RETREAT AT SUNNY VISTA, THE

A licensure complaint, prompted by #CO40666 was completed on 2/24/26. One deficiency was cited.

Based on interview, investigation, and record review, the residence failed to ensure residents had a right to live free from restraint and involuntary confinement, affecting 28 current residents who resided in the residence's memory support unit. Specifically, Resident #6 stated she was in the memory support unit from November 2023 to May 2025 against her will. She stated her daughter was her power of attorney and signed off on paperwork that read the resident required a secure environment due to wandering and exit seeking. She stated being confined in the memory support area behind an alarmed door made her have suicidal ideations and feel mentally distraught. Findings include:An environmental tour on 2/24/26 from 10:30 to 4:00 p.m. revealed the first floor of the residence had a memory support unit. Anytime the door leading from assisted living to the memory support unit was opened from either side, an alarm would sound until staff turned it off. The alarm sounded more than 10 times in the first hour of being onsite and continued to sound throughout the onsite. Resident #6 was admitted to the residence on 11/29/23 with diagnoses including frontal lobe dementia. On 2/24/26 at 10:41 a.m., Resident #6 stated during her residency in the memory support her movement was restricted; she felt could not leave the memory support which resulted in her feeling she was in a prison, confined and mentally distraught. She also stated she was aware of her surroundings and understood that "she did not fit in with the other residents" in the section of memory support due to her cognition.. She also stated that this sitution caused her to develop a sever depression along with suicidal ideation. A psychiatric assessment was completed twice in May 2025 for 12 hours each that revealed the resident was of sound mind and did not require a secure environment or memory support. Resident #2 was admitted to the residence on 3/31/23 with diagnoses including dementia and Alzheimer's disease. A care plan dated 4/28/25, read in part "Monitor me for signs of exit seeking, going toward exits."On 2/24/26 at 11:36 a.m., the spouse of Resident #2 stated she visited the resident almost every day or at least a few times a week at minimum. She stated Resident #2 wandered frequently and often wandered out of the memory support unit which sounded the alarm for staff to get him and redirect him back to the memory support unit. She said she has witnessed this and it happened often, however, staff knew to redirect him back to the memory unit. She also stated Resident #1 wandered often too and made the alarm sound. She stated staff were required to redirect the residents back to the memory support unit when they tried to leave. Resident #1 was admitted to the residence on 10/20/25 with diagnoses including Alzheimer's disease. A care plan dated 10/20/25, read in part, the resident sometimes wandered into other residents room and staff should monitor closely and redirect as needed. On 2/24/26 at 2:50 p.m., two legal representatives for Resident #1 stated they visited the residence ever weekend between the two of them. They stated staff monitored the door and if an alarm sounded that was a cue for staff to ensure a resident did not leave the memory support area unattended. Interviews On 2/24/26 at 11:33 a.m., Resident #3 and #4 stated they felt confined in the memory support area. They both stated they felt they were not able to leave because the alarm would sound. On 2/24/26 at 12:17 p.m. Staff #3 stated that the alarm system frightened residents when it was alarmed. She stated that resident #1 was particularly frightened by the alarm sound which caused her to turn around. She stated when the alarm sounded, staff looked around memory support first and did a head count, and then they looked out the door for any resident. She further stated if they saw a resident outside the memory support area, they diverted them back to memory support or walked alongside them until they went back. She also stated that someone attempting to leave memory support happened at least once a month..On 2/24/26 at 1:08 p.m. Staff #2 stated he worked at the residence for seven years and worked in memory care for 40 hours a week between 8:00 a.m.-4:00 p.m. He stated when the alarm sounded staff were required to open the alarmed. On 2/24/26 at 1:35 p.m. the housekeeper stated he had worked at the residence for five years and worked two days a week. He also stated if he heard an alarm sound in the memory support, it meant someone opened the memory support doors. The housekeeper stated if he saw a resident outside the memory support area, he had to bring them back inside the memory support area. On 2/24/26 at 1:45 p.m. Staff #1 stated he worked between assisted living and memory support for two years. She stated if she heard the memory support door alarm sound and a resident walked out of the memory support, she was required to redirect the resident back into the memory support. On 2/24/26 at 2:07 p.m. confidential staff #1 stated that if the alarm went off they tried to get there as quickly as possible. They further stated, sometimes family members let residents out of the memory support not understanding they should not do that. They further stated if a resident did leave the memory support, they were required to redirect them back to the memory support area.

A licensure complaint, prompted by #CO39922, was completed on 4/29/25. No deficiencies were cited.

A licensure complaint, prompted by #CO39591, was completed on 4/1/25. No deficiencies were cited.

A revisit survey was completed on 2/26/25 for all previous deficiencies cited on 9/27/24. The facility is in compliance with all deficiencies that were cited.

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

A licensure complaint, prompted by #CO37125, #CO37339 and #CO37543, was completed on 9/27/24. Deficiencies were cited.

Based on record review and interview, the residence failed to provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities affecting 25 current residents. Findings include:On 9/18/24 at 8:20 a.m., 9:35 a.m., 11:00 a.m., 12:00 p.m., 2:00 p.m., and 4:53 p.m., the staff schedule, last three months of call light response times, incident reports, the communication log in the residence's electronic health information system, resident agreement and resident admission documents were requested but not provided. On 9/19/24 at 1:45 p.m., the administrator stated she expected records to be provided to the Department upon request and without delay. The administrator acknowledged that the documents requested were not provided as requested.

Based on observation, record review and interview, the residence failed to ensure a correct name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire for four current sample staff (#1-#4) affecting 25 current residents and three former residents (#5-#7). Findings include:1. ObservationsOn 9/18/24 from 7:00 a.m. to 10:00 a.m., Staff #1 and #2 was observed providing personal care to residents. 2. Record ReviewThe personnel file for Staff #1 read in part that the staff member was hired on 8/14/24. However, the file contained no name-based criminal history check conducted by the CBI. The personnel file for Staff #2 read in part that the staff member was hired on 3/20/24. However, the file contained no name-based criminal history check conducted by the CBI. The personnel file for Staff #3 read in part that the staff member was hired on 1/8/24. However, the file contained no name-based criminal history check conducted by the CBI. The personnel file for Staff #4 read in part that the staff member was hired on 11/3/23. However, the file contained no name-based criminal history check conducted by the CBI. 3. InterviewsOn 9/18/24 at approximately 11:00 a.m., the executive director could not provide any evidence that the residence utilized a criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed.

Based on record review and interview , the residence failed to ensure that each staff member met the dementia training requirements in 7.9(B), affecting 25 current residents and three former residents (#5-#7). Findings include:On 9/18/24 at approximately 1:59 p.m., personnel files for Staff #1-#3 provided by the executive director revealed no evidence that the direct care staff members met the dementia training requirements in part 7.9(B). On 9/19/24 at approximately 8:45 a.m., Staff #3 stated that she had not received training that met the dementia training requirements in Chapter VII, part 7.9(B). On 9/18//24 at approximately 11:00 a.m., the executive director acknowledged that that Staff #1-#3 did not meet the training requirements in Chapter VII, part 7.9(B).

