Maria Droste Counseling Center

A complaint revisit was completed on 10/30/25 for all previous deficiencies cited on 6/9/25. A deficiency was cited.

Based on record review and interviews, the facility (residence) failed to protect individual rights affecting one sample member (resident) #14. This deficiency was cited previously during a state licensure survey on 6/9/25. The facility has not maintained compliance with this regulatory requirement. Findings include:1. Records ReviewMember #14 was admitted on 11/1/23 with diagnoses including unspecified psychosis, major depressive disorder, post-traumatic stress disorder and traumatic brain injury. On 9/15/25 an incident report in Member #14 records filed by the facility revealed that on 9/15/25 Member #5 threw coffee at her and pushed her. The facility contacted the police and advised Member #14 to avoid contact with Member #5. On 9/20/25 an incident report in Member #14 records filed by the facility revealed that Member #5 showed her and two other members pictures of his genitals. Member #14 was arrested and taken to the Pueblo County Jail. On 10/29/25 a discharge note provided by the facility revealed Member #14 went to stay with his brother after being released from the Pueblo County Jail and self discharged from the facility on 9/23/25.2. Interviews On 10/29/25 at approximately 3:45 p.m. Member #14 was interviewed regarding the incidents involving Member #5. Member #14 said that Member #5 made her feel frightened and uncomfortable and was told by the facility to avoid further contact with Member #5. The administrator, interviewed on 10/30/25 at 10:07 a.m., agreed the two incidences involving Member #14 constituted physical and sexual abuse.

A licensure complaint, prompted by #CO40106, #CO40200, #CO40299, and #CO40301 was completed on 6/9/25. Deficiencies were cited.

Based on record review and interview the residence failed to coordinate an involuntary discharge for one formerresident of ten sample residents (#1). Findings Include:1. PoliciesThe residence Involuntary Discharge Policy read that the residence would "coordinate a voluntary or involuntarydischarge with the resident, the resident's legal representative and/or the appropriate agency. Prior to discharging a resident because of increased care needs, (the residence) shall make documented efforts to meet those needs through other means."2. Records ReviewFormer Resident #1 was admitted to the residence on 12/18/23 with a diagnosis of schizophrenia. A 30 day eviction notice dated 1/28/25, read that Former Resident #1 would be evicted on 2/26/25. The reason foreviction read: "(Former Resident #1) is not following the house rules by using and dealing meth, fentanyl in thefacility, putting other residents in danger, threatening to kill or harm other residents. He will need a higher level ofcare."An observation note dated 2/24/25, read that Former Resident #1 was taken to the hospital for a mentalevaluation. An observation note dated 3/4/25, read that Former Resident #1 was discharged from the residence due to a visitat the hospital for a mental evaluation and a transfer to a mental hospital. Former Resident #1 was readmitted to the residence on 4/22/25 with a diagnosis of schizophrenia. An observation note dated 5/7/25, read that Former Resident #1 took a knife from the residence kitchen. He thentold his case manager that he was going to use the knife to stab anyone that walked into his room. An additionalnote dated 5/7/25 read that the police apprehended Former Resident #1 and took him to the hospital. An observation note dated 5/16-5/24/25 read that Former Resident #1 was in the hospital. An involuntary discharge notice dated 5/22/25 with an eviction date of 5/22/25, read that Former Resident #1 wasbeing discharged from the residence due to ongoing behaviors which posed a threat to staff and residents safety. An observation note dated, 5/27/25 read that Former Resident #1 was discharged from the residence because hewas in the hospital. An email document dated 6/3/25, read that the residence paid for a hotel from 6/3/25 to 6/8/25 for FormerResident #1. On 6/9/25 at approximately 10:00 a.m., documents related to efforts to find Former Resident #1 alternative caredue to the involuntary discharges were requested. The residence was unable to provide documentation for boththe 1/28/25 and 5/22/25 discharge notices. 3. InterviewsOn 6/9/25 at approximately 8:30 a.m., the resident care coordinator (RCC) stated that he and the case worker forFormer Resident #1 were looking for alternative placement for Former Resident #1, however, were unable to findalternative placement after Former Resident #1 was in the hospital in February 2025. The RCC stated that thecase worker informed Former Resident #1 to return to the residence after he was discharged from the hospital. The RCC stated that when Former Resident #1 returned from the hospital in February 2025 the decision was madeto readmit Former Resident #1 to the residence. On 6/9/25 at approximately 1:30 p.m., the administrator stated that Former Resident #1 returned to the residencein February and May 2025 after being discharged from the residence. She stated that the case manager wassupposed to help him look for alternative placement, however, she did not have any documentation that she hadcontacted the case manager about placement for Former Resident #1. She stated that she believed FormerResident #1's behaviors warranted a higher level of care.

Based on record review and interviews the residence failed to protect residents from sexual abuse affecting 32 current residents. Specifically, Resident #5, on numerous occasions, indecently exposed himself to residents and made unwanted sexual advances to both residents and staff. Additionally, residents reported that Resident #5 used scary language to talk about female residents. Residents reported being fearful of him. When asked what the residence was doing to protect other residents from the unwanted sexual advances the Resident Care Coordinator (RCC) and Administrator stated that they were performing frequent checks on Resident #5 and redirecting him, however the frequent checks and redirection did not remedy the situation. This failure created an immediate jeopardy risk of sexual abuse to all 32 current residents residing in the residence. On 6/9/25, the department directed the residence to provide written evidence that the risk of abuse had been removed. Findings Include:1. PolicyThe residence Residents Rights Policy, undated, read that all residents have the right to be free from sexual abuse. 2. Record ReviewResident #5 was admitted to the residence on 1/22/25 with a diagnosis of schizoaffective disorder and alcohol dependence. An observation dated 5/11/25, read that Resident #5 was masturbating in front of his bedroom door with the door open. Staff told Resident #5 that if he was going to masturbate to shut the door. An incident report dated 5/29/25, read that Resident #5 loudly proclaimed in the dining room that he would deflower a woman. The residents present reported being uncomfortable. An incident report dated 5/29/25, read that Resident #5 took his pants off in front of residents and staff in the dining room and when asked to pull his pants up by staff would ignore them. Resident #5 then proceeded to go to the television room pulled his pants down and asked a resident if she would put a sexual toy on. An incident report dated 5/31/25, read that Resident #5 was found near the smoking area laying on the ground with his pants down touching his testicles. An observation note dated 6/5/25, read that Resident #5 was found naked by the kitchen fridge. 3. InterviewOn 6/9/25 at approximately 8:00 a.m., Resident #7 stated that Resident #5 talks inappropriately and scary about the girls in the residence and that he leaves his room without pants on. On 6/9/25 at approximately 8:00 a.m., Staff #1 stated that Resident #5 made unwanted sexual comments to both residents and staff. On 6/9/25 at approximately 8:30 a.m., the RCC stated that Resident #5 had a lot of issues with sexual behaviors, such as asking residents and staff members for sex. He stated that he had directed staff to watch Resident #5 and redirect him as needed. The RCC stated then when redirected Resident #5 stopped the sexual behaviors for awhile but then would start back up again and that he would not know when Resident #5 would start back up again. On 6/9/25 at approximately 9:00 a.m., Resident #8 stated that Resident #5 triggered his post traumatic stress disorder (PTSD) because Resident #5 sexually harassed all of the residents and would act like it's a game. On 6/9/25 at approximately 12:00 p.m., the local ombudsman stated that she had numerous residents report to her that Resident #5 would invite them to his room, with no context, and when the residents would arrive Resident #5 would then be naked on his bed and inappropriately ask about sex. On 6/9/25 at approximately 1:00 p.m., Staff #1 stated that supervision directed her to document any incidents with Resident #5 and redirect him. She stated that he once asked her and a resident to go and have a threesome with him. She stated that she once found him masturbating in the public smoking area. Staff #1 stated that she did not believe the redirection was helping Resident #5. Staff #1 stated that the morning of 6/9/25 Resident #5 came out of his room completely naked again. On 6/9/25 at approximately 4:30 p.m., the administrator stated that she believed the redirection and talking to Resident #5 had resolved the issue she was not aware that Resident #5 on 6/9/25 was naked out of his room. She stated that since this incident occurred it was clear the redirection did not work. 4. Immediate Jeopardy Risk - Written evidence, immediate correctionThe investigation established that the findings above placed the 32 current residents at immediate jeopardy risk for sexual 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 6/9/25 at approximately 5:00 p.m., the administrator submitted written evidence that read in pertinent part: "Management (the regional director and administrator) will interview all residents about (Resident #5)'s sexual behavior, ask them questions to see how afraid they are of that behavior by 6/9/25. (The residence) will schedule a mental evaluation with (an outside provider) for (Resident #5) immediately. Does he need a higher level of care? By 6/9/25 by the regional director, administrator, and RCC. Family members to provide input on ideas to help redirect (Resident #5) when he has any sexual behavior by 6/9/25. Regional director, administrator and RCC responsible. (Resident #5)'s input on what triggers him to have these types of behaviors and what staff can do to help him avoid these behaviors by 6/10/25; RCC and administrator responsible. (The residence) will do in service for all staff to recognize signs and symptoms of (Resident #5) becoming aggressive, and how to avoid triggering him. (All staff will be trained by 6/11/25) the administrator and regional director will be responsible for training. (The residence) will begin 2-hour checks on (Resident #5) looking for any sexual behavior with observation notes starting 6/9/25 (monitored by administrator, regional director, RCC, and staff members). (The regional director and administrator) will update (Resident #5)'s care plan with the 2-hour checks immediately (6/9/25). When it is discovered that (Resident #5) is becoming/has become sexually abusive to either resident or staff, staff will encourage him to stay in his room and engage in other activities instead of asking for sexual advance to other residents. Ideas to make this happen without confrontation are to: suggest he watch a favorite tv show or watch a movie, have a snack in his room, or offer him to play board games in his room. Implement plan actions as identified above as of 6/9/25. When it is discovered that (Resident #5) is currently being sexually abusive, administrator/RCC, if available, will spend some one-on-one time with him to keep him calm, to reassure/redirect him with some positive verbal prompt. Call family, encourage them to talk to him immediately when he becomes sexually abusive. Call (local law enforcement) at the first sign of abusive behavior. Call provider, the crisis team. Call Adult Protective Services within 24 hours of the incident for self-neglect. The administrator/RCC will review ECP observations daily, and monthly sign and add observations to (Resident #5)'s resident binder. The director of operations will add specifically a review of (Resident #5) to the operations daily meetings with the administrator to verify that plan is being successfully followed and the administrator has daily eyes on the observation notes. If this plan doesn't work while (Resident #5) is in the facility, the administrator/RCC will send referral out for other placement."However, the written evidence did not indicate that the risk had been removed because it did not contain instructions to residence staff that they would not make Resident #5 stay in his room or restrain him in any way. It did not clarify that residence staff would be trained on Resident #5's triggers immediately, andit did not clarify the deciding factors for when the residence would discharge Resident #5 and a timeframe that the plan would be implemented before the residence decided that replacement or discharge would be necessary. The administrator was directed to submit additional written evidence. On 6/9/25 at approximately 5:15 p.m., the administrator submitted written evidence that read in pertinent part: "Get (Resident #5) input on what triggers him to have these types of behaviors and what staff can to help him avoid these behaviors. As soon as (Resident #5) tells us what's triggering him to have these type of behaviors administrator/RCC will do in service with all staff members to reeducate the staff on how to help ... Staff will encourage (Resident #5 to engage in activities in his room) ... offer him to go for a walk around the block with a male staff member. If this plan doesn't work for 30 day period, the administrator/RCC will send referral out for other placement."

A certification complaint, prompted by #CO40121, #CO40206, #CO40300, and #CO40303 was completed on 6/9/25. Deficiencies were cited.

Based on record review and interviews the residence failed to protect individual rights affecting 32 current residents. Specifically, Resident #5, on numerous occasions, indecently exposed himself to residents and made unwanted sexual advances to both residents and staff. Additionally, residents reported that Resident #5 used scary language to talk about female residents. Residents reported being fearful of him. When asked what the residence was doing to protect other residents from the unwanted sexual advances the Resident Care Coordinator (RCC) and Administrator stated that they were performing frequent checks on Resident #5 and redirecting him, however the frequent checks and redirection did not remedy the situation. This failure created an immediate jeopardy risk of sexual abuse to all 32 current residents residing in the residence. On 6/9/25, the department directed the residence to provide written evidence that the risk of abuse had been removed. Findings Include:1. PolicyThe residence Residents Rights Policy, undated, read that all residents have the right to be free from sexual abuse. 2. Record ReviewResident #5 was admitted to the residence on 1/22/25 with a diagnosis of schizoaffective disorder and alcohol dependence. An observation dated 5/11/25, read that Resident #5 was masturbating in front of his bedroom door with the door open. Staff told Resident #5 that if he was going to masturbate to shut the door. An incident report dated 5/29/25, read that Resident #5 loudly proclaimed in the dining room that he would deflower a woman. The residents present reported being uncomfortable. An incident report dated 5/29/25, read that Resident #5 took his pants off in front of residents and staff in the dining room and when asked to pull his pants up by staff would ignore them. Resident #5 then proceeded to go to the television room pulled his pants down and asked a resident if she would put a sexual toy on. An incident report dated 5/31/25, read that Resident #5 was found near the smoking area laying on the ground with his pants down touching his testicles. An observation note dated 6/5/25, read that Resident #5 was found naked by the kitchen fridge. 3. InterviewOn 6/9/25 at approximately 8:00 a.m., Resident #7 stated that Resident #5 talks inappropriately and scary about the girls in the residence and that he leaves his room without pants on. On 6/9/25 at approximately 8:00 a.m., Staff #1 stated that Resident #5 made unwanted sexual comments to both residents and staff. On 6/9/25 at approximately 8:30 a.m., the RCC stated that Resident #5 had a lot of issues with sexual behaviors, such as asking residents and staff members for sex. He stated that he had directed staff to watch Resident #5 and redirect him as needed. The RCC stated then when redirected Resident #5 stopped the sexual behaviors for awhile but then would start back up again and that he would not know when Resident #5 would start back up again. On 6/9/25 at approximately 9:00 a.m., Resident #8 stated that Resident #5 triggered his post traumatic stress disorder (PTSD) because Resident #5 sexually harassed all of the residents and would act like it's a game. On 6/9/25 at approximately 12:00 p.m., the local ombudsman stated that she had numerous residents report to her that Resident #5 would invite them to his room, with no context, and when the residents would arrive Resident #5 would then be naked on his bed and inappropriately ask about sex. On 6/9/25 at approximately 1:00 p.m., Staff #1 stated that supervision directed her to document any incidents with Resident #5 and redirect him. She stated that he once asked her and a resident to go and have a threesome with him. She stated that she once found him masturbating in the public smoking area. Staff #1 stated that she did not believe the redirection was helping Resident #5. Staff #1 stated that the morning of 6/9/25 Resident #5 came out of his room completely naked again. On 6/9/25 at approximately 4:30 p.m., the administrator stated that she believed the redirection and talking to Resident #5 had resolved the issue she was not aware that Resident #5 on 6/9/25 was naked out of his room. She stated that since this incident occurred it was clear the redirection did not work. 4. Immediate Jeopardy Risk - Written evidence, immediate correctionThe investigation established that the findings above placed the 32 current residents at immediate jeopardy risk for sexual 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 6/9/25 at approximately 5:00 p.m., the administrator submitted written evidence that read in pertinent part: "Management (the regional director and administrator) will interview all residents about (Resident #5)'s sexual behavior, ask them questions to see how afraid they are of that behavior by 6/9/25. (The residence) will schedule a mental evaluation with (an outside provider) for (Resident #5) immediately. Does he need a higher level of care? By 6/9/25 by the regional director, administrator, and RCC. Family members to provide input on ideas to help redirect (Resident #5) when he has any sexual behavior by 6/9/25. Regional director, administrator and RCC responsible. (Resident #5)'s input on what triggers him to have these types of behaviors and what staff can do to help him avoid these behaviors by 6/10/25; RCC and administrator responsible. (The residence) will do in service for all staff to recognize signs and symptoms of (Resident #5) becoming aggressive, and how to avoid triggering him. (All staff will be trained by 6/11/25) the administrator and regional director will be responsible for training. (The residence) will begin 2-hour checks on (Resident #5) looking for any sexual behavior with observation notes starting 6/9/25 (monitored by administrator, regional director, RCC, and staff members). (The regional director and administrator) will update (Resident #5)'s care plan with the 2-hour checks immediately (6/9/25). When it is discovered that (Resident #5) is becoming/has become sexually abusive to either resident or staff, staff will encourage him to stay in his room and engage in other activities instead of asking for sexual advance to other residents. Ideas to make this happen without confrontation are to: suggest he watch a favorite tv show or watch a movie, have a snack in his room, or offer him to play board games in his room. Implement plan actions as identified above as of 6/9/25. When it is discovered that (Resident #5) is currently being sexually abusive, administrator/RCC, if available, will spend some one-on-one time with him to keep him calm, to reassure/redirect him with some positive verbal prompt. Call family, encourage them to talk to him immediately when he becomessexually abusive. Call (local law enforcement) at the first sign of abusive behavior. Call provider, the crisis team. Call Adult Protective Services within 24 hours of the incident for self-neglect. The administrator/RCC will review ECP observations daily, and monthly sign and add observations to (Resident #5)'s resident binder. The director of operations will add specifically a review of (Resident #5) to the operations daily meetings with the administrator to verify that plan is being successfully followed and the administrator has daily eyes on the observation notes. If this plan doesn't work while (Resident #5) is in the facility, the administrator/RCC will send referral out for other placement."However, the written evidence did not indicate that the risk had been removed because it did not containinstructions to residence staff that they would not make Resident #5 stay in his room or restrain him in any way. Itdid not clarify that residence staff would be trained on Resident #5's triggers immediately, and it did not clarify thedeciding factors for when the residence would discharge Resident #5 and a timeframe that the plan would beimplemented before the residence decided that replacement or discharge would be necessary. The administratorwas directed to submit additional written evidence. On 6/9/25 at approximately 5:15 p.m., the administrator submitted written evidence that read in pertinent part: "Get (Resident #5) input on what triggers him to have these types of behaviors and what staff can to help himavoid these behaviors. As soon as (Resident #5) tells us what's triggering him to have these type of behaviorsadministrator/RCC will do in service with all staff members to reeducate the staff on how to help ... Staff willencourage (Resident #5 to engage in activities in his room) ... offer him to go for a walk around the block with amale staff member. If this plan doesn't work for 30 day period, the administrator/RCC will send referral out forother placement."

