him and an overturned shower chair in front of him. An incident report dated 8/20/23 read in part: Staff saw Resident #4 on the floor. The resident stated he fell while moving his stuff. An incident report dated 8/29/23 read in part: Staff found Resident #4 on his stomach next to bed. An incident report dated 9/4/23 read in part: Staff heard commotion and saw the resident lying on his side on the floor in front of his wheelchair. An incident report dated 9/25/23 read in part:Staff found Resident #4 lying on the ground in front of his wheelchair in the dining room. However, the above seven incident reports failed to include any known approaches to prevent future falls. On 11/1/23 at 5:09 p.m., the wellness director stated, the residence had not had monthly meetings regarding falls as the residence policy says. 3. Additionally, the residence failed to update Resident #8's assessment after she experienced changes in condition. 4. InterviewsOn 11/1/23 at approximately 5:09 p.m., the wellness director stated if a resident experienced a change of condition, the residence should have reassessed the resident. She added the residence should have reassessed Residents #4 and #8 after they experienced falls. The wellness director further stated she updated resident assessments for the residence. On 11/1/23 at approximately 5:50 p.m., the administrator stated that the residence was required to reassess a resident when the resident experienced a change in condition. She added that a change in condition included when a resident sustained a fall.

Based on observation, interview and record review, the residence failed to ensure resident care plans detailed specific personal service needs along with staff tasks necessary to meet those needs affecting resident (#4) . Findings include:1. Residence PolicyThe residence's undated Meal-Team Assistance policy read in part: "... A resident who is unable to feed him/herself will be fed by staff as identified in the service plan (care plan) ..."2. Resident #4 was admitted to the residence on 8/4/23 with diagnoses including vertigo. An assessment for Resident #4, dated 8/2/23, read in part: Resident #4 required complete assistance and supervision with eating. Also, the resident required two person assistance with transferring. A care plan for Resident #4, dated 8/5/23, read in part: Resident #4 was independent with eating. The care plan further read Resident #4 required a one person assist with transfers. However, the care plan failed to address that Resident #4 required two to three staff to assist with transfers. Additionally, the care plan failed to address Resident #4's assessed need for assistance with meals. On 11/1/23 at 12:11 p.m., Resident #4 was observed eating alone. Resident #4 was unable to retrieve food with his silverware and place it into his mouth to eat. Additionally, Resident #4 started to slide out of his wheelchair and spilled juice on himself. On 11/1/23 at 4:46 p.m., Resident #4 attempted to eat alone, with no assistance or supervision. Resident #4 could not reach the plate and was unable to keep food on his utensils. 3. InterviewsOn 11/1/23 at 8:36 a.m., Staff #1 stated Resident #4 required three staff to assist with transfers. On 11/1/23 at 12:24 p.m., the memory care coordinator said Resident #4 had recently begun to need more assistance with eating; however, the staff stated they followed instructions from the task list which was updated from the care plan. The memory care coordinator stated the care plan had not been updated and therefore staff did not assist until they saw the resident struggling to eat. On 11/1/23 at 2:12 p.m., Staff #5 said Resident #4 required a three person assist with transfers.