Based on interview and record review the residence failed to have a roster readily available affecting 25 current residents. Findings include:On 9/18/24 at approximately 8:30 a.m., the resident care coordinator (RCC) provided the resident roster with the resident names and room numbers; however, it failed to include a diagram showing the room locations and emergency contacts. On 9/18/24 at approximately 9:45 a.m., the RCC provided another version of the resident roster; however, it failed to include a diagram showing the room locations. On 9/18/24 at 1:44 p.m., the administrator stated that she was not aware of the requirement to have a readily available roster of current residents, their room assignments and emergency contact information, along with a diagram showing room locations

Based on record review and interview, the residence failed to ensure staff were trained to provide lift assistance when appropriate instead of relying on emergency medical responders, specifically the failure to do an evaluation post fall caused harm, affecting one former resident (#5). (Cross-reference S3072)Specifically, Former Resident #5 fell on 9/7/24 and sustained a hip fracture. However, the residence failed to evaluate the resident prior to requesting the local fire authority to lift her. Former Resident #5 passed away on 9/10/24. The local medical examiner's autopsy report, dated 9/17/24, revealed the cause of her death was due to an "accidental fall and hip fracture."Findings include:1. Residence Policya. The residence's Falls policy, dated December 2022, read in part: When a resident was unable to provide assistance while lifting them or unable to bear their own weight, staff were not permitted to lift them and were to notify emergency services.b. A residence agreement dated March 2024 read in part that the residence ensured staff were trained on fall prevention upon hire, on an ongoing basis and yearly, including analyzing risk factors, safe resident movement training and safety equipment usage. 2. Record ReviewA local fire authority incident report, dated 9/7/24, read in part: The local fire authority was notified of the residence's automatic fire alarm and arrived at 5:04 a.m. with audible alarms activated, and the residence had not been evacuated. Local fire authority personnel cleared the residence at 5:26 a.m. A post fall report, dated 9/7/24 at 5:40 a.m., read in part that Former Resident #5 was startled by the fire alarm, walked out of her room, and fell in the hallway. The former resident cried and complained of right hip pain. An external services provider nurse visit note, dated 9/7/24 at 6:51 a.m., read in part that the former resident sat in an office chair, in tears, with labored breathing, endorsed right hip pain and unable to stand up, and with mild palpitations on the right hip. An external service provider nurse note, dated 9/8/24, read Former Resident #5 had a diagnosis of "pathological hip fracture."The local medical examiner's autopsy report, dated 9/17/24, read that the cause of death was an "accidental fall and hip fracture."The personnel files for Staff #3 revealed that she was hired on 1/8/24 and had not completed any training specific to fall and lift assist. 3 . InterviewsOn 9/19/24 at approximately 8:51 a.m., Staff #3 stated that on 9/7/24 at 4:55 a.m. the fire alarm went off in the secure environment. Staff #3 stated she tried to evacuate Resident #5 but had to leave her in the hallway to help evacuate another resident. Staff #3 found Resident #5 on the floor unable to stand up. Staff #3 stated that she and Staff #4 tried to help her stand up but were unsuccessful. Staff #3 stated the local fire authority entered the secure environment at 5:04 a.m. due to the fire alarm. Staff #3 and #4 requested the assistance of the local authority to lift Resident #5; the local authority did so and sat Resident #5 on the office chair. Staff #3 confirmed the residence did not complete and assessment until 40 minutes after lifting Resident #5 and emergency medical personnel were not contacted. Staff #3 added, she did not have fall or lift assist training since she was hired on 1/5/24. Staff #4 confirmed that she completed a post fall assessment at 5:40 a.m. (approximately 40 minutes after the fall). Staff #2 and Staff #3 acknowledged the lack of training on fall and lift assist policies caused harm to Resident #5. On 9/18/24 at approximately 9:00 a.m., the administrator stated that she expected staff members to do an assessment immediately after a fall. She acknowledged that the residence had not provided Staff #3 any fall or lift assistance training. On 9/19/24 at approximately 12:00 p.m. the administrator and the executive director acknowledged that the residence did not ensure all staff were trained to do an evaluation after a resident fell to determine if a resident could be assisted in a safe manner such as when the resident had no pain and/or there was no change from their baseline status.

Based on record review and interview, the residence failed to ensure Resident #5's record contained documentation of the actions taken by staff and the residence's efforts to prevent the re-occurrence of falls and lift assist training for staff, affecting 25 current residents and one former resident (#1). (Cross-reference S1192, S3072)Findings include:1. Residence Policy a. The residence's Falls policy, dated December 2022, read in part: "Falls will have follow-up documentation in progress notes daily for 72 hours (or longer, as needed until resident returns to baseline) following the incident. Documentation will include immediate interventions taken to address fall risk. Designated (staff) will perform quality improvement to reduce falls, as needed."2. Record ReviewProgress notes, dated 9/7/24 through 9/9/24 revealed no evidence of follow-up daily documentation following the incident. The residence provided no documentation of immediate interventions staff took to address fall risks. 3. Interview On 9/19/24 at approximately 10:15 a.m., the administrator acknowledged the residence did not have documentation of progress notes since Resident #5's fall. She added that the residence did not address interventions to staff to address fall risk and quality improvement to reduce falls. On 9/19/24 at approximately 11:00 a.m., the executive director acknowledged the residence needed to provide more training to staff to ensure they documented in resident record the required elements to prevent the reoccurrence of falls.

Based on interview and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed or was reported to them, affecting two former residents (#6, #7). (Cross-reference S1410)Findings include:1. Record ReviewFormer Resident #7 was admitted to the residence on 6/14/24 with diagnosis of dementia, bacteremia including unstaged skin conditions and puncture wounds. External hospice progress notes for Resident #7, in June and July 2024, revealed the following:On 6/20/24 Resident #3 had poor coordination in getting food and drink to her mouth and ate 50% of her meal that ended up on her lap or table. On 7/3/24 Resident #7 was in and out of consciousness and unresponsive at times. On 7/5/24 Resident #7 had an injury occurred during staff transfer from bed to wheelchair. Resident #3 suffered a torn skin and bled. On 9/19/24 at 2:00 p.m., no residence-specific progress notes for Resident #7 were provided. 2. InterviewOn 9/19/24 at 2:15 p.m., the administrator stated that staff were expected to document a resident's status or wellbeing at the end of their shift. She acknowledged that the staff needed more training in documenting residents' progress notes. The administrator acknowledged that staff should have documented Resident #7's unresponsiveness and skin conditions in progress notes, but they did not. 3. Evidence obtained during the onsite investigation additionally revealed the same deficient practice for Former Resident #6.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.12 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(A) A description of the employee or volunteer duties;(B) Date of hire or acceptance of volunteer service and date duties commenced;(C) Orientation and training, including first aid and CPR certification, if applicable;(D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable;(E) Results of background checks and follow up, as applicable; 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.13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements: All documentation of the investigation, outcomes, and steps taken shall be retained by the assisted living residence, including, but not limited to, details of any interviews and/or records used in the investigation. Such documentation shall be made available for review at the Department's request.(1) Documentation on the investigation, outcomes, and steps taken may be maintained separately from the resident record, in which case a summary of the investigation and steps taken shall be included in the resident's care plan and progress notes.

A revisit survey was completed on 5/7/24 for all previous deficiencies cited on 2/7/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by ##CO34081, #CO34813, #CO34821, was completed on 2/7/24. Deficiencies were cited.