Based on record review and interview the residence failed to comply with 6 C.C.R. 1011-1 Chapter 7, Part 11 whenproviding a 30 days' notice of discharge for one former resident of ten sample residents (#1). Findings Include:1. PoliciesThe residence Involuntary Discharge Policy read that the residence would "coordinate a voluntary or involuntarydischarge with the resident, the resident's legal representative and/or the appropriate agency. Prior to discharging a resident because of increased care needs, (the residence) shall make documented efforts to meet those needs through other means."2. Records ReviewFormer Resident #1 was admitted to the residence on 12/18/23 with a diagnosis of schizophrenia. A 30 day eviction notice dated 1/28/25, read that Former Resident #1 would be evicted on 2/26/25. The reason foreviction read: "(Former Resident #1) is not following the house rules by using and dealing meth, fentanyl in thefacility, putting other residents in danger, threatening to kill or harm other residents. He will need a higher level ofcare."An observation note dated 2/24/25, read that Former Resident #1 was taken to the hospital for a mentalevaluation. An observation note dated 3/4/25, read that Former Resident #1 was discharged from the residence due to a visitat the hospital for a mental evaluation and a transfer to a mental hospital. Former Resident #1 was readmitted to the residence on 4/22/25 with a diagnosis of schizophrenia. An observation note dated 5/7/25, read that Former Resident #1 took a knife from the residence kitchen. He thentold his case manager that he was going to use the knife to stab anyone that walked into his room. An additionalnote dated 5/7/25 read that the police apprehended Former Resident #1 and took him to the hospital. An observation note dated 5/16-5/24/25 read that Former Resident #1 was in the hospital. An involuntary discharge notice dated 5/22/25 with an eviction date of 5/22/25, read that Former Resident #1 wasbeing discharged from the residence due to ongoing behaviors which posed a threat to staff and residents safety. An observation note dated, 5/27/25 read that Former Resident #1 was discharged from the residence because hewas in the hospital. An email document dated 6/3/25, read that the residence paid for a hotel from 6/3/25 to 6/8/25 for FormerResident #1. On 6/9/25 at approximately 10:00 a.m., documents related to efforts to find Former Resident #1 alternative caredue to the involuntary discharges were requested. The residence was unable to provide documentation for boththe 1/28/25 and 5/22/25 discharge notices. 3. InterviewsOn 6/9/25 at approximately 8:30 a.m., the resident care coordinator (RCC) stated that he and the case worker forFormer Resident #1 were looking for alternative placement for Former Resident #1, however, were unable to findalternative placement after Former Resident #1 was in the hospital in February 2025. The RCC stated that thecase worker informed Former Resident #1 to return to the residence after he was discharged from the hospital. The RCC stated that when Former Resident #1 returned from the hospital in February 2025 the decision was madeto readmit Former Resident #1 to the residence. On 6/9/25 at approximately 1:30 p.m., the administrator stated that Former Resident #1 returned to the residencein February and May 2025 after being discharged from the residence. She stated that the case manager wassupposed to help him look for alternative placement, however, she did not have any documentation that she hadcontacted the case manager about placement for Former Resident #1. She stated that she believed FormerResident #1's behaviors warranted a higher level of care.

8.7506. F Alternative Care Facility Provider Agency Requirements 6. Staffing Requirements a. Each Alternative Care Facility Provider Agency will divide the 24-hour day into two 12hour blocks which will beconsidered daytime and nighttime. The designation of daytime and nighttime hours shall be permanently documented in the Alternative Care Facilities policy and disclosed in the written Member agreements. In determining appropriate staffing levels, the Alternative Care Facility Provider Agency shall adjust staffing ratios based on the individual acuity and needs of the Members in the Alternative Care Facility. At a minimum, staffing must be sufficient in number to provide the services described in the Provider Care Plan, considering the Member's needs, level of assistance, and risks of accidents. A staff person may have multiple functions, as long as they meet the definition of Direct Care Worker at Section 8.7402. F Staff counted in the staff-to-Member ratio are those who are trained and able to provide direct services to Members. b. Staffing at an Alternative Care Facility shall meet the following standards i. A minimum of 1 staff to 10 Members during the daytime. ii. A minimum of 1 staff to 16 Members during the nighttime. iii. A minimum of 1 staff to 6 Members in a Secured Environment at all times. 1) The Alternative Care Facility Provider Agency shall ensure a minimum of one awake staff member that is on duty during all hours of operation in a Secured Environment

A revisit survey was completed on 1/23/25 for previous deficiencies cited on 11/14/24. The agency is in compliance with all regulations surveyed.

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

A complaint revisit was completed on 11/14/24 for the previous deficiency cited on 3/7/24. The facility is in compliance with all regulations surveyed.

A recertification survey and complaint revisit was completed on 11/14/24 for the previous deficiencies cited on 1/22/24. The facility is in compliance with all regulations surveyed.

A relicensure survey and complaint revisit was completed on 11/14/24 for all previous deficiencies cited on 1/22/24. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Based on interview and record review, the residence failed to meet the reporting requirements when they failed to report abuse allegations to Adult Protection Services (APS), affecting one of three sample residents (#31). This deficiency was cited previously during a state licensure survey 1/24/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.1, defines abuse as "any of the following acts or omissions: (A) The non-accidental infliction of bodily injury, serious bodily injury or death."b. The residence's Resident Rights policy, dated 12/21/23, read in part that residents had the right to be free from physical abuse and emotional intimidation. 2. Record ReviewResident #31 was admitted to the residence on 4/2/24 with diagnoses including bipolar and episode depression. A progress note for Resident #26, dated 10/30/24, read in part that Resident #31 had been upset, yelling, hitting walls, and getting into other residents' faces. The resident got into another resident's face and punched the resident in the face. Staff separated residents and contacted local law enforcement. An incident report for Resident #31, dated 10/30/24, read in part that Resident #26 had punched Resident #31 in the mouth, causing swelling to his upper lip. An occurrence report, dated 10/30/24, read in part that Resident #26 punched Resident #31 in the face. Local law enforcement had been contacted; however, the residence did not document that they notified APS, as required. 3. Interview On 11/14/34 at approximately 2:00 p.m., the administrator stated she was not aware the residence was required to notify APS when a resident knowingly caused bodily injury to another resident. She said she had called local law enforcement and assumed they would contact APS. The administrator acknowledged the residence's failure to notify APS. She confirmed Resident #31 was punched in the face by Resident #26. The administrator could not answer as to why this deficiency that was previously cited was not corrected.

A complaint revisit was completed on 11/14/24 for the previous deficiency cited on 3/7/24. The residence is in compliance with all regulations surveyed.

A revisit survey was completed on 4/8/24 for all previous deficiencies cited on 1/31/24. No deficiencies were cited.

A certification complaint, prompted by #CO35004 and #CO35039, was completed on 3/7/24. A deficiency was cited.

Based on observations, record review and interviews, the facility (residence) failed to discharge a participant (resident) in accordance to 6 CCR1011-1, Chapter VII, Section 11.11, who were a danger to themselves or others and required a higher level of care, affecting two residents (#5, #22). Based on observation, interview, and record review, the residence failed to discharge residents who were a danger to themselves or others and required a higher level of care, affecting two residents (#5, #22). Specifically, Resident #5 had a court order, dated 5/11/22, that read the resident required a secure living arrangement and daily assistance and supervision to ensure her own safety; however, the residence did not have a secure environment available. The care plan for Resident #5, dated 3/4/24, revealed the resident required supervision to reduce wandering behaviors and help manage destructive/abusive behaviors. Incident reports (IR) dated 1/29-3/3/24, revealed the resident had physically abused and caused harm to four residents (#3, #21, #23, #24) and had not been issued a discharge notice. Additionally, Resident #5 wandered outside of the residence for an unknown period of time. Findings include: 1. References and Residence Policiesa. Chapter VII regulations governing assisted living residences, defines "Discharge" as termination of the resident agreement and the resident's permanent departure from the facility.b. The residence's Discharge Policy, dated 12/25/23, read in part, "The assisted living residence shall arrange discharge for any resident who: Is profoundly disoriented to time, person, and place with safety concerns that require a secure environment, and the assisted living residence does not provide a secure environment; Exhibits conduct that poses a danger to self or others and the assisted living residence is unable to sufficiently address those issues through therapeutic approach."c. The residence's Resident Rights policy, dated 12/21/23, read in part, "Residents have the right to be free from sexual, verbal, physical, and emotional abuse, humiliation, intimidation, or punishment ..."2. Resident #5 was admitted to the residence on 11/2/23 with diagnoses including dementia and wandering behaviors. a. Court Order Review of a court order for Resident #5, dated 5/11/22, read, "The resident required a secure living arrangement and daily assistance and supervision to ensure her own safety."b. Care Plan Review of the care plan for Resident #5, dated 3/4/24, revealed the resident required supervision to reduce wandering behaviors and help manage destructive/abusive behaviors. However, there were no interventions in place, and it was unclear how staff were to reduce wandering behaviors and manage the resident's destructive/abusive behaviors. c. Incident Reports An IR, dated 1/29/24, at 2:29 p.m., read in part, "The qualified medication administration person (QMAP) had checked on (Resident #5) a half hour prior to 2:29 p.m. A caregiver (CG) asked the QMAP where (Resident #5) was and searched around. (Resident #5) had managed to get outside where the CG found her. No injuries were observed and the resident was unable to provide a statement ..."An IR, dated 2/25/24, read in part, "(Resident #5) wandered into a resident's room and hit the resident's knee. The CG saw (Resident #5) and led her to her room where she laid down in her own bed. (Resident #5) was unable to provide a statement ..."An IR, dated, 2/14/14, read in part, "On 2/14/24, Resident #21 complained Resident #5 hit him in his room with a book ..."An IR, dated 3/3/24, read in part, "On 3/3/24, Resident #23 was in her room sleeping when Resident #5 wandered into Resident #23's room and hit her ..."d. 30-Day Discharge NoticeA 30-day discharge notice for Resident #5, dated 3/1/24, and signed on 3/7/24, read in part, "Reason for notice: The resident needs a higher level of care due to the dementia progressing. The resident becomes physically aggressive with others, hitting them when they become close to her. The resident wanders into other residents' rooms and often picking up things that are not hers or hitting the other residents. The resident is cognitively impaired ..." e. Interviews On 3/4/24 at 8:59 a.m., Resident #24 stated Resident #5 often wandered into his room and hit him. He stated the last time Resident #5 had hit him was two days prior to the onsite visit; however, he had not reported it to anyone. On 3/4/24 at 9:11 a.m., Resident #23 stated Resident #5 hit her with Resident #23's cane. She stated Resident #5 had dementia, was aggressive, and was afraid of her. Resident #23 said, "When Resident #5 hits me, it hurts badly." She stated Resident #5 wandered into her room almost nightly and felt that Resident #5 was not closely monitored. On 3/4/24 at 9:27 a.m., Staff #1 stated Resident #5 required line of sight monitoring; however, there were not enough staff to be able to provide that type of monitoring 24 hours/seven days a week. She stated she had heard Resident #5 had hit another resident a week prior to the onsite visit; however, she was unsure who the other resident was. Staff #1 further added Resident #5 had eloped approximately two weeks prior to the onsite visit and that staff had found her outside of the residence. On 3/4/24 at 9:42 a.m., Resident #21 stated Resident #5 had gone into his room and had hit him 10 times since January, 2024. He stated Resident #5 hit him in the back with a book a week prior to the onsite visit. Resident #21 stated he was afraid of Resident #5 because she was violent and confused. On 3/4/24 at 9:50 a.m., the executive director (ED) stated she had been working with Resident #5's family member on finding placement for the resident, as the residence was no longer able to meet her needs. However, it had been difficult to find different placement. On 3/5/24 at 3:15 p.m., the ED and the administrator were interviewed. The ED stated Resident #5 had resided in a secure environment prior to being admitted to the residence on 11/2/23. She stated the residence had completed an assessment for Resident #5 and while she had been diagnosed with dementia, the resident had seemed "with it" at the time. The ED stated Resident #5 had started declining in January, 2024. She stated Resident #5 wandered, became easily agitated, and was physically aggressive with the other residents. She further stated the other residents were afraid of Resident #5. The ED stated the residence had a conversation with the resident's family member and informed him the residence was no longer able to meet Resident #5's needs; however, they had not issued a 30-day discharge notice as of yet. The administrator confirmed the ED's statement. On 3/6/24 at 3:21 p.m., Resident #5's outside provider stated she was unsure why the resident had been admitted to the residence in the first place, as she was not appropriate for a non-secured environment. She stated Resident #5 was completely non-verbal and wandered. The outside provider stated Resident #5 had aggressive behaviors; however, she was unaware the resident's aggression had become more frequent. She stated Resident #5 needed a higher acuity of care because the residence did not have enough staff to supervise the resident have. On 3/7/24/at 9:45 a.m., Resident #3 stated he had been hit by Resident #5 on multiple occasions; however, the worst incident was when Resident #5 had hit him in the head with a book and suffered from a concussion. He stated Resident #5 wandered around and would just hit people. On 3/7/24 at 10:00 a.m., Staff #2 stated Resident #5 wandered most of the day. She stated she had not witnessed Resident #5 become physically aggressive towards other residents; however, she had heard that the resident had hit other residents. Staff #2 stated Resident #5 was non-verbal so it was difficult to communicate with her. She further added she was unsure what triggered Resident #5. In an additional interview with the ED on 3/7/24 at 10:30 a.m., she stated the residence had begun the eviction process for Resident #5 in February 2024 when the department had last been out there. She stated the residence had not issued the 30-day discharge notice because they were having a difficult time finding placement for Resident #5. The ED stated the residence had the resident's outside provider involved now, so with her help, they would hopefully be able to find placement for her soon. Additionally, the ED stated she had spoken with Resident #5's family member on 3/6/24 and had drafted the 30-day discharge notice. 3. Resident #22 was admitted to the residence on 12/26/23 with a diagnosis of dementia.a. Incident Reports An IR, dated 2/17/24, read in part, "Around 3:00 p.m., Resident #22 threatened to fight another resident ..." An IR, dated 2/17/24, read in part, "Around 4:30 p.m., (Resident #22) had verbally attacked Residents #2 and #25. Had staff not stepped in, (Resident #22) would have attacked the other residents, as he shoved the staff member several times ... Law enforcement and emergency medical services (EMS) were notified and arrived at the residence a shor (sic) time later ... Resident #22 was transported to the hospital for evaluation. Resident #22's family was notified ..."An IR, dated 2/26/24, read in part, "Around 11:45 a.m., Resident #22 was yelling and screaming profanity words and slamming doors ... Law enforcement and EMS were called; however, Resident #22 refused to be transported to the hospital ... The resident blurted out he wanted to beat someone ..."b. 30-Day Discharge Notice A 30-day discharge notice for Resident #5, dated 3/1/24, and signed on 3/7/24, read in part, "Reason for notice: The resident becomes verbally aggressive ... The resident becomes destructive when he is upset and yells and curses at others during this time ... The resident has become a danger to himself and others when he is upset ..." c. Interviews On 3/4/24 at 8:42 a.m., Resident #1 stated Resident #22 had hit two people and was concerned with his violence. She stated she was unaware of any other incidents where he had hurt someone; however, on 2/27/24, he was angry and had broken a window. Resident #1 stated he often yelled at night and was afraid of him when he was in those moods. On 3/4/24 at 8:59 a.m., Resident #24 stated he was afraid of Resident #22 when he yelled out at night and after he had hit two people. He stated law enforcement had been to the residence about a month ago. On 3/7/24/at 9:45 a.m., Resident #3 stated he had not witnessed Resident #22 physically abuse anyone; however, he had witnessed him break things. He stated Resident #22 would often become so angry he would yell and swear which scared Resident #3. On 3/7/24 at 10:00 a.m., Staff #2 stated Resident #22 was scary sometimes. She stated, for example, this morning (3/7/24), Resident #22 ate breakfast, but then afterward, he started screaming and cussing. Staff #2 stated she attempted to calm Resident #22 down by talking to him and asked if he wanted to go outside or to his room. She stated Resident #22 had chosen to go to his room but he continued to scream and cuss. On 3/7/24 at 12:20 p.m., the ED stated when Resident #22 was first admitted to the residence in December, 2023, he was very sweet and had no aggression issues. She stated Resident #22 had a change of condition on 2/17/24 when he verbally attacked Resident #1 and he has had issues with verbally attacking residents and staff ever since. However, she stated she was unaware of any physical aggression. She stated she spoke with Resident #22's family member and informed him the residence was issuing the resident a 30-day discharge notice as of today (3/7/24).