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 two of two sample residents (#4, #8). (Cross-reference Q1146) 1. Residence PoliciesThe residence's undated Fall Management and Injury Response policy read in part: the purpose of the policy was to initiate follow-up interventions following a fall, to identify proactive fall prevention guidelines relative to fall risks and to identify proactive fall prevention guidelines relative to fall risks. Further, each resident care plan would be detailed with the individual approach necessary to address fall risks. The residence's undated Fall Management Program read in part: The risk management team evaluated fall data to analyze falls and review potential contributing factors and follow-up actions. Based on compiled incident report data, a periodic trend summary would be provided from the wellness director and the administrator. The report would be discussed at the Quality /Risk Management meetings and sent to the Quality Risk Management Committee. The tracking and trending report would include: Residents with incidents for the current month, residents with two or more falls in 30 days with interventions, number of previous month incidents, number of incidents with injuries, number of repeat falls, top three incident time of day and top three incident location, number for falls in the assisted living, number of falls in the memory care and the fall rate each month. 2. Resident #4 was admitted to the residence on 8/4/23 with diagnoses including hypertension, vertigo and repeated fallsA progress note, dated 8/8/23, read in part: Staff heard Resident #4 yell out and subsequently heard a thud. Staff rounded the corner to find him on the floor with a wheelchair beside him. A progress note, dated 8/12/23, read in part: Staff saw Resident #4 seated on the ground beside his wheelchair. A progress note, dated 8/17/23, read in part: Staff heard a crash down the hall, found Resident #4 on the floor outside his apartment with his wheelchair behind him and an overturned shower chair in front of him. A progress note, dated 8/20/23, read in part: Staff saw Resident #4 on the floor. The resident stated he fell while moving his stuff. A progress note, dated 8/29/23, read in part: Staff found Resident #4 laying on his stomach next to bed. A progress note, dated 9/04/23, read in part: Staff heard commotion and saw Resident #4 lying on his side on the floor in front of his wheelchair. A progress note, dated 9/25/23, read in part: Staff found Resident #4 lying on the ground in front of his wheelchair in the dining room. The care plan for Resident #4, dated 8/2/23, read in part: Staff were directed to complete a one person transfer from wheelchair to chair or bed. The care plan was not updated after falls to reflect individualized fall approaches necessary to address fall risks. 3. Additionally, the residence failed to detail in the care plan for Resident #8 the individualized approach necessary to address fall risks related to deficits in strength and balance after she fell on 10/22/23.4. InterviewsOn 11/1/23 at 3:15 p.m., Resident #8 stated she fell a little more than one week prior to the onsite survey. She stated she could not remember the reason for her fall; however, she may have tripped on her area rug when she was walking from her couch to her bedroom. She added that she needed to get tape for the rug for it to lay flat, or she needed to get rid of the rug. She added the residence had not discussed the possibility of the rug on her floor causing her fall and had not implemented any approaches to address her risk of falls. On 11/1/23 at approximately 5:09 p.m., the wellness director stated that when a resident experienced a fall, the residence should determine the cause andupdate the care plan with approaches to address the resident's risk of falls. She stated that she should have updated the care plan for Resident #4 and #8 after they sustained falls. She added that Resident #8 had a cluttered room and that a discussion and process of decluttering may reduce her risk of falls. She stated that Resident #4 sustained many falls and would likely need a higher level of care to meet his needs. She added that despite the fall management plan reading that the residence conducted care meetings when a resident experienced a fall, the residence did not conduct any post-fall meetings for residents. On 11/1/23 at approximately 5:50 p.m., the administrator stated that after a resident sustained a fall the residence should have updated the resident's care plan with individualized approaches that addressed the resident's risk of falls if and when the approach was an ongoing approach.

Based on record review and interview, the residence failed to direct staff to assist residents who have fallen or are otherwise unable to get up off the floor independently, affecting 71 current residents. Findings include: The residence's undated Lift Assist policy read in part: "Appropriately trained team members will evaluate residents and provide lift assistance when determined applicable for those who have fallen or are otherwise unable to independently get up from the floor."Resident #4 was admitted to the residence on 8/4/23 with diagnoses including vertigo and repeated falls. A progress note, dated 8/29/23, read in part: Resident #4 was found on the floor next to his bed. Staff notified emergency medical services (EMS) for lift assistance. On 11/1/23 at 8:52 a.m., Staff #1 stated the residence telephoned EMS for non emergent lift assistance at times when residents fell. On 11/1/23 at 5:09 p.m., the wellness director stated when Resident #4 fell he required three people to assist him off the floor. She stated the residence often relied on local fire authority to provide lift assistance as the staff were unable to safely get Resident #4 off the floor. The wellness director stated local fire authority was telephoned anytime a resident fell and staff were unable to assist them off the floor even if no injuries were identified.