Based on interviews and record review, the residence personnel failed to report suspected sexual abuse of at-risk residents to law enforcement within 24 hours of discovery, affecting 64 current residents. (Cross reference Q1312 and Q1360)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.7, defines an "at-risk person" as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), Colorado Revised Statutes (C.R.S.).b. Chapter VII regulations governing assisted living residences, part 2.1, defines "Abuse" as any of the following acts or omissions:(C) Subjection to sexual conduct or contact that is classified as a crime.c. Chapter II regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein."d. CRS 27-65-102 (14) reads, "Person with a mental illness" means a person with one or more substantial disorders of the cognitive, volitional, or emotional processes that grossly impairs judgment or capacity to recognize reality or to control behavior.e. According to Depend Care, "depends are briefs that are designed for both bladder and bowel incontinence" Depend Care, retrieved from: https://www.dependcare.com.au/en-au/productrange/products/depend-briefs#:~:text=Depend%C2%AE%20Briefs%20are%20designed,more%20informed%20change%20time%20decision.&text=For%20day%2Fnight%20use%20for%20heavy%20urinary%20incontinencef. The residence's Abuse Non-Tolerance policy, dated October 2022, read in part, "(the residence) will strive to prevent abuse and report, investigate, and respond to actual and suspected abuse ... (the residence) will meet the requirements of the Federal, State, and local law in its response to actual or suspected abuse ... sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault ... associates and volunteers must report suspected or actual abuse to their supervisor ... the executive director will ensure law enforcement and other regulatory agencies are notified within one business day of suspected abuse."2. Record ReviewResident #1 was born on 8/14/48 and was admitted to the residence on 5/2/23 with a diagnosis of senile degeneration of the brain. Resident #2 was born on 2/12/47 and was admitted to the residence on 10/19/22 with a diagnosis of unspecified dementia. Former Resident #8 was born on 3/31/26 and was admitted to the residence on 1/25/23 with a diagnosis of unspecified dementia. Former Resident #10 was born on 8/21/51 and was admitted to the residence on 9/1/23 with a diagnosis of Alzheimer's Disease. An email from Staff #1 to the executive director (ED) of her statement dated 1/2/24, read in part, on the week of 12/7/23 Staff #1 witnessed Former Staff #4 go back to check Resident #1's incontinence brief after Staff #1 had checked it and stated she was dry. Former Staff #4 proceeded to check Resident #1 with his fingers inside her incontinence brief from the front side where her private area was, and his fingers were inside her incontinence brief for approximately 3-4 minutes while she laid on her back. Staff #1 was concerned since normally Former Staff #4 had always rushed to change certain non-verbal residents; however, it took longer than normal to change Resident #1. In addition, Staff #1 noticed that Former Resident #8 was afraid when she saw Former Staff #4, and believed residents were being abused and something needed to be done. An undated follow up as part of the residence's investigation conducted by the ED, read that Staff #1 had put in her written statement she had seen Former Staff #4 put his fingers into Resident #1's vagina around 12/7/23. Staff #1 told the ED she had not actually seen Former Staff #4 place his fingers into the front end of the incontinence brief near Resident #1's private area, since it was dark and she had assumed that was what he was doing. Staff #1 stated while Former Staff #4 was checking Resident #1's incontinence brief, she was petting the resident's cat. Staff #1 stated she had asked other staff members if checking the incontinence brief from the inside was appropriate, and they had said it was not. Staff #1 stated she felt the incident was unusual and that the incontinence brief should be patted down from the outside on the front or back to check if it was soiled. Staff #1 clarified she was concerned that Former Staff #4 had abused other residents, because when Former Resident #8 saw Former Staff #4 shortly after the incident with Resident #1, she had grabbed her ear and made a face at him. Staff #1 was educated if she suspected abuse to contact the ED or administrator immediately. 3. InterviewsOn 2/6/24 at 7:50 a.m., Staff #2 stated she was hired three weeks prior to the onsite investigation and was trained to report suspected abuse to the administrator or ED. She stated she was not required to report to anyone else. On 2/6/24 at approximately 8:00 a.m., Staff #3 stated he had worked at the residence for a year and stated he was trained to report suspected abuse to the administrator or ED. Staff #3 further stated he was not trained or aware of the mandatory reporting requirement to report to law enforcement within 24 hours. On 2/6/24 at 11:02 a.m., the ED stated he was first made aware of the allegations of sexual abuse made by Staff #1, on 12/31/23. The ED stated he would have expected Staff #1 to have reported the allegation to himself or the administrator immediately. However, he stated he had found out from the maintenance director (MD) about the allegation who Staff #1 informed. On 2/6/24 at 11:47 a.m., a law enforcement officer stated his department was not made aware of the allegation of sexual abuse until 1/8/24. The law enforcement officer stated he would have expected the residence to have notified him when Staff #1 had observed the incident the week of 12/7/23. He further stated all staff were required to report and notify suspected crimes against at risk. He stated from his investigation he was informed by Former Staff #5 that potential victims included Resident #1, #2, and former Residents #8 and #10. On 2/6/24 at 1:11 p.m., the ED stated he was unaware of the requirement for staff to mandatory report until the middle of January 2024 when law enforcement came to the residence to investigation the sexual abuse allegations by Former Staff #4. The ED stated residence staff should report to himself and the administrator if there was suspected abuse, and they make a determination based on their investigation on whether to report to law enforcement. The ED stated he had not reported to law enforcement when he was made aware of the incident on 12/31/23 because his investigation determined no evidence of sexual abuse. On 2/7/24 at 9:19 a.m., Former Staff #5 stated Staff #1 made her aware she was concerned that residents were being sexually abused by Former Staff #4 toward the middle of December 2023. She further stated she worked at the residence for almost two years before she was terminated in January 2024, and stated she had not been trained on mandatory reporting to law enforcement within 24 hours of suspected abuse. On 2/7/24 at 10:00 a.m., Staff #1 stated she was hired toward the end of November 2023, and stated she was not trained on mandatory reporting and was unaware of the requirement to report suspected abuse to law enforcement within 24 hours. She further stated she was unsure what to do after she observed Former Staff #4 "check (Resident #1's) depends from inside face down." She further stated she was concerned he had done more then check the resident to see if she was soiled; however, was unaware how long it took him since it was dark and she was distracted with Resident #1's cat. She further stated after speaking with other staff members, including Former Staff #5, she decided to report to the MD on 12/31/23, who then informed the ED. On 2/7/24 at approximately 2:30 p.m., the administrator stated she was unaware of the requirement that suspected abuse needed to be reported to law enforcement within 24 hours. She stated she was made aware of the allegations against Former Staff #4 on 12/31/23. The administrator stated residence staff were trained to report to herself and the ED, who would then only report to law enforcement if abuse was verified.