A licensure complaint, prompted by #CO35003 and #CO35037, was completed on 3/7/24. A deficiency was cited.

Based on observation, interview, and record review, the residence failed to discharge residents who were a danger to themselves or others and required a higher level of care, affecting two residents (#5, #22). Specifically, Resident #5 had a court order, dated 5/11/22, that read the resident required a secure living arrangement and daily assistance and supervision to ensure her own safety; however, the residence did not have a secure environment available. The care plan for Resident #5, dated 3/4/24, revealed the resident required supervision to reduce wandering behaviors and help manage destructive/abusive behaviors. Incident reports (IR) dated 1/29-3/3/24, revealed the resident had physically abused and caused harm to four residents (#3, #21, #23, #24) and had not been issued a discharge notice. Additionally, Resident #5 wandered outside of the residence for an unknown period of time. Findings include: 1. References and Residence Policiesa. Chapter VII regulations governing assisted living residences, defines "Discharge" as termination of the resident agreement and the resident's permanent departure from the facility.b. The residence's Discharge Policy, dated 12/25/23, read in part, "The assisted living residence shall arrange discharge for any resident who: Is profoundly disoriented to time, person, and place with safety concerns that require a secure environment, and the assisted living residence does not provide a secure environment; Exhibits conduct that poses a danger to self or others and the assisted living residence is unable to sufficiently address those issues through therapeutic approach."c. The residence's Resident Rights policy, dated 12/21/23, read in part, "Residents have the right to be free from sexual, verbal, physical, and emotional abuse, humiliation, intimidation, or punishment ..."2. Resident #5 was admitted to the residence on 11/2/23 with diagnoses including dementia and wandering behaviors. a. Court Order Review of a court order for Resident #5, dated 5/11/22, read, "The resident required a secure living arrangement and daily assistance and supervision to ensure her own safety."b. Care Plan Review of the care plan for Resident #5, dated 3/4/24, revealed the resident required supervision to reduce wandering behaviors and help manage destructive/abusive behaviors. However, there were no interventions in place, and it was unclear how staff were to reduce wandering behaviors and manage the resident's destructive/abusive behaviors. c. Incident Reports An IR, dated 1/29/24, at 2:29 p.m., read in part, "The qualified medication administration person (QMAP) had checked on (Resident #5) a half hour prior to 2:29 p.m. A caregiver (CG) asked the QMAP where (Resident #5) was and searched around. (Resident #5) had managed to get outside where the CG found her. No injuries were observed and the resident was unable to provide a statement ..."An IR, dated 2/25/24, read in part, "(Resident #5) wandered into a resident's room and hit the resident's knee. The CG saw (Resident #5) and led her to her room where she laid down in her own bed. (Resident #5) was unable to provide a statement ..."An IR, dated, 2/14/14, read in part, "On 2/14/24, Resident #21 complained Resident #5 hit him in his room with a book ..."An IR, dated 3/3/24, read in part, "On 3/3/24, Resident #23 was in her room sleeping when Resident #5 wandered into Resident #23's room and hit her ..."d. 30-Day Discharge NoticeA 30-day discharge notice for Resident #5, dated 3/1/24, and signed on 3/7/24, read in part, "Reason for notice: The resident needs a higher level of care due to the dementia progressing. The resident becomes physically aggressive with others, hitting them when they become close to her. The resident wanders into other residents' rooms and often picking up things that are not hers or hitting the other residents. The resident is cognitively impaired ..." e. Interviews On 3/4/24 at 8:59 a.m., Resident #24 stated Resident #5 often wandered into his room and hit him. He stated the last time Resident #5 had hit him was two days prior to the onsite visit; however, he had not reported it to anyone. On 3/4/24 at 9:11 a.m., Resident #23 stated Resident #5 hit her with Resident #23's cane. She stated Resident #5 had dementia, was aggressive, and was afraid of her. Resident #23 said, "When Resident #5 hits me, it hurts badly." She stated Resident #5 wandered into her room almost nightly and felt that Resident #5 was not closely monitored. On 3/4/24 at 9:27 a.m., Staff #1 stated Resident #5 required line of sight monitoring; however, there were not enough staff to be able to provide that type of monitoring 24 hours/seven days a week. She stated she had heard Resident #5 had hit another resident a week prior to the onsite visit; however, she was unsure who the other resident was. Staff #1 further added Resident #5 had eloped approximately two weeks prior to the onsite visit and that staff had found her outside of the residence. On 3/4/24 at 9:42 a.m., Resident #21 stated Resident #5 had gone into his room and had hit him 10 times since January, 2024. He stated Resident #5 hit him in the back with a book a week prior to the onsite visit. Resident #21 stated he was afraid of Resident #5 because she was violent and confused. On 3/4/24 at 9:50 a.m., the executive director (ED) stated she had been working with Resident #5's family member on finding placement for the resident, as the residence was no longer able to meet her needs. However, it had been difficult to find different placement. On 3/5/24 at 3:15 p.m., the ED and the administrator were interviewed. The ED stated Resident #5 had resided in a secure environment prior to being admitted to the residence on 11/2/23. She stated the residence had completed an assessment for Resident #5 and while she had been diagnosed with dementia, the resident had seemed "with it" at the time. The ED stated Resident #5 had started declining in January, 2024. She stated Resident #5 wandered, became easily agitated, and was physically aggressive with the other residents. She further stated the other residents were afraid of Resident #5. The ED stated the residence had a conversation with the resident's family member and informed him the residence was no longer able to meet Resident #5's needs; however, they had not issued a 30-day discharge notice as of yet. The administrator confirmed the ED's statement. On 3/6/24 at 3:21 p.m., Resident #5's outside provider stated she was unsure why the resident had been admitted to the residence in the first place, as she was not appropriate for a non-secured environment. She stated Resident #5 was completely non-verbal and wandered. The outside provider stated Resident #5 had aggressive behaviors; however, she was unaware the resident's aggression had become more frequent. She stated Resident #5 needed a higher acuity of care because the residence did not have enough staff to supervise the resident have. On 3/7/24/at 9:45 a.m., Resident #3 stated he had been hit by Resident #5 on multiple occasions; however, the worst incident was when Resident #5 had hit him in the head with a book and suffered from a concussion. He stated Resident #5 wandered around and would just hit people. On 3/7/24 at 10:00 a.m., Staff #2 stated Resident #5 wandered most of the day. She stated she had not witnessed Resident #5 become physically aggressive towards other residents; however, she had heard that the resident had hit other residents. Staff #2 stated Resident #5 was non-verbal so it was difficult to communicate with her. She further added she was unsure what triggered Resident #5. In an additional interview with the ED on 3/7/24 at 10:30 a.m., she stated the residence had begun the eviction process for Resident #5 in February 2024 when the department had last been out there. She stated the residence had not issued the 30-day discharge notice because they were having a difficult time finding placement for Resident #5. The ED stated the residence had the resident's outside provider involved now, so with her help, they would hopefully be able to find placement for her soon. Additionally, the ED stated she had spoken with Resident #5's family member on 3/6/24 and had drafted the 30-day discharge notice. 3. Resident #22 was admitted to the residence on 12/26/23 with a diagnosis of dementia.a. Incident Reports An IR, dated 2/17/24, read in part, "Around 3:00 p.m., Resident #22 threatened to fight another resident ..." An IR, dated 2/17/24, read in part, "Around 4:30 p.m.,(Resident #22) had verbally attacked Residents #2 and #25. Had staff not stepped in, (Resident #22) would have attacked the other residents, as he shoved the staff member several times ... Law enforcement and emergency medical services (EMS) were notified and arrived at the residence a shor (sic) time later ... Resident #22 was transported to the hospital for evaluation. Resident #22's family was notified ..."An IR, dated 2/26/24, read in part, "Around 11:45 a.m., Resident #22 was yelling and screaming profanity words and slamming doors ... Law enforcement and EMS were called; however, Resident #22 refused to be transported to the hospital ... The resident blurted out he wanted to beat someone ..."b. 30-Day Discharge Notice A 30-day discharge notice for Resident #5, dated 3/1/24, and signed on 3/7/24, read in part, "Reason for notice: The resident becomes verbally aggressive ... The resident becomes destructive when he is upset and yells and curses at others during this time ... The resident has become a danger to himself and others when he is upset ..." c. Interviews On 3/4/24 at 8:42 a.m., Resident #1 stated Resident #22 had hit two people and was concerned with his violence. She stated she was unaware of any other incidents where he had hurt someone; however, on 2/27/24, he was angry and had broken a window. Resident #1 stated he often yelled at night and was afraid of him when he was in those moods. On 3/4/24 at 8:59 a.m., Resident #24 stated he was afraid of Resident #22 when he yelled out at night and after he had hit two people. He stated law enforcement had been to the residence about a month ago. On 3/7/24/at 9:45 a.m., Resident #3 stated he had not witnessed Resident #22 physically abuse anyone; however, he had witnessed him break things. He stated Resident #22 would often become so angry he would yell and swear which scared Resident #3. On 3/7/24 at 10:00 a.m., Staff #2 stated Resident #22 was scary sometimes. She stated, for example, this morning (3/7/24), Resident #22 ate breakfast, but then afterward, he started screaming and cussing. Staff #2 stated she attempted to calm Resident #22 down by talking to him and asked if he wanted to go outside or to his room. She stated Resident #22 had chosen to go to his room but he continued to scream and cuss. On 3/7/24 at 12:20 p.m., the ED stated when Resident #22 was first admitted to the residence in December, 2023, he was very sweet and had no aggression issues. She stated Resident #22 had a change of condition on 2/17/24 when he verbally attacked Resident #1 and he has had issues with verbally attacking residents and staff ever since. However, she stated she was unaware of any physical aggression. She stated she spoke with Resident #22's family member and informed him the residence was issuing the resident a 30-day discharge notice as of today (3/7/24).

Deficiency cited from Occurrence # 2323PKZ0001.

Chapter 02 General Licensure StandardsPart 4 - Quality Management Program, Occurrence Reporting, Palliative Care4.2 OCCURRENCE REPORTING4.2.1 Notwithstanding any other reporting required by state law or regulation, each facility or agency licensed pursuant to section 25-1.5-103, C.R.S. shall report to the Department the occurrences specified at section 25-1-124 (2), C.R.S.4.2.4 The Department may request further oral reports or a written report of the occurrence if it determines a report is necessary for the department's further investigation. The facility failed to provide additional information as requested for a Physical Abuse event #2323PKZ0001. Findings:On 12/11/23, the facility submitted an initial report of Physical Abuse for an alleged incident that occurred on 12/10/23. The final report was submitted on 12/19/23. Upon review of the investigation, the investigator required additional information regarding the event. Department staff sent messages through the COHFI system. The initial message was sent on 12/22/23 and opened by a facility provider on 1/25/24. No response was provided. A second message was sent on 12/28/23 requesting a facility representative respond to the 12/22/23 questions. The 12/28/23 message was opened on 1/25/24 by a facility representative, but there was no response. An external message was sent to the facility on 1/22/24 via email requesting a facility representative respond to the message/questions sent on 12/22/23 within the COHFI system. Several representatives responded to this email and indicated the information would be sent. However, no response was received. Another message response was sent again via external email on 1/25/24 requesting a response, but no information was submitted. On 1/25/24, a voice mail was left with a facility representative about the report needs and requesting someone respond to the questions asked about the report. As of 1/31/24, no follow up information has been provided in response to the 12/22/23 questions sent within the COHFI system.

A recertification survey with complaints #CO34060, #CO34141, #CO34296, #CO34547, #CO34651 was completed on 1/22/24. Deficiencies were cited.

Based on record review and interview, the facility (residence) failed to conduct assessments annually and whenever there was a significant change in physical, cognitive, or behavioral needs, affecting three of three sample participants (residents) (#2, #5 and #8) who experienced a change in condition. 1. Reference and Resident Agreementa. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(B) Information regarding the resident's overall health and physical functioning ability;(E) Current diagnoses and any known or anticipated need or impact related to the diagnoses;(J) History and circumstances of recent falls and any known approaches to prevent future falls;(L) Types of physical, mental, and social support required.b. The Residence's Change in Baseline Policy, dated 12/29/23, read in part: "the comprehensive assessment shall be updated for each resident at least annually or whenever the resident's condition changes from baseline status."2. Resident #8 was admitted to the residence on 12/6/23. The residence's most recent comprehensive assessment for Resident #8, dated 12/6/23, read the resident had no short or long term illness. The assessment did not include any information on Resident #8's seizures. There were no other assessments in Resident #8's record. An incident report, dated 12/10/23, read in part: "Resident came out of her room upset that she had not had her meds. Staff had her sit down for a few minutes because she was worried about having a seizure. After the staff asked her if she felt up to laying down, she stood up she nearly collapsed. (The qualified medication administration person (QMAP) and other caregiver assisted her to sit down. she voiced she wanted (the ambulance) called. Qmap called (the ambulance) and while on the phone with (the ambulance) she complained of chest pain and was dry heaving but no vomiting."A progress note, dated 12/18/23, read Resident #8 had a seizure that lasted seven minutes and was transported by the ambulance to the hospital. A discharge summary, dated 12/13/23, read Resident #8 was hospitalized due to seizures from 12/11-12/13/23, and had an abnormal blood level of phenytoin and troponin. On 1/17/24 at 7:42 a.m., Staff #3 stated she worked the day Resident #8 had her first seizure at the residence on 12/10/23 and was hospitalized and had suggested the resident be sent out. On 1/18/24 at 10:03 a.m., the practitioner for Resident #8 stated Resident #8's blood levels of phenytoin were tested on 12/10/23 and showed no evidence of the medication in her bloodstream. The practitioner stated Resident #8 had received medications inadequately which increased her risk of heart attacks due to the seizures. The practitioner further stated the resident had epilepsy and it was imperative she received her epilepsy medication as prescribed and stated her not receiving the medication as prescribed is likely what caused her seizure on 12/10/23. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated the administrator was responsible for conducting reassessments. She further stated Resident #8 should have been reassessed after her first seizure at the residence on 12/10/23 and would consider it to be a change in condition. The administrator designee stated she was unaware her comprehensive assessment did not include her seizures and how they are monitored and stated it should have been updated to include that information. 3. Based on interviews and record review, there was similar deficient practice for Residents #2 and #5.