Based on observation, record review and interview, the residence failed to ensure resident records were secured to preserve confidentiality and provide protection from unauthorized access, affecting 11 current residents residing in the secure environment. Findings include:The residence's undated Confidentiality in the Workplace policy read in part: "Assure that sensitive and personal information about residents was not shared with other residents by staff members, thereby creating an environment where residents feel that they can trust staff members to keep their personal business, decisions and actions confidential."On 11/1/23 at 7:13 a.m., the resident controlled substance binder was accessible on the medication cart, not in a protected or locked area. The controlled substance binder contained documents with each residents photograph, the name of their practitioner, their advanced directive status, their current dietary restrictions, current external service agencies and controlled substance medication count sheets. . During morning medication pass on 11/1/23 from 7:49 a.m to 9:02 a.m., the following was observed:At 7:49 a.m., Staff #1 initiated medication pass for Resident #4, the resident medication administration record (MAR) was left open and unlocked until 7:55 a.m., on laptop screen. At 8:00 a.m., Resident #5 walked past the medication cart with Resident #9's MAR open on the laptop screen. At 8:02 a.m., Staff #1 administered medication and left the MAR open and unattended. At 8:05 a.m., Staff #1 administered medication and left the MAR open and unattended. At 8:16 a.m., Staff #1 administered medication and left the MAR open and unattended. At 8:26 a.m., Staff #1 administered medication and left the MAR open and unattended. At 8:29 a.m., Staff #1 administered medication and left the MAR open and unattended. At 8:32 a.m., Staff #1 administered medication and left the MAR open and unattended. At 8:35 a.m., Staff #1 administered medication and left the MAR open and unattended. At 8:43 a.m., Staff #1 administered medication and left the MAR open and unattended. At 8:50 a.m., Staff #1 administered medication and left the MAR open and unattended. On 11/1/23 at 5:09 p.m., the wellness director stated the computers should have been closed by the qualified medication administration persons (QMAPs). She stated only the QMAPs and lead staff had access to the computes. The wellness director confirmed the controlled substance binder was left on the medication cart in the secure environment. She stated she would have to instruct staff to lock the binder box or lower drawer. On 11/1/23 at 5:50 p.m., the administrator stated resident records should have been kept confidential. She stated the records should have been locked up and not left out unattended. The administrator stated the controlled substance binder should have been stored securely inside the medication cart.

Based on interview and record review, the residence failed to ensure that resident records included progress notes, which contained documentation regarding any out-of-the-ordinary events that affected a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs, affecting two of eight sample residents (#1, #8) and one former resident (#9). Findings include:The residence's undated Resident Record policy read in part: "Daily documentation is not necessary. Documentation will occur when an activity, event, and incident that is not usual for the resident or change in level of assistance occurs."Resident #8 was admitted to the residence on 12/20/22 with diagnoses including osteoporosis and fibromyalgia. A practitioner's note, dated 10/24/23, read in part that the resident fell on 10/22/23 and sustained a laceration to the forehead. A review of the residence's progress notes for Resident #8, dated 9/22-10/26/23, revealed that the residence failed to document the fall sustained by the resident or any subsequent actions taken by staff to address any of the resident's changing needs. Additionally, the residence failed to document for Resident #1 and Former Resident #9 out-of-the-ordinary events or issues that affect the residents' physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address that resident's changing needs. On 11/1/23 at approximately 5:09 p.m., the wellness director stated that the residence's expectation was that progress notes for residents included coordination with external service providers (ESP). She added that Resident #8 should have documented coordination with ESP; however, she did not document the fall sustained by the resident on 10/22/23 or subsequent care coordination regarding the fall that occurred with the resident's ESP. She stated that she had not considered the incidents of incontinence on the furniture of other residents as out of the ordinary despite it only occurring to Resident #1 and had not documented the incidents. On 11/1/23 at approximately 5:50 p.m., the administrator stated that the residence should have documented falls, patterns of wandering, and incontinence in the residents' progress notes. She added she was unaware the residence had not documented all events in the progress notes for residents.