Based on observation, interview and record review the residence failed to either directly or indirectly through a resident agreement provide personal services and a safe and sanitary environment, affecting 64 current residents. (Cross reference Q1620)Findings include:1. Residence Policy and Referencesa. Chapter VII regulations governing assisted living residences, defines personal services as those services that an assisted living residence and its staff provide for each resident including, but not limited to: A) An environment that is sanitary and safe from physical harm. b. The residence's Resident Agreement, dated March 2022, read in part, "we will perform weekly light housekeeping for your apartment, including vacuuming, dusting and cleaning cleared surfaces ... we will provide you certain personal care services ... as specified in your resident care plan."2. ObservationsAn environmental tour from 2/6/24 at 8:45 a.m. to 2/7/24 at 2:15 p.m., revealed the following:Resident #1's room had cat food, pieces of food, and trash on the ground. Resident #7's room contained small pieces of trash and debris on the carpet, the laundry basket was filled to the brim with soiled clothes, and soiled linens were lying on the bathroom floor. The hallways in the common areas of the secure environment had particles of trash and debris. 3. Record ReviewA housekeeping schedule read Resident #1's room was supposed to be cleaned every Wednesday, Resident #5's room was supposed to be cleaned every Thursday and Resident #7's room was supposed to be cleaned every Saturday.a. Resident #1 was admitted to the residence on 5/2/23 with a diagnosis of senile degeneration of the brain. The care plan for Resident #1, dated 5/2/23, read housekeeping and laundry services would be provided weekly on scheduled days or more frequently as needed.b. Resident #5 was readmitted to the residence on 12/18/23 with a diagnosis of Parkinson's Disease. The care plan for Resident #5, dated 12/16/23, read housekeeping would be provided weekly on scheduled days. A room cleaning log for Resident #5, read his room was last cleaned on 1/26/24.c. Resident #7 was admitted to the residence on 6/13/23 with a diagnosis of unspecified dementia. The care plan for Resident #7, dated 6/12/23, read housekeeping would be provided weekly on scheduled days. 4. Interviews On 2/6/24 at 7:30 a.m., Resident #5 stated he had not had his room cleaned since January 2024. On 2/6/24 at 9:51 a.m., Resident #7 stated she moved into the residence in June 2023. She further stated she would like to have her carpet vacuumed but noticed it had been vacuumed twice since moving in. She stated her room was very dusty and she had been sneezing. She stated she did not know staff names due to turnover and stated the residence had all new staff; however, stated she had asked more than once for her room to be vacuumed. On 2/6/24 at 12:00 p.m., Resident #1's family member stated she was at the residence a week prior to the onsite investigation and the carpets were dirty and contained food and debris. She stated the issue had been ongoing and around a month prior to the onsite investigation there was an infestation of ants in Resident #1's room. On 2/7/24 at 2:03 p.m., the environmental services associate (ESA) stated the memory care housekeeper (MCH) was on vacation since the Sunday prior to the onsite investigation and normally worked Monday-Wednesdays. He stated he was filling in cleaning common areas of the secure environment; however, stated as far as he was aware there was not anyone cleaning resident rooms. On 2/7/24 at 8:06 a.m., Staff #3 stated he had not noticed anyone providing housekeeping services in the secure environment for at least one week. He stated he noticed the ESA the day of the onsite investigation cleaning common areas; however, that was the first time. On 2/7/24 at 8:13 a.m., the assisted living housekeeper (ALH) stated she worked Tuesday, Thursday, Friday, Saturdays and Sunday cleaning the non-secure environment and had last worked on 2/6/24. The ALH stated she had not had the chance to clean Resident #5's room since he moved into assisted living from the secure environment. On 2/7/24 at 8:32 a.m., the administrator stated Resident #5 moved into his room in assisted living on 1/17/24. On 2/7/24 at approximately 2:30 p.m., the administrator stated she was aware of the requirement to provide personal services and a sanitary environment to residents. She stated resident rooms should be cleaned weekly in accordance with the housekeeping log and stated staff members should not leave soiled linens on the ground and ensure Resident #1's laundry was taken to the laundry room so it was not so full.

Based on interviews and record review, the residence failed to ensure the residents were observed the right to be treated with dignity and respect, affecting of one of seven sample residents (#1). (Cross reference Q410 and Q1360). Findings include:1. Reference and Residence Policya. According to Depend Care, "depends are briefs that are designed for both bladder and bowel incontinence" Depend Care, retrieved from: https://www.dependcare.com.au/en-au/productrange/products/depend-briefs#:~:text=Depend%C2%AE%20Briefs%20are%20designed,more%20informed%20change%20time%20decision.&text=For%20day%2Fnight%20use%20for%20heavy%20urinary%20incontinenceb. The residence's Resident Rights policy, dated December 2022, read in part: "(residents had) the right to civil and religious liberties, including the right to be treated with dignity and respect." 2. Record ReviewResident #1 was admitted to the residence on 5/2/23 with a diagnosis of senile degeneration of the brain. The residence's care plan for Resident #1, dated 5/2/23, read Resident #1 had bladder incontinence and used incontinence briefs. The residence's investigation, written 12/31/23, read former Staff #4 was interviewed about sexual abuse allegations and denied them. He stated he checked a brief by placing two fingers inside the brief to determine if it needed to be changed. Former Staff #4 was educated to just go ahead and change a resident every two hours without checking. Nothing was found to substantiate the claim and the residence provided staff training on how to properly check resident briefs and Former Staff #4 was able to return to work on 1/1/24. 3. InterviewsOn 2/6/24 at 11:02 a.m., the executive director (ED) stated Resident #1 was incontinent of bladder and Former Staff #4 had checked her for wetness from the inside of the brief. The ED stated after interviewing other staff members, he identified there were differences on how briefs were changed, since it was dependent on who the staff member had shadowed during orientation. The ED further stated he would expect all staff to check briefs from the outside and determine if soiled based on wetness indicators on the outside; however, discovered Resident #1's brief did not have the indicator. He stated staff were trained, following the investigation that began on 12/31/23, not to check briefs from the inside. On 2/6/24 at 12:00 p.m., Resident #1's family member stated it was concerning to her that Former Staff #4 checked Resident #1's brief from inside for wetness. She further stated Resident #1 was unable to verbalize more than "yes" or "no" answers. The family member stated she was concerned her mother's rights were being violated, and that she was targeted due to the inability to speak. She further stated she was concerned the staff member had sexually assaulted the resident. On 2/7/24 at 9:19 a.m., Former Staff #5 stated she had not observed Former Staff #4 change resident briefs. However she stated sheheard from Staff #1 that he put his hand in Resident #1's brief and felt from the front of the brief where her privates were. She further stated she felt that was an inappropriate way to check a brief. On 2/7/24 at 9:47 a.m., Former Staff #4 stated he was trained when he was hired sometime in the fall of 2023 by the staff member he shadowed, to check resident briefs from the outside or check indicator lines. Former Staff #4 stated Resident #1 did not have indicator lines on her brief. He further stated resident changes were always done with Staff #1 present, and stated he tried to change briefs as quickly as possible and did not remember the specific day he changed Resident #1 with former Staff #4. He further stated he remembered he checked Resident #1's brief from inside the brief. On 2/7/24 at 10:00 a.m., Staff #1 stated she provided residents with brief changes on night shift with Former Staff #4. She stated the former staff member checked Resident #1's brief the week of 12/7/23 with three fingers face downfrom the front of the brief. Staff #1 stated although Former Staff #4 had his gloves on when he checked Resident #1, she felt checking a resident for soiledness from inside the brief was a very inappropriate way to check a resident. She added Former Staff #4 was newly hired within a few months prior to the incident and had no experience in healthcare prior; however, he had not checked a resident that way before, which was why she was concerned. Staff #1 stated she was trained by the person she shadowed during her first week of orientation in November 2023 and she was unsure who that was. She stated she learned that if you have to check a resident's brief from the inside, the palm of the hand should be facing up. She stated she checked from the resident's backside and felt if the brief was squishy to determine whether she needed to be changed. Staff #1 stated she would consider the way in which Former Staff #4 checked Resident #1 a violation of her right to dignity. On 2/7/24 at approximately 2:30 p.m., the administrator stated she would expect resident briefs to be checked from outside based on observing and should not be checked by feeling inside the brief. The administrator further stated she would expect the resident right to dignity and respect be upheld.