Based on observation and interviews the facility (residence) failed to ensure the policy on resident rights was in a visible location and available to participants and visitors at all times, affecting 29 current participants (residents). Throughout the on-site investigation from 1/17/24 from 7:00 a.m. to 6:30 p.m. and on 1/18/24 from 7:00 a.m. to 4:15 p.m., resident rights were observed to be posted approximately six feet off the ground and not in a publicly visible location. On 1/17/24 at approximately 9:10 a.m., Resident #6 stated that none of the residents in wheelchairs; himself included, could read the resident rights because they are posted so high above the ground. On 1/18/24 at 6:53 a.m., Resident #2 stated she was unable to even reach where the resident rights were posted let alone see them. Resident #2 further stated she was unsure what her rights were. On 1/18/24 at 7:17 a.m., Resident #1 stated that he had never noticed where the resident rights were posted and stated that everything was posted so high up he could not read anything from in his wheelchair. Resident #1 further stated he was unaware what his rights were. On 1/18/24 at 7:27 a.m., Resident #3 stated he was unsure what his rights were and had not seen them posted anywhere in the residence. On 1/18/24 at 2:58 p.m., Resident #10 stated she was unaware what her rights were and had not noticed them posted anywhere in the residence. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated she was aware that resident rights needed to be posted in a publicly visible location. She stated she had not thought about the possibility of residents being unable to see their rights due to them being posted higher above the ground.

Based on observations and interviews the facility (residence) failed to provide sufficient ventilation sufficient to meet participant (resident) needs, affecting 29 current residents. Findings include:1. ReferenceAccording to Weather Underground, the temperature on 1/16/24 dropped to -13 degrees F. Weather Underground (2024) Denver, CO Weather History. https://www.wunderground.com/history/daily/us/co/denver/KDEN/date/2024-1-162. ObservationsThroughout the on-site investigation from 1/17/24 from 7:00 a.m. to 6:30 p.m. and on 1/18/24 from 7:00 a.m. to 4:15 p.m., the following was observed:A large common area heater labeled "Olson PH" was observed in the dining room, which was installed by a professional HVAC company as a temporary heating solution until the residence's broken heater was fixed. Resident #13 had covered her floor vent with a rug due to it blowing cold air. Residents #1, #2, #3, #6 and #14 were observed wearing coats in the dining area both days of the onsite investigation. Portable heaters lined up down the hallways throughout the residence and in resident rooms. The dining room area with the Olson PH heater on measured 70.7 degrees F. Resident #1's room temperature was 83.5 degrees F without his portable heater plugged in and Resident #1's bedroom window would not open more than about one inch. There were only two thermostats to control the temperature of the residence, that were located near the television room and dining room. 3. InterviewsThroughout the on-site investigation from 1/17/24 from 7:00 a.m. to 6:30 p.m. and on 1/18/24 from 7:00 a.m. to 4:15 p.m., the following interviews were conducted:Staff #3 stated there were issues with the ventilation system and the residence heater broke. Staff #3 stated she had worked at the residence for a month and stated the heater had broken within the past week prior to the onsite investigation. She further stated the portable heaters and the Olson PH heater were put in over the weekend prior to the onsite investigation. Resident #13 stated her floor vent blows cold air so she covered it up with an area rug. Resident #13 stated she was provided two portable heaters a week prior to the onsite investigation and with them she would get too hot. However, she stated without the portable heaters she was freezing cold, which had been an ongoing issue and she was unsure for how long. The resident care coordinator (RCC) stated she had only worked at the residence for two weeks prior to the onsite investigation and stated that the Olson PH heater was placed by an external maintenance company the day before the onsite investigation due to issues with the heater going on and off. The maintenance director (MD) stated two weeks prior to the onsite investigation the heater broke and the residence had three maintenance companies come out and discovered the heater required a new coil. He stated it was a little over 70 degrees in the common area since the portable heaters were placed. The MD stated he brought portable heaters upstairs from the basement and placed them down the hallway and in resident rooms the Friday prior to the onsite investigation. He stated it was because residents had complained of being cold and the temperature had dropped to 65 degrees fahrenheit. Resident #3 stated that the residence had experienced issues with the heater going off since a year prior to the onsite investigation and stated he was currently cold in the dining room area which was why he had a coat on. The administrator designee stated issues with the heater began around December 2023 and a maintenance company discovered a broken coil. She stated there were some rooms where there were no ventilation issues that had too much heat and others had no heat since the cold air chill the weekend prior to the onsite investigation. She further stated residents were unable to control thermostats since the thermostats were located in the north and south hallway of the residence and would control each area of resident rooms. Resident #14 stated he put on a coat the morning of the onsite investigation because he was cold and had been cold for a long time, but was unsure for how long. He stated since the portable heaters were put into his room over the weekend prior to the onsite investigation it was the first time he had been warm. Resident #14 further stated the residence should have heat. He stated before the portable heater was put into his room, he wanted to move out because he was so uncomfortable. Resident #6 stated since he moved in around August 2023, the residence has had ongoing heating and cooling issues and around November 2023 the residence was down to 62 degrees F. Resident #6 stated it had been increasingly cold in the two weeks prior to the onsite investigation and portable heaters were brought in over the weekend. However, he stated prior to that the temperature had dropped to 62 degrees F in the television room. Resident #15 stated she had been cold almost every night and had brought in a portable fireplace which had worked to keep herself and roommate warm. Resident #15 stated she had been cold for as long as she could remember at the residence. Resident #16 stated he had been cold since two weeks prior to the onsite investigation and stated it felt to be around 60 degrees F overnight. He stated he was cold the night prior to the onsite investigation and had to turn on his portable heater. Resident #2 stated around four days prior to the onsite investigation she got really cold. She stated the temperature was so cold in her room that her drink froze. Resident #2 stated it was that same day that the MD provided her with a portable heater and since then it had helped keep her warm. Resident #2 further stated she was cold in the common area and that was why she wore a jacket. Resident #1 stated his window had been broken since he was admitted to the residence in August 2023 and he would frequently overheat. He also stated he wanted to open his window and was overheating the day of the onsite investigation. Resident #1 stated his room was one of the few rooms where the heater still worked since it had broken over the weekend prior to the onsite investigation. Resident #1 stated the heater would blast hot air into his room whereas other residents were cold. He stated he was told by other staff members, whose name he did not recall, that it would get fixed and still had not. Resident #1 stated there were other times the heat did not work in his room either and he would get too cold and stated the last time was about a week prior to the onsite investigation. Resident #1 further stated he would put on a jacket since he would get cold in the dining room. The family member for Resident #1 stated Resident #1 was unable to open his window more than an inch since the fall of 2023. She stated there had been days that his room temperature was over 80 degrees including the day of the onsite investigation and the resident wanted to open his window, and other days where it was in the 60s and she had purchased him a space heater herself as a solution. The administrator designee stated she was aware of the requirement for sufficient heating and ventilation; however the building was old and the heater broke. The administrator further stated she expected the heater to be fixed within the week following the onsite investigation.

Based on interviews and record review, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting 29 current residents. Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires that the assisted living residence comply with authorized practitioner's orders associated with medication administration except for those medications which a resident self-administers. Specifically, a written practitioner's order, dated 8/31/23, directed the residence to administer phenytoin sodium 100 mg at bedtime for seizures to Resident #8. The residence failed to administer Resident #8's phenytoin sodium from when she was admitted to the residence on 12/6/23, until she experienced a seizure on 12/10/23 and was hospitalized until 12/13/23. Further, the residence failed to transcribe Resident #8's medications, which included the phenytoin sodium, onto the electronic medication administration record (eMAR) until after Resident #8 returned from the hospital on 12/13/23. Resident #8's practitioner stated Resident #8's blood levels of phenytoin were tested and showed no evidence in her bloodstream, which would indicate she had not received the medication for at least a week prior. Resident #8's practitioner further stated that Resident #8 troponin levels were high which indicated the resident had received medications inadequately and increased her risk of heart attacks due to the seizures. The practitioner further stated the resident had epilepsy and it was imperative she received her epilepsy medication as prescribed and stated it was what caused her seizure on 12/10/23. Findings include:a. References and Residence PolicyAccording to the Epilepsy Foundation, phenytoin is a widely used seizure medication used to treat temporal lobe epilepsy. "Don't stop using phenytoin or change the amount taken without talking to the doctor first. Stopping any seizure medicine all at once can affect other medicines in the body. It may even cause non stop seizures that can be life-threatening ..." Epilepsy.com (2023), retrieved from: https://www.epilepsy.com/tools-resources/seizure-medication-list/phenytoin#:~:text=Abruptly%20stopping%20phenytoin%20can%20lead,they%20will%20be%20less%20effective. The residence's Medication Administration Policy, dated 12/21/23, read in part: "(the residence) shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers."b. Resident #8 was admitted to the residence on 12/6/23. Phenytoin SodiumA written practitioner's order, dated 8/31/23, directed the residence to administer phenytoin sodium 100 mg at bedtime for epilepsy. However, the December 2023 electronic medication administration record (eMAR) read the medication was not administered until 12/13/23 and was completely blank prior. The resident had not received the medication from 12/6/23 until she was hospitalized on 12/10/23, for a total of four missed doses. An incident report, dated 12/10/23, read in part: "Resident came out of her room upset that she had not had her meds. Staff had her sit down for a few minutes because she was worried about having a seizure. After the staff asked her if she felt up to laying down, she stood up she nearly collapsed. The (qualified medication administration person) QMAP and other caregiver assisted her to sit down. she voiced she wanted (the ambulance) called. Qmap called (the ambulance) and while on the phone with (the ambulance) she complained of chest pain and was dry heaving but no vomiting. A medication release form from Resident #8's former residence, read there were 31 doses of phenytoin released on 12/6/23. The administrator designee signed off on 12/6/23 to pick up the medications from the former residence. A progress note, dated 12/18/23, read Resident #8 had a seizure that lasted seven minutes and was transported by the ambulance to the hospital. A hospital discharge summary, dated 12/13/23, read Resident #8 had a diagnosis of epilepsy and had an abnormal blood level of phenytoin and troponin. On 1/17/24 at 8:28 a.m., Resident #8's family member stated Resident #8 was currently in the hospital and had been since 12/18/24 due to not receiving seizure medication. The family member stated a month's worth of medication was provided from Resident #8's former residence and stated the administrator designee had picked up the medication. However, she stated Resident #8 had not received medications between 12/6 and 12/10 and was unsure what had happened to them. She further stated that even after the resident came back on 12/13/23, there were still medications that were not administered. On 1/18/24 at 10:03 a.m., the practitioner for Resident #8 stated Resident #8's blood levels of phenytoin were tested on 12/10/23 and showed no evidence of the medication in her bloodstream. The practitioner further stated the levels would indicate the resident had not received the medication for at least a week. Resident #8's practitioner further stated that Resident #8 troponin levels were high which indicated the resident had received medications inadequately and increased her risk of heart attacks due to the seizures. The practitioner further stated the resident had epilepsy and it was imperative she received her epilepsy medication as prescribed and stated it was what caused her seizure on 12/10/23. On 1/18/24 at 4:22 p.m., the administrator designee stated she had picked up all of Resident #8's medications on 12/6/23 and completed a medication reconciliation. The administrator designee stated she was responsible for transcribing medications onto the eMAR and thought she had done so on 12/6/23. The administrator designee stated she was unsure why the December eMAR was blank until 12/13/23 and stated as far as she was aware Resident #8 had received all her medications. AcetaminophenA written practitioner's order, dated 7/12/23, directed the residence to administer acetaminophen 650 mg three times daily. However, the December 2023 eMAR read the medication was not administered due to being out of stock, for the morning dose on 12/18, for the evening dose on 12/13 and 12/15, and all three doses on 12/14, 12/16 and 12/17/23, for a total of 12 missed doses. A medication release form from Resident #8's former residence, read there were 93 doses of acetaminophen released on 12/6/23. The administrator designee signed off on 12/6/23 to pick up the medications from the former residence. Breztri arosphereA written practitioner's order, dated 3/15/23, directed the residence to administer breztri arosphere 160-9-4.8 mcg one puff every 12 hours. However, the December 2023 eMAR read the medication was not administered due to being out of stock, for the morning dose on 12/18, for the evening dose on 12/13, 12/15 and 12/16, and all three doses on 12/17/23, for a total of seven missed doses. HydroxyzineA written practitioner's order, dated 7/27/23, directed the residence to administer hydroxyzine 25 mg twice daily. However, the December 2023 eMAR read the medication was not administered due to being out of stock, for the morning doses on 12/17 and 12/18, and for the evening dose on 12/13, 12/15 and 12/16/23, for a total of five missed doses. PromethazineA written practitioner's order, dated 7/27/23, directed the residence to administer promethazine 12.5 mg twice daily. However, the December 2023 eMAR read the medication was not administered due to being out of stock, in the evening on 12/13, in the morning on 12/14 and 12/18, and both doses on 12/17/23, for a total of five missed doses. Fluticasone A written practitioner's order, dated 3/15/23, directed the residence to administer fluticasone 50 mcg in each nostril daily. However, the December 2023 eMAR read the medication was not administered due to being out of stock, 12/17 and 12/18/23 for a total of two missed doses. FycompaA written practitioner's order, dated 5/18/23, directed the residence to administer fycompa 4 mg at bedtime. However, the December 2023 eMAR read the medication was not administered due to being out of stock, 12/13 and 12/14/23 for a total of two missed doses. A medication release form from Resident #8's former residence, read there were 93 doses of acetaminophen, 31 doses of amlodipine, 62 doses of benztropine mesylate, full bottle of fluticasone propionate, 27 doses of fycompa, 62 doses of gabapentin, 62 doses of hydroxyzine, 62 doses of levetiracetam, 31 doses of losartan hydrochlorothiazide, 62 doses of omeprazole and 62 doses of promethazine released on 12/6/23. The administrator designee signed off on 12/6/23 to pick up the medications from the former residence. However, there was no evidence the medications were transcribed onto the January eMAR prior to 12/13/23. c. InterviewsOn 1/17/24 at 8:28 a.m., Resident #8's family member stated a month's worth of medication was provided from Resident #8's former residence and stated the administrator designee had picked up the medication; however, did not think Resident #8 received her medications between 12/6 and 12/10/23 and was unsure what had happened to them. On 1/18/24 at 4:22 p.m., the administrator designee stated she had picked up all of Resident #8's medications on 12/6/23 and completed a medication reconciliation. The administrator designee stated she was responsible for transcribing medications onto the eMAR. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated QMAPs, the resident care coordinator (RCC), and the administrator were all responsible for order medications that were not cycle filled. The administrator designee stated she would expect the residence to comply with practitioner's orders and was unsure why that had not occurred for Resident #8. d. Record review, observation and interviews revealed similar deficient practice for Resident #1-#5. 2. Chapter VII regulations governing assisted living residents part 14.29, requires all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications. Findings include:a. Residence policyThe residence's Medication and Medication Administration policy, dated 12/21/23, read in part: "all prescribed and pro re nata (PRN) medications shall be listed and recorded on a medication administration record (MAR) ... each qualified medication administration person (QMAP) ... shall accurately document each medication administration or monitoring event at the time the event is completed for each resident."b. Resident #8 was admitted to the residence on 12/6/23. AcetaminophenA written practitioner's order, dated 7/12/23, directed the residence to administer acetaminophen 650 mg three times daily. However, the December 2023 electronic medication administration record (eMAR), revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning. Additionally, on 12/15/23 in the afternoon, the medication was marked under "1" for "other." However, there was no documentation on the back of the eMAR as to why the medication was marked under code 1, for a total of 23 inaccurately documented doses. Hydroxyzine A written practitioner's order, dated 7/27/23, directed the residence to administer hydroxyzine 25 mg twice daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning. Additionally, on 12/14/23 in the evening, the medication was marked under "1" for "other." However, there was no documentation on the back of the eMAR as to why the medication was marked under code 1, for a total of 14 inaccurately documented doses. LevetiracetamA written practitioner's order, dated 8/23/23, directed the residence to administer levetiracetam 750 mg two tablets twice daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented doses. Gabapentin A written practitioner's order, dated 8/31/23, directed the residence to administer gabapentin 300 mg twice daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented doses. Breztri aerosphereA written practitioner's order, dated 3/15/23, directed the residence to administer breztri aerosphere 160-9-4.8 mcg one puff every 12 hours. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented doses. Benztropine MesylateA written practitioner's order, dated 7/27/23, directed the residence to administer benztropine mesylate 1 mg every 12 hours. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented doses. PromethazineA written practitioner's order, dated 7/27/23, directed the residence to administer promethazine 100 mg at bedtime. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented doses. OmeprazoleA written practitioner's order, dated 7/19/23, directed the residence to administer omeprazole 40 mg every 12 hours. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented dosesAmlodipine BesylateA written practitioner's order, dated 10/18/23, directed the residence to administer amlodipine besylate 5 mg daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/13/23, for a total of seven inaccurately documented doses. Losartan hydrochlorothiazideA written practitioner's order, dated 9/20/23, directed the residence to administer losartan hydrochlorothiazide 100-12.5 mg daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/13/23 for a total of seven inaccurately documented doses. Fluticasone propionateA written practitioner's order, dated 3/15/23, directed the residence to administer fluticasone 50 mcg in each nostril daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/13/23, for a total of seven inaccurately documented doses. FycompaA written practitioner's order, dated 5/18/23, directed the residence to administer fycompa 4 mg at bedtime. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12/23, for a total of six inaccurately documented doses. c. Interviews On 1/18/24 at 4:22 p.m., the administrator designee stated she was unsure why the December eMAR was blank up until 12/13/23 and stated it should have been documented as to whether Resident #8 received her medications. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated she was aware of the requirement for all medications to be listed on the eMAR and for accurate documentation at the time of administration. She stated a blank space on the eMAR meant that no one documented the medication as administered and would have expected it to have been documented. The administrator designee further stated if a medication was not administered then a corresponding exception code should be used along with documentation on the back of the eMAR. d. Record review and interviews revealed similar deficient practice for Resident #1-#5. 3. Chapter VII regulations governing assisted living residents part 14.31 requires the administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review. The residence's Medication Administration policy, dated 12/21/23, read in part: "(the residence) shall conduct on a monthly basis, a joint two person audit of medications ... the results of the audit shall be documented."On 1/17/24 at 8:54 a.m., documentation of quarterly medication audits was requested but not provided. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated the administrator and resident care coordinator (RCC) were responsible for completing medication audits together and was aware of the requirement that they needed to be completed quarterly. The administrator designee further stated she was unable to locate evidence of medication audits or whether they were being completed since the RCC was hired at the residence two weeks prior to the onsite investigation. 4. Chapter VII regulations governing assisted living residences, part 14.11, requires that only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.a. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 14.17, requires the assisted living residence shall ensure that each authorized practitioner's order for medication includes ... the signature of the practitioner. The residence's Medication Administration policy, dated 12/21/23, read in part: "All medications must have a physician's prescription ... only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents."b. Resident #2 was admitted to the residence on 6/29/23 with a diagnosis of epilepsy. DivalproexThe January 2024 electronic medication administration record (eMAR) read Resident #3 was administered divalproex 500 mg twice daily on 1/1-1/8 and 1/13-1/17, and in the morning on 1/9 and 1/18/24, for a total of 28 doses. However, the residence was unable to provide a signed practitioner order for the medication. c. Additionally, the residence failed to ensure that only medications ordered and signed by an authorized practitioner were administered to Resident #3. d. InterviewsOn 1/18/24 at 12:14 p.m., the administrator designee stated she was unable to locate a signed order for Resident #3's divalproex 500 mg twice daily, and stated she only had an unsigned medication list with the medication on it. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated she was responsible for medication orders and transcribing orders onto the eMAR and stated she had gotten busy. The administrator designee stated orders should have been signed for Resident #2 and #3 and medications should not have been administered without signed orders.