Based on observation, interview and record review, the residence failed to ensure each care plan for a resident in a secure environment included a description of wandering patterns, known behavioral expressions along with individualized approaches, and a description of how the resident would have continuous independent access to his or her individual room, along with the plan to protect the resident from unwanted visitation by other residents affecting three of three sample residents (#4-#6). Findings include:1. Residence PolicyThe residence's undated Monitoring Resident Memory Care policy read in part; "Residents will be allowed as much freedom and independence as possible but will be supervised to the extent necessary to avoid negative outcomes ... Being aware of a resident's general whereabouts, although the resident may travel independently in the community ... Additionally, all assisted living and memory care team members complete training in Alzheimer's/dementia care, including environmental safety, behavior management, wandering and care of residents with applicable diagnoses ..."2. Resident #5 was admitted to the residence on 1/12/21 with a diagnosis of Alzheimer's Disease. On 11/1/23 at 7:53 a.m., Resident #5 wandered around the halls and common area trying to open other resident rooms, however, all rooms were locked. A comprehensive assessment for Resident #5, dated 9/1/23, read in part: Resident #5 wandered throughout the residence. The resident required frequent observation and supervision. Resident #5 exhibited exit seeking behaviors and required a secure enviroment. A progress note, dated 10/25/23, read in part: Resident #5 was continuously walking around, touching staff and other residents. A care plan for Resident #5, dated 11/1/23, did not include Resident #5's wandering patterns, exit seeking behaviors or individualized approaches to be implemented by staff to protect the resident and other residents with whom they had contact. 3. Resident #6 was admitted 3/8/23 with diagnoses including dementia, depression and history of deep vein thrombosis. On 11/1/23 at 7:25 a.m., the room for Resident #6 had a gate in front of the door to her room. On 11/1/23 at 8:19 a.m., Resident #6 attempted to open the gate in front of her room; however, the resident was unable to on her own. Staff #1 subsequently opened the gate and let Resident #6 into her room. 4. Additionally, the residence failed to detail in the care plan for Resident #4 and #6 known behavioral expressions along with individualized approaches, and a description of how the resident would have continuous independent access to his or her individual room. 5. InterviewsOn 11/1/23 at 8:19 a.m., Staff #1 stated the family member of Resident #6 installed a gate in front of the residents room to prevent other residents from entering. The staff stated, the Resident #6 was able to open and close the gate on her own. On 11/1/23 at 4:00 p.m., the memory care coordinator stated Resident #5 was easily redirected while wandering. She stated all residents except for Resident #6 allowed Resident #5 to sit on their couches. On 11/1/23 at 4:16 p.m., the family member of Resident #5 stated the resident had been known to wander in the past, however, they had not been notified about it prior to last fall. The family member stated the only episode they were notified about was in November 2022 when Resident #5 wandered into another resident's room and urinated on their chair. On 11/1/23 at 5:50 p.m., the administrator and wellness director stated they were unaware that locking resident doors was a violation of regulations as residents did not have continuous independent access to their rooms. They stated the resident rooms were locked to protect resident from unwanted residents wandering into their rooms.

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 7.14.7 The assisted living residence shall ensure that each resident receives proper administration and/or monitoring of medications. 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (A) Intravenous, intramuscular, or subcutaneous injections; (B) Gastrostomy or jejunostomy tube feeding; (C) Chemical debridement; (D) Administration of medication for purposes of restraint; (E) Titration of oxygen; (F) Decision making regarding PRN or "as needed" medication administration; (G) Assessment of residents or use of judgment including, but not limited to, medication effect; (H) Pre-pouring of medication; or (I) Masking or deceiving administration of medication including, but not limited to, concealing in food or liquid. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication. (B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.