Based on record review and interview, the residence failed to investigate all allegations of abuse in accordance with regulation and their written policy, affecting 64 current residents. (Cross-reference Q410 and Q1312)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator;(B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation. b. Chapter VII regulations governing assisted living residences, part 2.1, defines "Abuse" as any of the following acts or omissions:(C) Subjection to sexual conduct or contact that is classified as a crime.c. Chapter VII regulations governing assisted living residences, part 2.7, defines an "at-risk person" as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), Colorado Revised Statutes (C.R.S.).d. Chapter II regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein."e. According to Depend Care, "depends are briefs that are designed for both bladder and bowel incontinence" Depend Care, retrieved from: https://www.dependcare.com.au/en-au/productrange/products/depend-briefs#:~:text=Depend%C2%AE%20Briefs%20are%20designed,more%20informed%20change%20time%20decision.&text=For%20day%2Fnight%20use%20for%20heavy%20urinary%20incontinencef. The residence's Abuse Non-Tolerance policy, dated October 2022, read in part, "(the residence) will strive to prevent abuse and report, investigate, and respond to actual and suspected abuse ... (the residence) will meet the requirements of the Federal, State, and local law in its response to actual or suspected abuse ... sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault ... associates and volunteers must report suspected or actual abuse to their supervisor ... families/responsible parties will be involved throughout the investigation ... the executive director will ensure the police and other regulatory agencies are notified within one business day of suspected abuse." However, the residence's policy did not include reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county, Department of Social Services and the requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation. 2. Record ReviewResident #1 was born on 8/14/48 and was admitted to the residence on 5/2/23 with a diagnosis of senile degeneration of the brain. Former Resident #8 was born on 3/31/26 and was admitted to the residence on 1/25/23 with a diagnosis of unspecified dementia. The residence's investigation, written 12/31/23, read former Staff #4 was interviewed about sexual abuse allegations and denied them. He stated he checked a brief by placing two fingers inside the brief to determine if it needed to be changed. Former Staff #4 was educated to change a resident every two hours without checking for wetness. The staff member was placed on administrative leave while the investigation was ongoing. Written statements were conducted with all residence staff and interviews with Staff #1 and Former Resident #5. Nothing was found to substantiate the claim and provided staff training on how to properly check resident briefs and Former Staff #4 was able to return to work on 1/1/24. An anonymous statement, dated 12/31/23, read the unnamed staff member was informed by a coworker that Former Staff #4 was inappropriately touching Resident #2's brief. An anonymous statement, dated 12/31/23, read they heard Former Staff #4 was inappropriate when changing non verbal residents which included Resident #1, #2 and Former Resident #10. An email from Staff #1 to the executive director (ED) of her statement dated 1/2/24, read in part, on the week of 12/7/23 Staff #1 witnessed Former Staff #4 go back to check Resident #1's brief after Staff #1 had checked it and stated she was dry. Former Staff #4 proceeded to check Resident #1 with his fingers inside her brief from the side and his fingers were inside her brief for approximately three to four minutes while she laid on her back. Staff #1 was concerned since normally Former Staff #4 had always rushed to change certain non-verbal residents; however, it took longer than normal to change Resident #1. In addition, Staff #1 noticed that Former Resident #8 was afraid when she saw Former Staff #4, and believed residents were being abused and something needed to be done. An undated follow up as part of the residence's investigation conducted by the ED, read that Staff #1 had submitted her written statement she had seen Former Staff #4 put his fingers into Resident #1's vagina around 12/7/23. Staff #1 told the ED she had not actually seen Former Staff #4 place his fingers into Resident #1's vagina, since it was dark and she had assumed that was what he was doing. Staff #1 stated while Former Staff #4 was checking Resident #1's brief, she was petting the resident's cat. Staff #1 stated she had asked other staff members if checking resident briefs from the inside was appropriate, and they had said it was not. Staff #1 stated she felt the incident was unusual and that briefs should be patted down from the outside on the front or back to check if it was soiled. Staff #1 clarified she had concerns that Former Resident #8 was being abused by Former Staff #4, since when she saw him shortly after the incident with Resident #1, she had grabbed her ear and made a face at Former Staff #4. Staff #1 was educated that if she suspected abuse to contact the ED or administrator immediately. A follow up investigation noted dated 1/2/24, read that former Resident #8's family member stated he was informed by Former Staff #5 that Resident #8 was a potential victim of sexual abuse. 3. InterviewsOn 2/6/24 at 7:50 a.m., Staff #2 stated she was hired three weeks prior to the onsite investigation and was trained to report suspected abuse to the administrator or ED. On 2/6/24 at approximately 8:00 a.m., Staff #3 stated he had worked at the residence for a year and stated he was trained to report suspected abuse to the administrator or ED. Staff #3 further stated he was not trained or aware of the requirement to report to adult protective services (APS) or resident family members. On 2/6/24 at 11:02 a.m., the ED stated he was first made aware of the allegations of sexual abuse made by Staff #1, on 12/31/23. The ED stated he would have expected Staff #1 to have reported the allegation to himself or the administrator immediately, however, he had found out about the allegation from the maintenance director (MD) about the allegation who Staff #1 informed. On 2/6/24 at 11:30 a.m., an APS case worker stated she was concerned that residence staff were not reporting as required. She further stated she was made aware of the sexual abuse allegation on 1/16/24; however, was informed by a family member and not by residence staff. On 2/6/24 at 11:47 a.m., a law enforcement officer stated his department was not made aware of the allegation of sexual abuse until 1/8/24. The law enforcement officer stated he would have expected the residence to have notified him when Staff #1 had observed the incident the week of 12/7/23. He further stated all staff were required to report and notify suspected crimes against at risk adults. He stated from his investigation he was informed by Former Staff #5 that potential victims included Resident #1, #2, and Former Residents #8 and #10. On 2/6/24 at 12:00 p.m., Resident #1's family member stated she was not informed of any allegation of sexual abuse related to Resident #1 until 1/16/24. She further stated she found a law enforcement contact card in Resident #1's room and spoke to Former Staff #5 who informed her of the allegation and had heard nothing in relation to the incident since. On 2/6/24 at 1:11 p.m., the ED stated he was unaware of the requirement to report abuse allegations to APS until the middle of January 2024. The ED stated residence staff should have reported the allegations to himself and the administrator if there was suspected abuse. On 2/7/24 at 9:19 a.m., Former Staff #5 stated Staff #1 made her aware she was concerned that residents were being sexually abused by Former Staff #4 toward the middle of December 2023. She stated she had concerns with non-verbal Resident #2 and Former Resident #8 and #10 as well being targeted after hearing of Resident #1. Former Staff #5 acknowledged she never observed any abuse; however, told the family members of the above residents of concerns. She further stated she worked at the residence for almost two years before she was terminated in January 2024. She stated she was not aware she was supposed to or able to report allegations to APS. On 2/7/24 at 10:00 a.m., Staff #1 stated she was hired toward the end of November 2023, and stated she was not aware of the requirement to report suspected abuse to APS. On 2/7/24 at 11:19 a.m., Resident #2's family member stated he was informed by Former Staff #5 that Resident #2 had been "molested" by former Staff #4 around the beginning of January 2024 and had not been informed prior. On 2/7/24 at 12:42 p.m., Former Resident #8's family member stated on 1/7/24 he was in Former Resident #8's room and Former Staff #5 entered the room and told him that she suspected Former Staff #4 was sexually abusing her. The family member further stated he had not been notified or updated by residence staff prior or since regarding the findings of the investigation. On 2/7/24 at approximately 2:30 p.m., the administrator stated she was unaware of the requirement that residence policy for investigations of abuse, needed to include reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county and Department of Social Services. Contrary to the ED's statement, the administrator stated she was aware of the requirement to report to APS and stated staff were trained at an inservice in December 2023. She stated an occurrence report was made on the department website on 12/31/23; however, stated the ED completed the investigation since she was unable to take part due to Former Staff #4 being her relative. The administrator further stated she was unsure why the residence policy did not include notifying family members within 24 hours and stated staff members should have notified family members within 24 hours as well as herself of allegation of sexual abuse. On 2/7/24 at 3:17 p.m., the ED stated when law enforcement came to the residence to investigate toward the beginning of January 2024, he was notified of rumors that were spread about Resident #1, #2, and Former Resident #8 and #10. He stated both law enforcement and APS informed him not to reach out to family members. He stated that Former Staff #5 had reached out to family members instead of himself or the ED prior to law enforcement investigating and lied about it. The ED would not answer the surveyor's question on whether resident family members should have been notified within 24 hours of Staff #1 observing the incident on 12/7/23 or even from when he was made aware on 12/31/23. The ED further stated he was unsure of the policy requirements for investigation of allegations of abuse, and stated he was not too familiar with assisted living regulations.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of five sample residents (#3, #4, #5) whose medications were reviewed, and one former resident (#9). (Cross reference Q1510 and Q1522)Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated November 2023, read in part, "the community provides medication administration services to residents according to Colorado Department of Public Health (CDPHE) regulations. Licensed nurses or qualified medication administration personnel (QMAPs) administer prescription and over the counter (OTC) medications accurately and in a timely manner to residents requiring this service."2. Resident #3 was admitted to the residence on 11/29/23 with diagnoses that included frontotemporal dementia, hypothyroidism and chronic kidney disease.a. AcetaminophenA written practitioner's order, dated 11/21/23, directed the residence to administer acetaminophen 325 mg two tablets three times daily. However, the January and February 2024 electronic medications administration records (eMARs) read the medication was not administered in the morning on 1/11, 1/12, 1/16, 1/17-1/19, 1/23, 1/25, 1/30, 2/1, 2/2 and 2/6, in the afternoon on 1/11, 1/12, 1/16, 1/17, 1/23, 1/25 1/30, 2/1 and 2/6, in the evening on 1/3, 1/18, 1/26, 1/27 and 2/2 for all three doses on 1/4-1/10, 1/13-1/15, 1/20-1/22, 1/24, 1/28, 1/29, 1/31 and 2/3-2/5/24 due to the medication being out of stock, for a total of 86 missed doses.b. GuaifenesinA written practitioner's order, dated 11/21/23, directed the residence to administer guaifenesin 600 mg two times daily. However, the January and February 2024 eMARs read the medication was not administered on 1/17, 1/23 and 2/6 in the morning, in the evening on 1/26 and 1/27 and both doses on 1/1-1/16, 1/18-1/22, 1/24, 1/25, 1/28-1/31, 2/2-2/5/24, due to the medication being out of stock, for a total of 67 missed doses. c. Trolamine salicylateA written practitioner's order, dated 11/21/23, directed the residence to administer trolamine salicylate 10% two times daily. However, the January and February 2024 eMARs read the medication was not administered in the morning on 1/11, 1/12, 1/17, 1/23, 1/25, 1/30, 1/31, 2/1 and 2/6, in the evening on 1/16, 1/20, 1/21, 1/26, 1/27, and both doses on 1/1-1/10, 1/13-1/15, 1/18, 1/19, 1/22, 1/24, 1/29 and 2/2-2/5/24 due to the medication being out of stock, for a total of 58 missed doses.d. MeloxicamA written practitioner's order, dated 11/21/23, directed the residence to administer meloxicam 7.5 mg daily. However, the January and February 2024 eMARs read the medication was not administered on 1/1-1/25 and 2/2-2/6/24 due to the medication being out of stock, for a total of 30 missed doses.e. LisinoprilA written practitioner's order, dated 11/21/23, directed the residence to administer lisinopril 40 mg daily. However, the January and February 2024 eMARs read the medication was not administered on 1/1-1/25 and 2/3-2/6/24 due to the medication being out of stock, for a total of 29 missed doses.f. GabapentinA written practitioner's order, dated 11/21/23, directed the residence to administer gabapentin 300 mg daily. However, the January 2024 eMAR read the medication was not administered on 1/8-1/16 and 1/18-1/22/24 due to medication being out of stock, for a total of 14 missed doses.g. Triamcinolone acetonideA written practitioner's order, dated 11/21/23, directed the residence to administer triamcinolone acetonide 0.1% two times daily. However, the January and February 2024 eMARs read the medication was not administered in the morning on 1/7, 1/18-1/20 and 2/3, in the evening on 1/4 and 1/29, and both doses on 1/5 and 1/6/24 due to the medication being out of stock, for a total of 11 missed doses.h. PantoprazoleA written practitioner's order, dated 11/21/23, directed the residence to administer pantoprazole sodium 20 mg daily. However, the January and February 2024 eMARs read the medication was not administered on 1/22-1/25 and 2/2-2/6/24 due to medication being out of stock, for a total of nine missed doses.i. PreserVisionA written practitioner's order, dated 11/21/23, directed the residence to administer preserVision one capsule daily. However, the January and February 2024 eMARs read the medication was not administered on 1/3, 1/25, 1/26, and 2/2-2/6/24 due to the medication being out of stock, for a total of eight missed doses.j. Quetiapine A written practitioner's order, dated 11/21/23, directed the residence to administer quetiapine fumarate 50 mg daily. However, the January 2024 eMAR read the medication was not administered on 1/20-1/22/24 due to the medication being out of stock, for a total of three missed doses. k. Diclofenac sodiumA written practitioner's order, dated 11/21/23, directed the residence to administer diclofenac sodium 1% 4 grams two times daily. However, the January 2024 eMAR read the medication was not administered in the morning on 1/11 or in the afternoon on 1/19/24 due to the medication being out of stock, for a total of two missed doses.l. Calcium carbonateA written practitioner's order, dated 11/21/23, directed the residence to administer calcium carbonate 500 mg three times daily. However, the February 2024 eMAR read the medication was not administered on 2/1/24 in the evening due to the medication being out of stock, for a total of one missed dose. 3. Former Resident #9 was admitted to the residence on 10/19/22.a. LidocaineA written practitioner's order, dated 9/27/23, directed the residence to administer lidocaine 4% once daily for 12 hours then remove at night. However, the September and October 2023 eMARs read the medication was not transcribed onto the eMARs and administered until 10/18/23, for a total of 21 missed doses.b. Citalopram HydrobromideA written practitioner's order, dated 7/25/23, directed the residence to administer citalopram hydrobromide 10 mg daily. However, the October 2023 eMAR read the medication was not administered on 10/17-10/20/23 due to the medication being out of stock, for a total of four missed doses.c. MeloxicamA written practitioner's order, dated 10/18/22, directed the residence to administer meloxicam 15 mg daily. However, the October 2023 eMAR read the medication was not administered on 10/10 and 10/11/23 due to the medication being out of stock, for a total of two missed doses.d. LevothyroxineA written practitioner's order, dated 7/25/23, directed the residence to administer levothyroxine 75 mg daily. However, the October 2023 eMAR read the medication was not administered on 10/3/23 due to the medication being out of stock, for a total of one missed dose. 4. There was similar deficient practice for Residents #4 and #5.5. InterviewsOn 2/6/24 at 8:00 a.m., Staff #3 stated he was responsible for ordering medications from the pharmacy for the secure environment residents and stated he had not gotten around to ordering refills for Resident #3 and #4. He also stated he was busy on shifts and there was no time to order medication. On 2/7/24 the administrator stated herself and the resident care coordinator (RCC) were responsible for transcribing medications onto the eMAR, and QMAPS, herself and the RCC were responsible for ordering medications daily or as needed since no medications were on cycle fills. The administrator stated she expected the residence comply with practitioner's orders for Residents #3, #4, #5 and Former Resident #9.

Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event was completed for each resident along with each of their signatures and, if used, their initials, affecting two of five sample residents (#1, #3) whose medications were reviewed and one former resident (#9). (Cross reference Q1468 and Q1522)Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated November 2023, read in part, "the qualified medication administration person (QMAP) will document each medication as given or refused."2. Resident #3 was admitted to the residence on 11/29/23 with a diagnosis of frontotemporal dementia.a. AcetaminophenA written practitioner's order, dated 11/21/23, directed the residence to administer acetaminophen 325 mg two tablets three times daily. However the January and February 2024 electronic medication administration records (eMARs) contained blank spaces in the afternoon on 1/19 and 2/2 and in the evening on 1/17 and 1/23/24, for a total of four inaccurately documented doses.b. Calcium carbonateA written practitioner's order, dated 11/21/23, directed the residence to administer calcium carbonate 500 mg three times daily. However the January and February 2024 eMARs contained blank spaces in the afternoon on 1/19 and 2/2, and in the evening on 1/17 and 1/23/24, for a total of four inaccurately documented doses. c. GabapentinA written practitioner's order, dated 11/21/23, directed the residence to administer gabapentin 300 mg daily. However, the January 2024 eMAR contained blank spaces on 1/17 and 1/23/24, for a total of two inaccurately documented doses. d. Trolamine salicylateA written practitioner's order, dated 11/21/23, directed the residence to administer trolamine salicylate 10% two times daily. However, the January 2024 eMAR contained blank spaces in the evening on 1/17 and 1/23/24, for a total of two inaccurately documented doses. e. Triamcinolone AcetonideA written practitioner's order, dated 11/21/23, directed the residence to administer triamcinolone acetonide 0.1% two times daily. However, the January 2024 eMAR contained blank spaces in the evening on 1/17 and 1/23/24, for a total of two inaccurately documented doses. f. GuaifenesinA written practitioner's order, dated 11/21/23, directed the residence to administer guaifenesin 600 mg two times daily. However, the January 2024 eMAR contained blank spaces in the evening on 1/17 and 1/23/24, for a total of two inaccurately documented doses. g. TrazodoneA written practitioner's order, dated 11/21/23, directed the residence to administer trazodone 50 mg daily. However, the January 2024 eMAR contained blank spaces on 1/17 and 1/23/24, for a total of two inaccurately documented doses. h. Quetiapine fumarateA written practitioner's order, dated 11/21/23, directed the residence to administer quetiapine fumarate 50 mg daily. However, the January 2024 eMAR contained blank spaces on 1/17 and 1/23/24, for a total of two inaccurately documented doses. i. Diclofenac sodiumA written practitioner's order, dated 11/21/23, directed the residence to administer diclofenac sodium 1% 4 grams two times daily. However, the January 2024 eMAR contained a blank space in the evening on 1/23/24, for a total of one inaccurately documented dose. 3. Former Resident #9 was admitted to the residence on 10/19/22. FenofibrateA written practitioner's order, dated 10/18/22, directed the residence to administer fenofibrate 160 mg daily. However, the September 2023 eMAR contained a blank space on 9/23/23, for a total of one inaccurately documented dose. 4. There was similar deficient practice for Resident #1.5. InterviewOn 2/7/24 at approximately 2:30 p.m., the administrator stated blank spaces in the eMAR meant that staff failed to document whether the medication was administered, refused or otherwise. The administrator stated she would expect medication administration events to be documented at the time of administration.