A relicensure survey with complaints #CO34059, #CO34140, #CO34295, #CO34548, #CO34650 was completed on 1/22/24. Deficiencies were cited.

Based on record review and interview, the residence failed to accept only those persons whose needs can be fully met by the existing staff, physical environment, and services already being provided, affecting one sample resident (#5). (Cross-reference Q1312)Findings include: 1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 11.2, require no resident to move in who is profoundly disoriented to time, person, and place with safety concerns that require a secure environment and the assisted living residence does not provide a secure environment.b. Chapter VII regulations governing assisted living residences, part 2.43, defines "Secure environment" as any grounds, building or part thereof, method, or device that prohibits free egress of residents. An environment is secure when the right of any resident thereof to move outside the environment during any hours is limited. c. The residence's Admission Policy, dated 12/23/23, read in part: "(the residence) shall accept only those persons whose needs can be fully met by existing staff ... based on a comprehensive pre-admission assessment ... (and) shall not allow any person to move in who ... is profoundly disoriented to time, person, and place with safety concerns that require a secure environment, and does not provide a secure environment ..." 2. Resident #5 was admitted to the residence on 11/2/23 with diagnoses that included dementia and wandering. The residence's pre-admission assessment, completed by the administrator designee for Resident #5 and dated 10/22/23, read Resident #5 was alert and oriented and had no history of wandering or combativeness. The pre-admission assessment was completed at the resident's previous residence which was a secure environment residence. A post admission assessment, dated 11/2/23, read in part: Resident #5 had abusive, destructive and aggressive behaviors that required intervention from staff to help the resident maintain positive and appropriate interactions with others. The assessment further read: "does the resident require a secure environment based off of the pre-admission assessment" and the assessment was marked "yes." However, the residence was not licensed as a secure environment. A progress note dated 11/24/23, read Resident #5 had been aggressive to staff and residents. She tried to enter Resident #3's room stating it was the bathroom. A progress note dated 11/25/23, read Resident #5 wandered into Resident #12's room. Resident #12 yelled out and Staff #2 removed the resident from the inappropriate room. A progress note, dated 12/2/23, read Resident #5 tried to escape the resident through the fire escape door. A progress note dated 12/9/23, read Resident #5 used the bathroom in Resident #11's room. The residence's investigation of abuse, dated 12/11/23, which was written by the administrator designee, read in part, Resident #3 stated he was drinking coffee at the dining room table at 11:30 p.m. and fell asleep. He was awoken by Resident #5 having hit him in the head with the back of a book. Resident #3 experienced no injury at the time of the incident; however, three days later experienced severe headaches and was sent to the hospital. Both residents were spoken to and Resident #3 was placed on hourly checks following his return from the hospital. Resident #5 was place on line of sight monitoring daily, care plan and face sheet were updated, and and the administrator began looking for alternative placement for Resident #5. A progress note dated 12/21/23, read Resident #5 attempted to enter two different resident's rooms and was redirected by Staff #2. 3. InterviewsOn 1/17/24 at 10:45 a.m., the administrator designee stated she had completed a preadmission assessment at Resident #5's former residence (a secure environment) on 10/22/23. The administrator designee further stated she was unaware of Resident #5's history of aggression and based upon her own assessment had determined she was cognitively aware enough for admission to the non-secure residence. However, the administrator designee stated she was aware that Resident #5 was in a secure environment prior to admission and stated she self-determined that Resident #5 was cognitively aware enough to be admitted to the residence. The administrator designee stated it was not until after Resident #5 was admitted that she noticed wandering into other resident rooms, aggression such as grabbing staff and resident arms. The administrator designee stated she was only provided a care plan and orders from the former residence, which did not reveal her altercations and wandering history. However, during the onsite investigation the pre-admission care plan, from the former residence was not provided. On 1/17/24 at 8:20 a.m., Staff #3 stated she was made aware of the altercation between Resident #3 and #5; although she was not working that shift. Staff #3 stated she used to work at the former residence which Resident #5 was admitted from. She further stated Resident #5 hit other residents, wandered into other resident rooms, and attempted to exit seek at at her previous residence. The staff added Resident #5 had the same behaviors since she was admitted. On 1/17/24 at 9:59 a.m., the practitioner for Resident #5 stated the resident had a history of altercations at her former residence, wandered and was required to have a one on one sitter. The practitioner stated she was not made aware that Resident #5 was admitted to a non-secure environment until after the administrator designee admitted her on 11/2/23. Further, the practitioner stated she thought Resident #5 was placed into another secure environment, and stated her current placement was not safe for her due to her dementia and history of wandering. On 1/18/24 at 2:08 p.m., the former residence's administrator stated that Resident #5 was discharged from their secure environment because of resident to resident altercations. She also stated when the administrator designee had conducted the preadmission assessment in October 2023, she had informed the administrator designee reasons for discharge which included the resident's history of wandering. The former residence's administrator further stated she provided the administrator designee with care plans, a face sheet, and progress notes for the previous 90 days. She further stated she was under the impression that the residence was a secure environment, and "would have never discharged her to (the administrator designee) if she had known it was not a secure facility."On 1/18/24 at 2:35 p.m., the family member of Resident #5 stated that Resident #5 had a history of wandering, physically aggressive behaviors and altercations with other residents as well as wandering at the former residence. He further stated Resident #5 was provided a discharge notice to evict her due to the reports of the altercations. Resident #5's family member stated he was aware the residence was not a secure environment unlike the former residence; however, believed Resident #5's behaviors had improved since admission. On 1/22/24 at 11:02 a.m., the administrator designee stated she was not aware of the requirement that no resident shall move in who was disoriented with safety concerns that require a secure environment. The administrator designee stated she used assessment questions she generally asked residents prior to admission. She stated when she spoke to Resident #5 on 10/22/23, she appeared to be alert enough for admission to the non-secure residence. The administrator designee stated Resident #5 resided in a secure environment previously and contrary to her admission assessment and the former residence's administrator interview, she claimed she was unaware of her wandering history or aggression.

Based on record review and interview, the residence failed to contact the resident's primary practitioner following a significant change in their baseline status, affecting one sample resident (#5). Findings include:1. Residence PolicyThe residence's Practitioner Assessment Policy, dated 12/29/23, read in part: "(the residence) shall contact the resident's primary practitioner when any of the following circumstances occur ... the resident experiences a significant change from their baseline status."2. Record Review Resident #5 was admitted to the residence on 11/2/23 with diagnoses that included dementia and wandering. The residence's pre-admission assessment, completed by the administrator designee, for Resident #5, dated 10/22/23, read Resident #5 was alert and oriented and had no history of wandering or combativeness. The pre-admission assessment was completed at the resident's previous residence which was a secure environment residence. Contrary to the residence's pre-admission assessment, the residence's admission assessment for Resident #5, completed by the administrator designee, dated 11/2/23, read Resident #5 had abusive, destructive and aggressive behaviors that required intervention from staff to help the resident maintain positive and appropriate interactions with others. The residence's investigation of abuse, dated 12/11/23, which was written by the administrator designee, read in part, Resident #3 stated he was drinking coffee at the dining room table at 11:30 p.m. and fell asleep. He was awoken by Resident #5 having hit him in the head with the back of a book. Resident #3 experienced no injury at the time of the incident; however, three days later experienced severe headaches and was sent to the hospital. Both residents were spoken to and Resident #3 was placed on hourly checks following his return from the hospital. Staff was required to ensure Resident #5 was within line of sight at all times and the care plan and face sheet were updated. Further, the administrator began began looking for at discharge options for Resident #5. Contrary to the investigation, an emergency room discharge summary, dated 12/10/23, read Resident #3 was admitted to the emergency room with headaches. A computed tomography (CT) scan, revealed the resident had sustained a closed head injury and was diagnosed with a concussion. A change of condition assessment, dated 12/11/23, read staff was required to ensure Resident #5 was within line of sight at all times. The record for Resident #5 revealed no documentation of progress notes or other documentation from the residence having attempted to contact his practitioner when Resident #5 hit Resident #3 over the head with a book on 12/10/23. 3. Interviews On 1/17/24 at 8:45 a.m., the administrator designee stated she was unaware whether Resident #5 had a history of aggression. The administrator designee stated it was not until after Resident #5 was admitted that she became non-verbal, aggressive toward staff, and would grab staff and resident arms. The administrator designee stated when Resident #5 got into an altercation with Resident #3 that it was the first she was aware of Resident #5 engaging in a physical altercation with another resident. She stated it was a change in her baseline from when she had conducted the pre-admission assessment and updated Resident #5's assessment to put in a line of sight intervention after the altercation with Resident #3. On 1/17/24 at 9:59 a.m., Resident #5's practitioner stated that Resident #5 had a history of altercations and wandering at her former residence which required her to have a one on one sitter. The practitioner further stated it had been reported to her that Resident #5 had aggressively grabbed staff at the residence; however, was unaware of her having grabbed or hit another resident. Resident #5's practitioner stated she would have expected to have been notified. On 1/22/24 at approximately 11:00 p.m., the administrator designee stated shewould have expected Resident #5's practitioner to have been notified of the altercation with Resident #3 and stated she would consider it a change in condition since it was the first altercation she was aware of. The administrator designee stated the qualified medication administration person (QMAP) or the administrator were responsible for notifying the practitioner and stated she should have been made aware.

Based on observation, record review and interview, the residence failed to ensure a comprehensive assessment was completed, documented in writing and kept in the resident's record, affecting two of two newly admitted residents (#4 and #9). Finding include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences in part 12.6 requires that; at the time a new resident moves in, the assisted living residence shall 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. Information from the comprehensive assessment shall be used to establish an individualized care plan.b. The residence's Comprehensive Assessment policy, dated 12/29/23 read in part: "at the time a new resident moves in, the assisted living residence shall complete a comprehensive assessment ... information from the comprehensive assessment shall be used to establish an individualized care plan."2. Record Review a. Resident #4 was admitted to the residence on 1/11/24. On 1/18/24, review of Resident #4's electronic and paper records showed no evidence of a comprehensive assessment completed at the time of move in. b. Resident #9 was admitted to the residence on 1/12/24. On 1/18/24 review of Resident #9's electronic and paper records showed no evidence of a comprehensive assessment completed at the time of move in. 3. InterviewOn 1/22/24 at approximately 11:00 a.m., the administrator designee stated she was unaware a comprehensive assessment was required to be completed upon move into the residence. The administrator designee stated she had thought she completed comprehensive assessments in the electronic health system for Residents #4 and #9; however, they were newly admitted and must have failed to complete the assessments.

Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated at least annually or whenever the residents' conditions changed from baseline status, affecting three of three sample residents (#2, #5 and #8) who experienced a change in condition. 1. Reference and Resident Agreementa. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(B) Information regarding the resident's overall health and physical functioning ability;(E) Current diagnoses and any known or anticipated need or impact related to the diagnoses;(J) History and circumstances of recent falls and any known approaches to prevent future falls;(L) Types of physical, mental, and social support required.b. The Residence's Change in Baseline Policy, dated 12/29/23, read in part: "the comprehensive assessment shall be updated for each resident at least annually or whenever the resident's condition changes from baseline status."2. Resident #8 was admitted to the residence on 12/6/23. The residence's most recent comprehensive assessment for Resident #8, dated 12/6/23, read the resident had no short or long term illness. The assessment did not include any information on Resident #8's seizures. There were no other assessments in Resident #8's record. An incident report, dated 12/10/23, read in part: "Resident came out of her room upset that she had not had her meds. Staff had her sit down for a few minutes because she was worried about having a seizure. After the staff asked her if she felt up to laying down, she stood up she nearly collapsed. (The qualified medication administration person (QMAP) and other caregiver assisted her to sit down. she voiced she wanted (the ambulance) called. Qmap called (the ambulance) and while on the phone with (the ambulance) she complained of chest pain and was dry heaving but no vomiting."A progress note, dated 12/18/23, read Resident #8 had a seizure that lasted seven minutes and was transported by the ambulance to the hospital. A discharge summary, dated 12/13/23, read Resident #8 was hospitalized due to seizures from 12/11-12/13/23, and had an abnormal blood level of phenytoin and troponin. On 1/17/24 at 7:42 a.m., Staff #3 stated she worked the day Resident #8 had her first seizure at the residence on 12/10/23 and was hospitalized and had suggested the resident be sent out. On 1/18/24 at 10:03 a.m., the practitioner for Resident #8 stated Resident #8's blood levels of phenytoin were tested on 12/10/23 and showed no evidence of the medication in her bloodstream. The practitioner stated Resident #8 had received medications inadequately which increased her risk of heart attacks due to the seizures. The practitioner further stated the resident had epilepsy and it was imperative she received her epilepsy medication as prescribed and stated her not receiving the medication as prescribed is likely what caused her seizure on 12/10/23. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated the administrator was responsible for conducting reassessments. She further stated Resident #8 should have been reassessed after her first seizure at the residence on 12/10/23 and would consider it to be a change in condition. The administrator designee stated she was unaware her comprehensive assessment did not include her seizures and how they are monitored and stated it should have been updated to include that information. 3. Based on interviews and record review, there was similar deficient practice for Residents #2 and #5.

Based on observation, interview and record review the residence failed to ensure each resident care plan detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting one of nine sample residents (#5). Findings include:1. Residence PolicyThe residence's care plan policy, dated 12/29/23, read in part: "each resident care plan shall: (A) Be developed with input from the resident and the resident's representative, (B) Reflect the most current assessment information, (C) Promote resident choice, mobility, independence and safety, (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs, (E) Identify all external service providers along with care coordination arrangements, and (F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident's personal choices and needs."2. ObservationsOn 1/18/24 at 2:30 p.m., Resident #5 was observed in line of sight of Staff #4 and was coloring. On 1/18/24 at 2:49 p.m., Staff #4 led Resident #5 into Resident #9's room. Resident #5 walked up to Resident #9's bed within ten seconds after entering the room, Resident #5 quickly grabbed Resident #9's arm aggressively and Resident #9 yelled "hey!" Staff #4 intervened and pried Resident #5's hand off Resident #9's arm. Staff #4 then asked Resident #5 to leave the room so she could "administer this nice lady's medications." 3. Resident #5 was admitted to the residence on 1/11/24. A progress note, written by Staff #2, dated 11/4/23, read Resident #5 wanted to go into other resident rooms and was aggressive toward another resident. A progress note, written by Staff #1, dated 11/24/23, read Resident #5 had been aggressive to staff and residents. She tried to enter Resident #3's room stating it was the bathroom. A progress note, dated 12/2/23, read Resident #5 tried to escape the resident through the fire escape door. A progress note, written by Staff #1, dated 12/16/23, read Resident #5 was aggressive toward another resident in the dining room. Resident #5's care plan, dated 1/17/24, (the day of the onsite investigation), read in part, Resident #5 had behaviors of wandering, required staff supervision to monitor and redirect aggressive and combative behavior, required staff assistance for positive interactions and to maintain low levels of abuse and destructive behaviors. However, the care plan did not specify individualized staff tasks necessary to meet Resident #5's needs and monitor/redirect her behaviors. There were no other care plans in the record for Resident #5. 4. InterviewsOn 1/18/24 at 6:58 a.m., Staff #1 stated she had observed Resident #5 grabbing other residents' and staff's arms. Staff #1 stated she responded to redirection such as offering an activity or a cup of coffee. On 1/18/24 at 2:49 p.m., Staff #4 stated she had to overly communicate what she was doing to Resident #5 because Resident #5 responded well and understood it since Resident #5 used to be a nurse. She stated she also responded well to activities which was why she was coloring previously. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated the care interventions Resident #5 had in place was to offer a book since she loved to read, crossword puzzles and the piano to redirect her if she exhibited behaviors toward other staff or residents. She further stated she logged onto the electronic health system the day of the onsite investigation for Resident #5 and viewed Resident #5's care plan and it automatically updated it. The administrator designee stated she was unaware when Resident #5's care plan had been updated prior. The administrator designee stated care plans were updated by the administrator and was aware there were issues with care plans not being person-centered, and stated that Resident #5's care plan should have been updated to include staff tasks necessary to meet her needs.

Based on observation, record review and interviews the residence failed to coordinate care with known external service providers (ESP), affecting one of two newly admitted sample residents (#4). Findings include:1. Residence PolicyThe Residence's Change in Baseline Policy, dated 12/29/23, read in part: "the assisted living residence shall be responsible for the coordination of resident care services with known external service providers."2. Resident #4 was admitted to the residence on 1/11/24. Resident #4's January 2024 electronic medication administration record (eMAR), read that he refused all of his medications besides his levothyroxine. On 1/18/24 at approximately 7:00 a.m., Resident #4 had asked for Tylenol to Staff #1. However, Staff #1 stated "we can not give you Tylenol you don't have an order for it." On 1/18/24 at approximately 10:54 a.m., a medication cart audit revealed there was no Tylenol for Resident #4.3. InterviewsOn 1/17/24 at 7:24 a.m., Resident #4 stated he had been requesting Tylenol since he was admitted due to back pain; however, staff have refused to provide it for him. On 1/18/24 at approximately 7:00 a.m., Staff #1 stated that Resident #4 had refused his medication the morning of the onsite investigation because he was upset that she was unable to provide him Tylenol. She further stated he had requested Tylenol the last couple of days prior to the onsite investigation. Staff #1 stated she could not provide Resident #4 Tylenol since there was no order. She further stated she had not reached out to obtain a written order from the practitioner either. On 1/18/24 at 10:54 a.m., Staff #4 stated Resident #4 had been requesting Tylenol the last couple of days and they did not have it in stock so he had refused medications. Staff #4 stated she had not reached out to his practitioner and was unsure what she could do since he did not have an order for it anyway. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated she was aware of the requirement for coordination of care and stated qualified medication administration persons (QMAPS) were responsible for reaching out to practitioners. She also stated the QMAPs could reach out to herself, the administrator, or resident care coordinator (RCC) regarding medications or requests so they could reach out to the practitioner themselves. The administrator designee stated she was not aware Resident #4 had requested Tylenol and refused his medications the day of the onsite investigation as a result of not having Tylenol. She stated would have expected the QMAPs to have notified her.

Based on observation and interview, the residence failed to place in a publicly visible location a statement regarding the rights and responsibilities of its residents, affecting 29 current residents. Throughout the on-site investigation from 1/17/24 from 7:00 a.m. to 6:30 p.m. and on 1/18/24 from 7:00 a.m. to 4:15 p.m., resident rights were observed to be posted approximately six feet off the ground and not in a publicly visible location. On 1/17/24 at approximately 9:10 a.m., Resident #6 stated that none of the residents in wheelchairs; himself included, could read the resident rights because they are posted so high above the ground. On 1/18/24 at 6:53 a.m., Resident #2 stated she was unable to even reach where the resident rights were posted let alone see them. Resident #2 further stated she was unsure what her rights were. On 1/18/24 at 7:17 a.m., Resident #1 stated that he had never noticed where the resident rights were posted and stated that everything was posted so high up he could not read anything from in his wheelchair. Resident #1 further stated he was unaware what his rights were. On 1/18/24 at 7:27 a.m., Resident #3 stated he was unsure what his rights were and had not seen them posted anywhere in the residence. On 1/18/24 at 2:58 p.m., Resident #10 stated she was unaware what her rights were and had not noticed them posted anywhere in the residence. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated she was aware that resident rights needed to be posted in a publicly visible location. She stated she had not thought about the possibility of residents being unable to see their rights due to them being posted higher above the ground.

Based on observation, record review and interview, the residence failed to observe a resident's right to be free from physical abuse and intimidation, affecting three sample residents (#3, #6 and #9) that were abused or intimidated by Resident #5. (Cross reference Q1010)Specifically, Resident #5 was admitted to the residence on 11/2/23 from a secure environment where she had been discharged due to history of resident to resident altercations. The administrator designee claimed to be unaware of Resident #5's history of altercations or aggressive behaviors which was contrary to the administrator designee's admission assessment, dated 11/2/23, which read the resident had aggressive and combative behaviors. On 12/11/23, the residence's investigation revealed that Resident #3 was hit in the head with a book by Resident #5 when he fell asleep at the residence's dining room table. Resident #3 had no injury at the time of the incident; however, three days later Resident #3 experienced severe headaches and was hospitalized. A scan of Resident #3's brain revealed he had sustained a closed head injury with a concussion due to the altercation with Resident #5. Findings include:1. References and Residence Policya. Chapter VII regulations, governing assisted living residences, part 2.1, defined abuse as any of the following acts or omissions: (A) The non-accidental infliction of bodily injury, serious bodily injury or death."b. According to the Cleveland Clinic, "a concussion is a mild traumatic brain injury caused by a bump, violent jolt, or blow to the head. Anyone from infants to elderly can sustain a concussion. Headaches are the most common symptom ..." Cleveland Clinic (6/2/20), retrieved from:https://my.clevelandclinic.org/health/diseases/15038-concussionc. The residence Resident Rights policy, dated 12/21/23, read in part, residents had the right to be free from physical abuse and emotional intimidation. 2. ObservationOn 1/18/24 at 2:49 p.m., Staff #4 led Resident #5 into Resident #9's room after the surveyor. Resident #5 walked up to Resident #9's bed within ten seconds after entering the room, and her facial expression changed from smiling to a look of anger with furrowed eyebrows. Resident #5 quickly grabbed Resident #9's arm aggressively and Resident #9 yelled "hey!" Staff #4 intervened and pried Resident #5's hand off Resident #9's arm and asked her to leave the room and leave the surveyor to "administer this nice lady's medications." Staff #4 whispered to the surveyor she had to say to Resident #5 the surveyor was passing medications to Resident #9, because Resident #5 responded well and understood it since Resident #5 used to be a nurse. 3. Resident #5 was admitted to the residence on 11/2/23 with diagnoses that included dementia and wandering. An admission assessment, dated 11/2/23, completed by the administrator designee read Resident #5 had abusive, destructive and aggressive behaviors that required intervention from staff to help the resident maintain positive and appropriate interactions with others. A progress note, written by Staff #2, dated 11/4/23, read Resident #5 wanted to go into other resident rooms and was aggressive toward another resident. A progress note, written by Staff #1 dated 11/24/23, read Resident #5 had been aggressive to staff and residents. She tried to enter Resident #3's room stating it was the bathroom. The residence's investigation of abuse, dated 12/11/23 which was written by the administrator designee, read in part, Resident #3 stated he was drinking coffee at the dining room table at 11:30 p.m. and fell asleep. He was awoken by Resident #5 having hit him in the head with the back of a book. Resident #3 experienced no injury at the time of the incident; however, three days later experienced severe headaches and was sent to the hospital. Both residents were spoken to and Resident #3 was placed on hourly checks following his return from the hospital. Resident #5 was place on line of sightmonitoring daily, care plan and face sheet were updated, and and the administrator began looking for alternative placement for Resident #5. A progress note, written by Staff #1, dated 12/16/23, read Resident #5 was aggressive toward another resident in the dining room. 4. Resident #3 was admitted to the residence on 9/1/23. An emergency room discharge summary, dated 12/10/23, read Resident #3 was admitted to the emergency room with headaches. A computed tomography (CT) scan, revealed the resident had sustained a closed head injury and was diagnosed with a concussion. 5. InterviewsOn 1/17/24 at 8:18 a.m., Resident #3 stated he was hit in the head with a book by Resident #5 in December 2023 and went to the hospital and "his head got hurt." Resident #3 stated he had been hit in the arm on another occasion by Resident #5; however, he was unable to recall when. On 1/17/24 at 9:05 a.m., Resident #6 stated a few months ago Resident #5 had slapped him hard on the arm. Resident #6 stated Resident #5 would also wander in and out of other resident rooms and hit other residents. On 1/17/24 at 10:45 a.m., the administrator designee stated she was unaware of Resident #5's history of aggression and based upon her own assessment had determined she was cognitively aware enough for admission to the non-secure residence. The administrator designee stated it was not until after Resident #5 was admitted that she became non-verbal, aggressive toward staff, and would grab staff and resident arms. The administrator designee stated Resident #5 got into an altercation with Resident #3. She further stated she was unaware of any additional resident to resident altercations. Further, the administrator designee stated she was only provided a care plan, MOST form and orders from the former residence which did not reveal her altercations. On 1/17/24 at 8:20 a.m., Staff #3 stated she was made aware of the altercation between Resident #3 and #5; however, was not on shift. Staff #3 further stated she used to work at the former residence that Resident #5 was admitted from, and stated the resident would hit other residents; however had not witnessed anything more than grabbing staff and resident arms at the current residence. On 1/17/24 at 9:59 a.m., Resident #5's practitioner stated that Resident #5 had a history of altercations at her former residence and wandering which required her to have a one on one sitter. The practitioner further stated it had been reported to her that Resident #5 had grabbed staff at the residence; however, was unaware of her having grabbed or hit another resident. On 1/18/24 at 6:58 a.m., Staff #1 stated she had observed aggressive behaviors from Resident #5 that included grabbing other residents' and staff's arms. Staff #1 stated she had not witnessed Resident #5 hit anyone; however, had made progress notes of the resident's arms who she had grabbed in the past. Staff #1 stated she did not remember who Resident #5 had aggressively grabbed. On 1/18/24 at 2:08 p.m., contrary to what the administrator designee stated, Resident #5's former residence's administrator stated that Resident #5 was discharged from the secured environment due to resident to resident altercations and had informed the administrator designee of the aggressive behavior when she conducted an initial assessment on Resident #5 in October 2023. The former residence's administrator stated the administrator designee was made aware of the residence's reasons for discharge and provided the administrator designee with care plans, a face sheet, and progress notes for the previous 90 days. On 1/18/24 at 2:35 p.m., Resident #5's family member stated that Resident #5 had a history of physically aggressive behaviors and altercations with other residents at the former residence. He further stated Resident #5 was provided a discharge notice to evict her due to the reports of the altercations. On 1/18/24 at 2:49 p.m., Resident #9 stated Resident #5 "scared her" when she grabbed her aggressively and stated "she was glad (the surveyor and Staff #4) were there." Resident #9 further stated she was "okay" and Resident #5 having grabbed her arm did not physically hurt her; however, she was afraid. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated she would expect the resident rights to be free from abuse or intimidation to be upheld and was aware of the requirement. The administrator designee stated the administrator was aware of Resident #5's aggressive behavior; however, outside the incident with Resident #3 on 12/10/23, had thought Resident #5 had only been aggressive toward other staff.

Based on observation and interviews, the residence failed to place written house rules in a publicly visible location so that they were always available to residents and visitors, affecting 29 current residents. Throughout the on-site investigation from 1/17/24 from 7:00 a.m. to 6:30 p.m. and on 1/18/24 from 7:00 a.m. to 4:15 p.m., house rules were observed to be approximately six feet off the ground and not in a publicly visible location. On 1/17/24 at approximately 9:10 a.m., Resident #6 stated that none of the residents in wheelchairs; himself included, could read the house rules because they are posted so high above the ground. On 1/18/24 at 6:53 a.m., Resident #2 stated she was unable to even reach the house rules let alone see them. Resident #2 further stated she was unsure what the house rules were. On 1/18/24 at 7:17 a.m., Resident #1 stated that he had never noticed where the house rules were posted and stated that everything was posted so high up he could not read anything from in his wheelchair. Resident #1 further stated he was unaware what the house rules were. On 1/18/24 at 7:18 a.m., Resident #7 stated she was unsure what the house rules were and had not observed them. On 1/18/24 at 7:27 a.m., Resident #3 stated he was unsure what the house rules were and had not seen them posted anywhere in the residence. He stated he was not aware they were posted high off the ground in the front entryway hallway. On 1/18/24 at 2:58 p.m., Resident #10 stated she was unaware what the house rules were and had not noticed them posted anywhere in the residence. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated she was aware that house rules needed to be posted in a publicly visible location. She stated she had not thought about the possibility of residents being unable to see the house rules due to them being posted higher above the ground.

Based on record review and interview, the residence failed to prepare or administer only medication that had been ordered by an authorized practitioner, affecting two of six sample resident (#2, #3) whose medications were reviewed. Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 14.17, requires the assisted living residence shall ensure that each authorized practitioner's order for medication includes ... the signature of the practitioner.b. The residence's Medication Administration policy, dated 12/21/23, read in part: "All medications must have a physician's prescription ... only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents."2. Resident #2 was admitted to the residence on 6/29/23 with a diagnosis of epilepsy. The January 2024 electronic medication administration record (eMAR) read Resident #3 was administered divalproex 500 mg twice daily on 1/1-1/8 and 1/13-1/17, and in the morning on 1/9 and 1/18/24, for a total of 28 doses. However, the residence was unable to provide a signed practitioner order for the medication. 3. Additionally, the residence failed to ensure that only medications ordered and signed by an authorized practitioner were administered to Resident #3. 4. InterviewsOn 1/18/24 at 12:14 p.m., the administrator designee stated she was unable to locate a signed order for Resident #3's divalproex 500 mg twice daily, and stated she only had an unsigned medication list with the medication on it. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated she was responsible for medication orders and transcribing orders onto the eMAR and stated she had gotten busy. The administrator designee stated orders should have been signed for Resident #2 and #3 and medications should not have been administered without signed orders.