Based on record review and interview, the residence failed to ensure that the resident's legal representative was promptly notified of a resident's pattern of refusal, affecting one of five sample residents (#3). (Cross reference Q1468 and Q1510)Findings include: Resident #3 was admitted to the residence on 11/29/23 with diagnoses that included frontotemporal dementia, hypothyroidism and chronic kidney disease. Power of attorney (POA) paperwork signed 9/19/16 by Resident #3's family member, read that the family member was Resident #3's medical and financial POA. a. MetoprololA written practitioner's order, dated 11/21/23, directed the residence to administer metoprolol 100 mg 1.5 tablet daily. However, the January and February 2024 electronic medication administration record (eMAR) for Resident #3 read she refused the medication on 1/3, 1/24-2/1 and 2/3-2/6/24 for a total of fourteen doses refused.b. Pramipexole Dihydrochloride A written practitioner's order, dated 11/21/23, directed the residence to administer pramipexole dihydrochloride 0.25 mg daily. However, the January and February 2024 eMAR for Resident #3 read she refused the medication on 1/3, 1/24-2/1 and 2/3-2/6/24 for a total of fourteen doses refused.c. Clopidogrel Bisulfate A written practitioner's order, dated 11/21/23, directed the residence to administer clopidogrel bisulfate 75 mg daily. However, the January and February 2024 eMAR for Resident #3 read she refused the medication on 1/3, 1/24-2/1 and 2/3-2/6/24 for a total of fourteen doses refused.d. Quetiapine fumarateA written practitioner's order, dated 11/21/23, directed the residence to administer quetiapine fumarate 50 mg daily. However, the January and February 2024 eMAR for Resident #3 read she refused the medication on 1/1, 1/3, 1/4 1/24-1/27, 1/30 and 2/3/24 for a total of nine doses refused. e. LisinoprilA written practitioner's order, dated 11/21/23, directed the residence to administer lisinopril 40 mg daily. However, the January and February 2024 eMAR for Resident #3 read she refused the medication on 1/3, 1/26-2/2/24 for a total of nine doses refused. f. MeloxicamA written practitioner's order, dated 11/21/23, directed the residence to administer meloxicam 7.5 mg daily. However, the January and February 2024 eMAR for Resident #3 read she refused the medication on 1/3, 1/26-2/1/24 for a total of eight doses refused. g. Pantoprazole Sodium A written practitioner's order, dated 11/21/23, directed the residence to administer pantoprazole sodium 20 mg daily. However, the January and February 2024 eMAR for Resident #3 read she refused the medication on 1/3, 1/26-2/1/24 for a total of eight doses refused. h. PreservisionA written practitioner's order, dated 11/21/23, directed the residence to administer preserVision one capsule daily. However, the January and February 2024 eMAR for Resident #3 read she refused the medication on 1/3, 1/26-2/1/24 for a total of eight doses refused. i. Calcium carbonateA written practitioner's order, dated 11/21/23, directed the residence to administer calcium carbonate 500 mg three times daily. However, the January 2024 eMAR for Resident #3 read she refused the medication on 1/26 and 1/27 in the morning, 1/3, 1/26 and 1/27 in the afternoon and 1/24 and 1/30/24 in the evening for a total of seven doses refused.j. AcetaminophenA written practitioner's order, dated 11/21/23, directed the residence to administer acetaminophen 325 mg two tablets three times daily. However, the January 2024 eMAR for Resident #3 read she refused the medication on 1/3, 1/26 and 1/27 in the morning, 1/3, 1/26 and 1/27 in the afternoon and 1/30/24 in the evening for a total of seven doses refused.k. Levothyroxine A written practitioner's order, dated 11/21/23, directed the residence to administer levothyroxine 75 mcg daily. However, the January 2024 eMAR for Resident #3 read she refused the medication on 1/3 and 1/24-1/26/24, for a total of four doses refused. l. TrazodoneA written practitioner's order, dated 11/21/23, directed the residence to administer trazodone 50 mg daily. However, the January 2024 eMAR for Resident #3 read she refused the medication on 1/24-1/26 and 1/30/24 for a total of four doses refused. m. Triamcinolone AcetonideA written practitioner's order, dated 11/21/23, directed the residence to administer triamcinolone acetonide 0.1% two times daily. However, the January 2024 eMAR for Resident #3 read she refused the medication 1/16, 1/26 and 1/27 in the morning and 1/30/24 in the evening for a total of four doses refused.n. GabapentinA written practitioner's order, dated 11/21/23, directed the residence to administer gabapentin 300 mg daily. However, the January 2024 eMAR for Resident #3 read she refused the medication on 1/24, 1/25 and 1/30/24 for a total of three doses refused. o. Trolamine salicylateA written practitioner's order, dated 11/21/23, directed the residence to administer trolamine salicylate 10% two times daily. However, the January 2024 eMAR for Resident #3 read she refused the medication 1/26 and 1/27 in the morning and 1/30/24 in the evening for a total of three doses refused.p. GuaifenesinA written practitioner's order, dated 11/21/23, directed the residence to administer guaifenesin 600 mg two times daily. However, the January 2024 eMAR for Resident #3 read she refused the medication 1/26 and 1/27/24 in the morning for a total of two doses refused.q. Diclofenac sodiumA written practitioner's order, dated 11/21/23, directed the residence to administer diclofenac sodium 1% 4 grams two times daily. However, the January 2024 eMAR for Resident #3 read she refused the medication 1/26 in the morning and 1/30/24 in the evening for a total of two doses refused. On 2/6/24 at 8:24 a.m., Resident #3 stated she did not understand why she needed to take all the medication she was on and stated she did not want any of her medication besides her triamcinolone acetonide lotion and her levothyroxine. On 2/7/24 at 8:06 a.m., Staff #3 stated he was aware of the requirement to report to resident family members or the administrator of refusals and had noticed Resident #3 refusing her medications; however, had not gotten around to reporting to either. On 2/7/24 at 10:42 a.m., Resident #3's practitioner stated she was not notified by the residence of Resident #3 refusing her January or February 2024 medications. She further stated she came to the residence on 1/23/24 and asked residence staff questions about Resident #3 medications, and that was when she found out about Resident #3's non-compliance with her medication regimen. She stated she would have expected to have been notified by residence staff and had concerns about them not communicating with her. Resident #3's practitioner stated she had a discussion with Resident #3 about the importance of taking her medication and decided to continue with all her medications for now. On 2/7/24 at 11:01 a.m., the administrator stated she was not aware of Resident #3 refusals of medication and would have expected herself or the resident care coordinator (RCC) to be notified. On 2/7/24 at 11:02 a.m., the RCC stated he was not notified of Resident #3 medication refusals. On 2/7/24 at 2:15 p.m., the family member for Resident #3 stated Resident #3 had a history of medication refusals; however, hadn't been notified by residence staff in January or February 2024 of her refusals. On 2/7/24 at approximately 2:30 p.m., the administrator stated she expected Resident #3's family member and practitioner to have been notified of Resident #3's refusals and stated qualified medication administration persons (QMAPs) and/or the RCC were responsible for notifying and reporting to her. The administrator stated she believed the resident's practitioner was not notified because there was confusion on who it was, since Resident #3 had a discussion with the residence's practitioner, about changing practitioners to her. She stated Resident #3 had also expressed to staff that she didnot want them speaking to her family member. The administrator acknowledged that they should have still notified the family member since she is the POA.