Based on record review and interviews, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting six of six sample residents (#1-#5 and #8). (Cross reference Q1510)Specifically, a written practitioner's order, dated 8/31/23, directed the residence to administer phenytoin sodium 100 mg at bedtime for seizures to Resident #8. The residence failed to administer Resident #8's phenytoin sodium from when she was admitted to the residence on 12/6/23, until she experienced a seizure on 12/10/23 and was hospitalized until 12/13/23. Further, the residence failed to transcribe Resident #8's medications, which included the phenytoin sodium, onto the electronic medication administration record (eMAR) until after Resident #8 returned from the hospital on 12/13/23. Resident #8's practitioner stated Resident #8's blood levels of phenytoin were tested and showed no evidence in her bloodstream, which would indicate she had not received the medication for at least a week prior. Resident #8's practitioner further stated that Resident #8 troponin levels were high which indicated the resident had received medications inadequately and increased her risk of heart attacks due to the seizures. The practitioner further stated the resident had epilepsy and it was imperative she received her epilepsy medication as prescribed and stated it was what caused her seizure on 12/10/23. Findings include:1. References and Residence Policya. According to the Epilepsy Foundation, phenytoin is a widely used seizure medication used to treat temporal lobe epilepsy. "Don't stop using phenytoin or change the amount taken without talking to the doctor first. Stopping any seizure medicine all at once can affect other medicines in the body. It may even cause non stop seizures that can be life-threatening ..." Epilepsy.com (2023), retrieved from: https://www.epilepsy.com/tools-resources/seizure-medication-list/phenytoin#:~:text=Abruptly%20stopping%20phenytoin%20can%20lead,they%20will%20be%20less%20effective.b. The residence's Medication Administration Policy, dated 12/21/23, read in part: "(the residence) shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers."2. Resident #8 was admitted to the residence on 12/6/23. a. Phenytoin SodiumA written practitioner's order, dated 8/31/23, directed the residence to administer phenytoin sodium 100 mg at bedtime for epilepsy. However, the December 2023 electronic medication administration record (eMAR) read the medication was not administered until 12/13/23 and was completely blank prior. The resident had not received the medication from 12/6/23 until she was hospitalized on 12/10/23, for a total of four missed doses. An incident report, dated 12/10/23, read in part: "Resident came out of her room upset that she had not had her meds. Staff had her sit down for a few minutes because she was worried about having a seizure. After the staff asked her if she felt up to laying down, she stood up she nearly collapsed. The (qualified medication administration person) QMAP and other caregiver assisted her to sit down. she voiced she wanted (the ambulance) called. Qmap called (the ambulance) and while on the phone with (the ambulance) she complained of chest pain and was dry heaving but no vomiting. A medication release form from Resident #8's former residence, read there were 31 doses of phenytoin released on 12/6/23. The administrator designee signed off on 12/6/23 to pick up the medications from the former residence. A progress note, dated 12/18/23, read Resident #8 had a seizure that lasted seven minutes and was transported by the ambulance to the hospital. A hospital discharge summary, dated 12/13/23, read Resident #8 had a diagnosis of epilepsy and had an abnormal bloodlevel of phenytoin and troponin. On 1/17/24 at 8:28 a.m., Resident #8's family member stated Resident #8 was currently in the hospital and had been since 12/18/24 due to not receiving seizure medication. The family member stated a month's worth of medication was provided from Resident #8's former residence and stated the administrator designee had picked up the medication. However, she stated Resident #8 had not received medications between 12/6 and 12/10 and was unsure what had happened to them. She further stated that even after the resident came back on 12/13/23, there were still medications that were not administered. On 1/18/24 at 10:03 a.m., the practitioner for Resident #8 stated Resident #8's blood levels of phenytoin were tested on 12/10/23 and showed no evidence of the medication in her bloodstream. The practitioner further stated the levels would indicate the resident had not received the medication for at least a week. Resident #8's practitioner further stated that Resident #8 troponin levels were high which indicated the resident had received medications inadequately and increased her risk of heart attacks due to the seizures. The practitioner further stated the resident had epilepsy and it was imperative she received her epilepsy medication as prescribed and stated it was what caused her seizure on 12/10/23. On 1/18/24 at 4:22 p.m., the administrator designee stated she had picked up all of Resident #8's medications on 12/6/23 and completed a medication reconciliation. The administrator designee stated she was responsible for transcribing medications onto the eMAR and thought she had done so on 12/6/23. The administrator designee stated she was unsure why the December eMAR was blank until 12/13/23 and stated as far as she was aware Resident #8 had received all her medications. b. AcetaminophenA written practitioner's order, dated 7/12/23, directed the residence to administer acetaminophen 650 mg three times daily. However, the December 2023 eMAR read the medication was not administered due to being out of stock, for the morning dose on 12/18, for the evening dose on 12/13 and 12/15, and all three doses on 12/14, 12/16 and 12/17/23, for a total of 12 missed doses. A medication release form from Resident #8's former residence, read there were 93 doses of acetaminophen released on 12/6/23. The administrator designee signed off on 12/6/23 to pick up the medications from the former residence. c. Breztri arosphereA written practitioner's order, dated 3/15/23, directed the residence to administer breztri arosphere 160-9-4.8 mcg one puff every 12 hours. However, the December 2023 eMAR read the medication was not administered due to being out of stock, for the morning dose on 12/18, for the evening dose on 12/13, 12/15 and 12/16, and all three doses on 12/17/23, for a total of seven missed doses. d. HydroxyzineA written practitioner's order, dated 7/27/23, directed the residence to administer hydroxyzine 25 mg twice daily. However, the December 2023 eMAR read the medication was not administered due to being out of stock, for the morning doses on 12/17 and 12/18, and for the evening dose on 12/13, 12/15 and 12/16/23, for a total of five missed doses. e. PromethazineA written practitioner's order, dated 7/27/23, directed the residence to administer promethazine 12.5 mg twice daily. However, the December 2023 eMAR read the medication was not administered due to being out of stock, in the evening on 12/13, in the morning on 12/14 and 12/18, and both doses on 12/17/23, for a total of five missed doses. f. Fluticasone A written practitioner's order, dated 3/15/23, directed the residence to administer fluticasone 50 mcg in each nostril daily. However, the December 2023 eMAR read the medication was not administered due to being out of stock, 12/17 and 12/18/23 for a total of two missed doses. g. FycompaA written practitioner's order, dated 5/18/23, directed the residence to administer fycompa 4 mg at bedtime. However, the December 2023 eMAR read the medication was not administered due to being out of stock, 12/13 and 12/14/23 for a total of two missed doses. A medication release form from Resident #8's former residence, read there were 93 doses of acetaminophen, 31 doses of amlodipine, 62 doses of benztropine mesylate, full bottle of fluticasone propionate, 27 doses of fycompa, 62 doses of gabapentin, 62 doses of hydroxyzine, 62 doses of levetiracetam, 31 doses of losartan hydrochlorothiazide, 62 doses of omeprazole and 62 doses of promethazine released on 12/6/23. The administrator designee signed off on 12/6/23 to pick up the medications from the former residence. However, there was no evidence the medications were transcribed onto the January eMAR prior to 12/13/23. 3. InterviewsOn 1/17/24 at 8:28 a.m., Resident #8's family member stated a month's worth of medication was provided from Resident #8's former residence and stated the administrator designee had picked up the medication; however, did not think Resident #8 received her medications between 12/6 and 12/10/23 and was unsure what had happened to them. On 1/18/24 at 4:22 p.m., the administrator designee stated she had picked up all of Resident #8's medications on 12/6/23 and completed a medication reconciliation. The administrator designee stated she was responsible for transcribing medications onto the eMAR. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated QMAPs, the resident care coordinator (RCC), and the administrator were all responsible for order medications that were not cycle filled. The administrator designee stated she would expect the residence to comply with practitioner's orders and was unsure why that had not occurred for Resident #8. 4. Record review, observation and interviews revealed similar deficient practice for Resident #1-#5.

Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting six of six sample residents (#1-#5 and #8) . (Cross reference Q1468)Findings include:1. Residence policyThe residence's Medication and Medication Administration policy, dated 12/21/23, read in part: "all prescribed and pro re nata (PRN) medications shall be listed and recorded on a medication administration record (MAR) ... each qualified medication administration person (QMAP) ... shall accurately document each medication administration or monitoring event at the time the event is completed for each resident."2. Resident #8 was admitted to the residence on 12/6/23. a. AcetaminophenA written practitioner's order, dated 7/12/23, directed the residence to administer acetaminophen 650 mg three times daily. However, the December 2023 electronic medication administration record (eMAR), revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning. Additionally, on 12/15/23 in the afternoon, the medication was marked under "1" for "other." However, there was no documentation on the back of the eMAR as to why the medication was marked under code 1, for a total of 23 inaccurately documented doses.b. Hydroxyzine A written practitioner's order, dated 7/27/23, directed the residence to administer hydroxyzine 25 mg twice daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning. Additionally, on 12/14/23 in the evening, the medication was marked under "1" for "other." However, there was no documentation on the back of the eMAR as to why the medication was marked under code 1, for a total of 14 inaccurately documented doses.c. LevetiracetamA written practitioner's order, dated 8/23/23, directed the residence to administer levetiracetam 750 mg two tablets twice daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented doses. d. Gabapentin A written practitioner's order, dated 8/31/23, directed the residence to administer gabapentin 300 mg twice daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented doses. e. Breztri aerosphereA written practitioner's order, dated 3/15/23, directed the residence to administer breztri aerosphere 160-9-4.8 mcg one puff every 12 hours. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented doses.f. Benztropine MesylateA written practitioner's order, dated 7/27/23, directed the residence to administer benztropine mesylate 1 mg every 12 hours. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented doses.g. PromethazineA written practitioner's order, dated 7/27/23, directed the residence to administer promethazine 100 mg at bedtime. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented doses.h. OmeprazoleA written practitioner's order, dated 7/19/23, directed the residence to administer omeprazole 40 mg every 12 hours. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12 and 12/13/23 in the morning, for a total of 13 inaccurately documented dosesi. Amlodipine BesylateA written practitioner's order, dated 10/18/23, directed the residence to administer amlodipine besylate 5 mg daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/13/23, for a total of seven inaccurately documented doses. j. Losartan hydrochlorothiazideA written practitioner's order, dated 9/20/23, directed the residence to administer losartan hydrochlorothiazide 100-12.5mg daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/13/23 for a total of seven inaccurately documented doses. k. Fluticasone propionateA written practitioner's order, dated 3/15/23, directed the residence to administer fluticasone 50 mcg in each nostril daily. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/13/23, for a total of seven inaccurately documented doses. l. FycompaA written practitioner's order, dated 5/18/23, directed the residence to administer fycompa 4 mg at bedtime. However, the December 2023 eMAR, revealed blank spaces from 12/6-12/12/23, for a total of six inaccurately documented doses. 3. Interviews On 1/18/24 at 4:22 p.m., the administrator designee stated she was unsure why the December eMAR was blank up until 12/13/23 and stated it should have been documented as to whether Resident #8 received her medications. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated she was aware of the requirement for all medications to be listed on the eMAR and for accurate documentation at the time of administration. She stated a blank space on the eMAR meant that no one documented the medication as administered and would have expected it to have been documented. The administrator designee further stated if a medication was not administered then a corresponding exception code should be used along with documentation on the back of the eMAR. 4. Record review and interviews revealed similar deficient practice for Resident #1-#5.

Based on interview and record review, the administrator and the qualified medication administration person (QMAP) supervisor failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting 29 current residents. Findings include:The residence's Medication Administration policy, dated 12/21/23, read in part: "(the residence) shall conduct on a monthly basis, a joint two person audit of medications ... the results of the audit shall be documented."On 1/17/24 at 8:54 a.m., documentation of quarterly medication audits was requested but not provided. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated the administrator and resident care coordinator (RCC) were responsible for completing medication audits together and was aware of the requirement that they needed to be completed quarterly. The administrator designee further stated she was unable to locate evidence of medication audits or whether they were being completed since the RCC was hired at the residence two weeks prior to the onsite investigation.

Based on record review and interview, the residence failed to ensure resident records contained documented progress notes, by staff before the end of their shift, of out of ordinary events or issues 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 documented, affecting five of nine sample residents (#2, #3, #5, #7 and #8). Findings include:1. Resident #3 was admitted to the residence on 9/1/23. An emergency room discharge summary, dated 12/10/23, read Resident #3 was admitted to the emergency room with headaches. A computed tomography (CT) scan, revealed the resident had sustained a closed head injury and was diagnosed with a concussion. The residence's abuse investigation, dated 12/11/23 which was written by the administrator designee, read in part, Resident #3 stated he was drinking coffee at the dining room table at 11:30 p.m. and fell asleep. He was awoken by Resident #5 having hit him in the head with the back of a book. Resident #3 experienced no injury at the time of the incident; however, three days later experienced severe headaches and was sent to the hospital. Review of Resident #3's record revealed there were no progress notes of the incident that caused Resident #3 to go to the hospital and action taken by staff, no progress notes of his admission to the hospital, or of his return to the residence on 12/10/23. On 1/17/24 at 8:18 a.m., Resident #3 stated he was hit in the head with a book by Resident #5 back in December 2023 and went to the hospital and "his head got hurt." Resident #3 stated he had been hit in the arm on another occasion by Resident #5; however, he was unable to recall when. On 1/22/24 at approximately 11:00 am., the administrator stated she expected there to have been a progress note of the altercation between Resident #3 and #5 and stated she expected progress notes to include details of a resident being sent to the hospital and coming back. 2. Resident #7 was admitted to the residence on 9/15/23 with diagnoses that included osteoarthritis and fall risk. On 1/17/23 at approximately 9:10 a.m., Resident #6 stated he witnessed Resident #7 fall in November 2023. On 1/18/24 at 7:18 a.m., Resident #7 stated she sustained a fall after she first moved in around October or November 2023. Review of Resident #7's record revealed there were no progress notes of any falls from admission to do the day of the onsite investigation for Resident #7. On 1/22/24 at 11:00 a.m., the administrator designee stated there should have been a progress note written regarding Resident #7's fall since the administrator designee was unaware the resident had fallen. The administrator designee stated Resident #7 was alert and oriented enough to be able to recall if she had sustained a fall. 3. InterviewsOn 1/18/24 at 6:58 a.m., Staff #1 stated that all qualified medication administration persons (QMAPs) and caregivers were able to make progress notes. Staff #1 stated a progress note should be made whenever there was a physical altercation or resident aggression, a fall or hospitalization. On 1/22/24 at 11:00 a.m., the administrator designee stated all staff can make progress notes except kitchen staff, who would have to notify QMAPs to make one. The administrator designee stated she would expect a progress note to be written whenever there is an altercation, fall, hospitalization or change in condition. She further stated the residence had incident reports and provided me all the reports she had; however, stated incident reports were more detailed follow-ups to progress notes and were not the same as progress notes. 4. Record review and interviews revealed similar deficient practice for Residents #2, #5 and #8.

Based on observations and interviews the residence failed to provide sufficient heating and ventilation sufficient to meet the needs of the residents affecting 29 current residents. Findings include:1. ReferenceAccording to Weather Underground, the temperature on 1/16/24 dropped to -13 degrees F. Weather Underground (2024) Denver, CO Weather History. https://www.wunderground.com/history/daily/us/co/denver/KDEN/date/2024-1-162. ObservationsThroughout the on-site investigation from 1/17/24 from 7:00 a.m. to 6:30 p.m. and on 1/18/24 from 7:00 a.m. to 4:15 p.m., the following was observed:A large common area heater labeled "Olson PH" was observed in the dining room, which was installed by a professional HVAC company as a temporary heating solution until the residence's broken heater was fixed. Resident #13 had covered her floor vent with a rug due to it blowing cold air. Residents #1, #2, #3, #6 and #14 were observed wearing coats in the dining area both days of the onsite investigation. Portable heaters lined up down the hallways throughout the residence and in resident rooms. The dining room area with the Olson PH heater on measured 70.7 degrees F. Resident #1's room temperature was 83.5 degrees F without his portable heater plugged in and Resident #1's bedroom window would not open more than about one inch. There were only two thermostats to control the temperature of the residence, that were located near the television room and dining room. 3. InterviewsThroughout the on-site investigation from 1/17/24 from 7:00 a.m. to 6:30 p.m. and on 1/18/24 from 7:00 a.m. to 4:15 p.m., the following interviews were conducted:Staff #3 stated there were issues with the ventilation system and the residence heater broke. Staff #3 stated she had worked at the residence for a month and stated the heater had broken within the past week prior to the onsite investigation. She further stated the portable heaters and the Olson PH heater were put in over the weekend prior to the onsite investigation. Resident #13 stated her floor vent blows cold air so she covered it up with an area rug. Resident #13 stated she was provided two portable heaters a week prior to the onsite investigation and with them she would get too hot. However, she stated without the portable heaters she was freezing cold, which had been an ongoing issue and she was unsure for how long. The resident care coordinator (RCC) stated she had only worked at the residence for two weeks prior to the onsite investigation and stated that the Olson PH heater was placed by an external maintenance company the day before the onsite investigation due to issues with the heater going on and off. The maintenance director (MD) stated two weeks prior to the onsite investigation the heater broke and the residence had three maintenance companies come out and discovered the heater required a new coil. He stated it was a little over 70 degrees in the common area since the portable heaters were placed. The MD stated he brought portable heaters upstairs from the basement and placed them down the hallway and in resident rooms the Friday prior to the onsite investigation. He stated it was because residents had complained of being cold and the temperature had dropped to 65 degrees fahrenheit. Resident #3 stated that the residence had experienced issues with the heater going off since a year prior to the onsite investigation and stated he was currently cold in the dining room area which was why he had a coat on. The administrator designee stated issues with the heater began around December 2023 and a maintenance company discovered a broken coil. She stated there were some rooms where there were no ventilation issues that had too much heat and others had no heat since the cold air chill the weekend prior to the onsite investigation. She further stated residents were unable to control thermostats since the thermostats were located in the north and south hallway of the residence and would control each area of resident rooms. Resident #14 stated he put on a coat the morning of the onsite investigation because he was cold and had been cold for a long time, but was unsure for how long. He stated since the portable heaters were put into his room over the weekend prior to the onsite investigation it was the first time he had been warm. Resident #14 further stated the residence should have heat. He stated before the portable heater was put into his room, he wanted to move out because he was so uncomfortable. Resident #6 stated since he moved in around August 2023, the residence has had ongoing heating and cooling issues and around November 2023 the residence was down to 62 degrees F. Resident #6 stated it had been increasingly cold in the two weeks prior to the onsite investigation and portable heaters were brought in over the weekend. However, he stated prior to that the temperature had dropped to 62 degrees F in the television room. Resident #15 stated she had been cold almost every night and had brought in a portable fireplace which had worked to keep herself and roommate warm. Resident #15 stated she had been cold for as long as she could remember at the residence. Resident #16 stated he had been cold since two weeks prior to the onsite investigation and stated it felt to be around 60 degrees F overnight. He stated he was cold the night prior to the onsite investigation and had to turn on his portable heater. Resident #2 stated around four days prior to the onsite investigation she got really cold. She stated the temperature was so cold in her room that her drink froze. Resident #2 stated it was that same day that the MD provided her with a portable heater and since then it had helped keep her warm. Resident #2 further stated she was cold in the common area and that was why she wore a jacket. Resident #1 stated his window had been broken since he was admitted to the residence in August 2023 and he would frequently overheat. He also stated he wanted to open his window and was overheating the day of the onsite investigation. Resident #1 stated his room was one of the few rooms where the heater still worked since it had broken over the weekend prior to the onsite investigation. Resident #1 stated the heater would blast hot air into his room whereas other residents were cold. He stated he was told by other staff members, whose name he did not recall, that it would get fixed and still had not. Resident #1 stated there were other times the heat did not work in his room either and he would get too cold and stated the last time was about a week prior to the onsite investigation. Resident #1 further stated he would put on a jacket since he would get cold in the dining room. The family member for Resident #1 stated Resident #1 was unable to open his window more than an inch since the fall of 2023. She stated there had been days that his room temperature was over 80 degrees including the day of the onsite investigation and the resident wanted to open his window, and other days where it was in the 60s and she had purchased him a space heater herself as a solution. The administrator designee stated she was aware of the requirement for sufficient heating and ventilation; however the building was old and the heater broke. The administrator further stated she expected the heater to be fixed within the week following the onsite investigation.

Based on observation and interviews, the residence failed to ensure each sleeping room shall have at least one window of eight square feet with opening capability. (Cross-reference Q2520)Findings include:On 1/18/24 at 7:19 a.m., an environmental tour revealed the only window in Resident #1's room would not open more than about one inch. On 1/18/24 at approximately 7:19 a.m., Resident #1 stated that the maintenance director (MD) had to utilize a drill to allow Resident #1 to open his window when he asked. He stated his window had been broken since he was admitted to the residence back in August 2023 and he would frequently overheat and want to open his window. Resident #1 stated he was told by other staff members whose name he did not recall, that it would get fixed and still had not. On 1/18/24 at 1:42 p.m., the family member for Resident #1 stated Resident #1 was unable to open his window more than an inch and had been a problem at least since the fall of 2023. She stated there had been days that his room temperature was over 80 degrees, including the day of the onsite investigation. The family member stated the resident wanted to open his window and was unable without the MD opening it for him with a screwdriver. She further stated the MD had to close it for him with it as well. The family member stated two months ago the window was supposed to be fixed and still had not been. On 1/22/24 at 11:00 am., the administrator designee stated she was aware of the requirement for resident room windows to have opening capability. The administrator designee stated she was first made aware that Resident #1 was unable to open his window due to overheating approximately two weeks prior to the onsite investigation. The administrator designee stated she had an external maintenance company come in and thought they had fixed the problem and was not aware it was still ongoing.

Based on record review, observations and interview, the residence failed to prohibit the use of portable heaters in resident rooms, affecting one of one residents with poor safety awareness who had a portable heater in their room (#5). (Cross Reference Q2520)Specifically, the heating system at the residence was not sufficient to provide heat to all resident rooms. Resident #5's practitioner stated the resident had Alzhiemer's disease and poor safety awareness; however, Resident #5 had a portable heater on a nightstand by her bed within arms reach. There was no UL on the portable heater and it reached a temperature of 151.5 degrees F, which created a high risk for burns. On 1/17/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Residence Policya. According to Healthline, "Almost half a million people in the United States go to the emergency room yearly with burn injuries. Burns can be caused by heat ... a thermal burn is most common when your skin comes into contact with a hot object ... Thermal burns are the primary cause of all burn injuries in the United States. Dry and wet sources of heat can cause them ... Dry sources of heat are fire flames, hot metal, glass, or other objects." Healthline (6/27/22) All About Thermal Burns, retrieved from: https://www.healthline.com/health/thermal-burn b. According to Weather Underground, the temperature on 1/16/24 dropped to -13 degrees F. Weather Underground (2024) Denver, CO Weather History. https://www.wunderground.com/history/daily/us/co/denver/KDEN/date/2024-1-16c. According to Safety Files, "an underwriters laboratory (UL) ... listing specifies the standard of protection the fireproof container provides its contents when exposed to fire." Safety Files (2024). https://www.safetyfile.com/pages/ul-fire-and-impact-ratings#:~:text=A%20product%20with%20an%20Underwriters,to%20be%20%22UL%20Listed.%E2%80%9D&text=With%20fireproof%20safes%20and%20files,contents%20when%20exposed%20to%20fire.d. According to the American Burn Association, in adults, exposure for 30 seconds at 130°F will produce burn injury. At 140°F, tissue destruction (second degree burn) occurs in five seconds in adults. At 160°F, a full thickness (third degree) burn occurs almost instantaneously. ABA (2018). https://ameriburn.org/wp-content/uploads/2019/08/2018-abls-providermanual.pdfe. The residence's Resident Agreement, dated 12/22/23, read in part: "(the residence) will provide monitored care 24 hours per day. This will include monitoring the resident's needs and ensuring that the resident receives the services and care necessary to protect the resident's health, safety and well being." 2. ObservationsOn 1/17/24 at 7:10 a.m., a large common area heater labeled "Olson PH" was observed in the dining room, which was installed by a professional HVAC company as a temporary heating solution until the residence's broken heater was fixed. On 1/17/24 at 9:44 a.m., a portable heater was on a nightstand within arms reach of Resident #5's bed where she was lying in. The temperature of the portable heater measured 151.5 degrees F and did not contain a UL label. The air emitted from the heater alone from about a foot away measured 106.7 degrees F. 3. InterviewsOn 1/17/24 at approximately 9:59 a.m., Resident #5's practitioner stated that Resident #5 had decreased safety awareness due to her diagnosis of Alzheimer's disease. Resident #5's practitioner stated she had noticed it was hot in Resident #5's room due to the portable heater and stated it would be of concern that the resident could grab the portable heater given Resident #5's history of grabbing objects and moving them around. On 1/17/24 at 10:45 a.m., the administrator designee stated that Resident #5 was the only current resident with poor safety awareness and was incapable of making safe decisions on her own. The administrator designee stated that the Friday prior to the onsite investigation, a portable heater was placed in Resident #5's room due to the increased cold weather since Resident #5 did not have a thermostat in her room. On 1/17/24 at 11:32 a.m., the maintenance director (MD) stated the Friday prior to the onsite investigation he had brought the portable heater into Resident #5's room, due to the residence's heater being broken and the temperature dropping to 65 degrees F. On 1/17/24 at 2:06 p.m., the administrator designee stated she was aware that space heaters were against the regulations and stated the resident care coordinator (RCC) and the MD had placed the space heaters in the rooms due to the residence's heater being broken. The administrator designee stated she informed the RCC the day of the onsite investigation that space heaters were not allowed in resident rooms; however she had only been employed at the residence for two weeks and was not aware of the regulation. The administrator designee further stated she was aware of the safety concern and burn risk the portable heater in Resident #5's room presented. On 1/22/24 at approximately 11:00 a.m., the administrator designee stated she would have expected the MD or RCC had reached out to her prior to placing a portable heater in Resident #5's room. 4. Immediate Jeopardy Risk- Written Evidence, Immediate CorrectionThe survey established that the findings above placed one current resident (#5) at immediate jeopardy risk for the failure to prohibit the use of portable heaters in resident rooms, thus exposing them to potential injuries that could have been caused by the temperature of the heater that measured up to 151.5 degrees F. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 1/17/24 at 3:55 p.m., the administrator designee submitted written evidence that read in pertinent part that the assisted living shall prohibit the use of space heaters in resident rooms. Adverse events including burns could occur due to the high temperatures of the space heater. "The space heater was removed immediately (and was put) in place due to the temporary heating issue that occurred last night, which was the coldest night on record in the last year. Olson Heating and Cooling came yesterday, January 16, 2024, to resolve the heating issue that occurred. On January 17, 2024 employees will be in-serviced today by the administrator or designee regarding the requirement of using UL label heaters only." However, the written evidence did not indicate the risk had been removed because it failed to clarify the heating issues were not resolved the day prior to the onsite investigation and did not address Resident #5 and her poor safety awareness. Specifically, the residence failed to include in their plan of correction what they would do to monitor, document and remove the safety risk to prevent the adverse outcome from occurring or recurring rather than remove the portable heater; since this was an emergency situation. The plan also did not include when the action would be complete. On 1/17/24 at 5:29 p.m., the administrator designee submitted additional written evidence that read in pertinent part that the residence placed Resident #5 on 30 minute checks throughout the night when she is in her room to ensure she was safe and warm, and provide her with extra blankets in the event her heat stops working during the night. If the blankets were not sufficient enough to sustain the chill, staff would relocate her to sleep in Room #7 temporarily. Overnight staff would provide documentation and observation notes every half hour to ensure safety and monitoring. All space heaters would be removed from the residence immediately. On January 16, 2024 a cold from cracked the heating coiling in the commercial HVAC system and a brand new replacement coil was on order withthe supplier and the HVAC technicians would install it once it comes in. (The residence) had enabled a backup HVAC heating plan which immediately starting warming the building and the HVAC technicians confirmed the backup heating plan was functioning correctly and would remain in place until the replacement coil was installed. However, the written evidence read the residence would remove all portable heaters; which was contrary to what the plan read about how the residence would ensure Resident #5 was monitored with a portable heater to ensure her safety. On 1/17/24 at 6:18 p.m., the administrator designee crossed out the part about removing all portable heaters on the plan of correction.

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 VII. 18.9 The face sheet shall be updated at least annually and contain the following information:(A) Resident's full name, including maiden name, if applicable;(B) Resident's sex, date of birth, and marital status;(C) Resident's most recent former address;(D) Resident's medical insurance information and Medicaid number, if applicable;(E) Date of admission and readmission, if applicable;(F) Name, address and contact information for family members, legal representatives, and/or other persons to be notified in case of emergency

A revisit survey was completed on 6/13/23 for all previous deficiencies cited on 3/29/23. The facility is in compliance with all deficiencies that were cited.

An initial certification survey was completed on 3/29/23. No deficiencies were cited.

An initial survey was completed on 3/29/23. A deficiency was cited.

Based on observations and record review, the residence failed to be in compliance with all applicable regulations. This failure created the potential for mismanagement of care and services for the residents who would be served by this residence. Findings include:- 6.8 The administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(J) Complying with all applicable federal, state, and local laws concerning licensure and certification;The CDPHE Assisted Living and Group Home COVID-19 Mitigation and Outbreak Guidance, dated 2/22/23, required residences to:- Assign at least one staff member to complete training in infection prevention and control (IPC) and provide on-site management of infectious disease prevention and response activities and general infection prevention duties. The designated person must complete the Colorado RCF Infection Prevention Training using CO.TRAIN within two weeks of the assignment of duties and each following calendar year thereafter.- Facilities should have supplies of face masks, N95 or higher-level respirators, gowns, gloves, and eye protection (e.g., face shield or goggles that cover the front and sides of the face).- Make necessary PPE available in areas where resident care is provided.- Designate a staff member responsible for stewarding those supplies, monitoring and providing timely feedback, and promoting appropriate use by staff.- Monitor daily PPE use to identify when supplies will run low. Use the PPE burn rate calculator or other tools. The administrator stated she was the designated staff member for infection prevention and control; however, she did not complete the RCF infection prevention training. Additionally, the residence did not have a supply of PPE. - 8.6 Each assisted living residence shall have at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization such as the American Red Cross, the American Heart Association, National Safety Council, or American Safety and Health Institute. The certification shall either be in Adult First Aid or include Adult First Aid. The administrator of the residence, who was the only trained staff member at the time of the survey, had a first aid certification from an online organization that did not include a skills portion.- 8.7 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.The administrator of the residence, who was the only trained staff member at the time of the survey, had a CPR certification from an online organization that did not include a skills portion.- 12.18 The assisted living residence's policy shall also require documentation of the action taken by staff and ongoing efforts to prevent a reoccurrence of the situation in the future. The residence's policy and procedure book contained a policy which listed the above regulation; however, there was no policy that described the residence's process that included documentation of any action taken by staff and ongoing efforts to prevent a reoccurrence of falls in the future. - 12.32 Each assisted living residence shall provide sufficient recreational equipment and supplies to meet the needs of the resident engagement program. Special equipment and supplies necessary to accommodate persons with special needs shall be made available as appropriate. When not in use, recreational equipment and supplies shall be stored in such a way that they do not create a safety hazard. The residence did not have recreational equipment and supplies for any resident engagement program. - 13.3 The assisted living residence shall establish written house rules and place them in a publically visible location so that they are always available to residents and visitors. The residence house rules were not posted in a visible location available to residents and visitors. - 13.10 Each assisted living residence shall develop and implement an internal process to ensure the routine and prompt handling of grievances or complaints brought by residents, family members, or advocates. The process for raising and addressing grievances and complaints shall be placed in a visible on-site location along with full contact information for the following agencies:(A) The state and local long-term care ombudsman;(B) The Adult Protection Services of the appropriate county Department of Social Services;(C) The advocacy services of the area's agency on aging;(D) The Colorado Department of Public Health and Environment; and(E) The Colorado Department of Health Care Policy and Financing, in those cases where the assisted living residence is licensed to provide services specifically for persons with intellectual and developmental disabilities. The residence's grievance process was not posted in a visible location. - 14.32 The assisted living residence shall have policies and procedures for documenting, investigating, reporting, and responding to any errors related to accurate accounting of controlled substances and/or medication administration. The residence's policy and procedure book contained a policy which listed the above regulation; however, the policy did not describe how the residence would investigate, report and respond to errors related to counting of controlled substances and medication administration. - 22.4 Designated areas where smoking is allowed shall be equipped with fire resistant wastebaskets. Resident rooms occupied by smokers, even when house rules prohibit smoking in resident rooms, shall have fire resistant wastebaskets. The administrator stated the residence would allow smoking; however, she had not yet determined where the designated smoking area would be located and there was no fire resistant wastebasket to be placed in the designated smoking area. - 22.5 Each room shall have heat, lighting, and ventilation sufficient to meet the use of the room and the needs of the residents. The temperature of the residence was set at 69 degrees fahrenheit; however, resident rooms on the south east side of the residence measured to be 77 degrees. The administrator and owner stated that there was only one temperature control for the residence which controlled the temperature for both the common areas and the resident bedrooms at the same time.