Based on observation, record review and interview, the residence failed to ensure bed linens were cleaned at least weekly to meet individual resident needs, affecting one of seven sample residents (#5). (Cross reference Q1110)Findings include:The residence's Resident Agreement, dated March 2022, read in part, "we will launder your personal clothing, bed linens and bath linens on a weekly basis in accordance with the laundry schedule ... we will provide you certain personal care services ... as specified in your resident care plan."A room cleaning log dated 1/26/24 read Resident #5's sheets were last changed on 1/26/24. On 2/6/24 at 7:30 a.m., Resident #5 stated he had not had his bed sheets changed since January 2024. On 2/7/24 at 8:13 a.m., the assisted living housekeeper (ALH) stated she worked Tuesday, Thursday, Friday, Saturdays and Sunday cleaning assisted living and had last worked on 2/6/24. The ALH stated she had not had the chance to change Resident #5's bed linens he moved into assisted living from memory care. On 2/7/24 at 8:32 a.m., the administrator stated Resident #5 moved into his room in assisted living on 1/17/24. On 2/7/24 at 12:48 p.m., Resident #5's bed linens were observed wrinkled with small white pieces of debris. His linens had a musty odor. On 2/7/24 at 2:58 p.m., an undated log provided by the maintenance director (MD) under Resident #5's room contained a "no" to sheets being changed, with a "yes" written in a different shade pen over the "no." On 2/7/24 at 2:58 p.m., contrary to the evidence on the undated log and the interview with the ALH, the MD stated the log he provided was from the Sunday prior to the onsite investigation (2/4/24) and was filled out by the ALH to show she had changed Resident #5's linens. On 2/7/24 at approximately 2:30 p.m., the administrator stated she was aware of the requirement for resident linens to be changed weekly or more frequently to meet resident needs. She stated the only housekeeper who changed linens in assisted living was the ALH. The administrator stated she had personally changed Resident #5's linens at the end of January 2024 and stated around the 26th sounded accurate. She further stated she was unsure why the linen log for Resident #5 had a "no" with a "yes" over it and found that interesting and stated the ALH would know if she had completed it.

A revisit survey was completed on 1/24/24 for all previous deficiencies cited on 10/4/23. No deficiencies were cited.

A relicensure survey with complaints #CO28874, #CO28931, #CO29827, #CO30885, #CO31239, #CO33749 was completed on 10/4/23. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting five of five sample residents (#1-#5) and three former residents (#7, #9, #10) (Cross-reference Q1514, Q1510)Findings include 1. References and Residence Policya. The residence's Medication and Medication Administration policy, dated December 2022, read in part, "This community complies with all applicable federal and state statutes and regulations, including but not limited to Chapter 7 and Chapter 24 ... The community is responsible for complying with physician orders associated with the administration of medication or treatment unless the resident self-administers such medication or treatment."b. According to medlineplus.com, Morphine is used to ensure effective pain management. Morphine may cause serious or life-threatening breathing problems, especially during the first 24 to 72 hours of your treatment and any time your dose is increased. A physician must make dose adjustments and start low and gradually increase to treat and maintain effective pain control. Morphine must not be abruptly discontinued as it will result in withdrawal symptoms, including restlessness and more. Medication changes must be made by the prescribing physician. Take morphine exactly as directed. MedlinePlus (2023) Morphine, retrieved from: https://medlineplus.gov/druginfo/meds/a682133.html.c. According to medlineplus.com, Oxycodone is used for moderate to severe pain enough to require an opioid pain medicine. Oxycodone works by changing the brain and nervous system to respond to pain. Oxycodone must not be abruptly discontinued as it will result in withdrawal symptoms, including joint aches or pains, weakness, fast heartbeat, or fast breathing. Take Oxycodone as prescribed by a physician. MedlinePlus (2023) Oxycodone, retrieved from: https://medlineplus.gov/druginfo/meds/a682132.html. 2. Former Resident #7 was admitted to the residence on 8/12/23 with multiple diagnoses, including Alzheimer's disease. a. Morphine A written practitioner's order, dated 9/20/23, directed the residence to administer morphine 5 mg every four hours. However, Former Resident #7's September 2023 medication administration record (MAR) revealed the medication was not available at 4:00 p.m. on 9/23, at midnight and 4:00 a.m. on 9/24/23, and at 8:00 a.m. on 9/25/23. b. Lorazepam A written practitioner's order, dated 8/20/23, directed the residence to administer lorazepam 1 mg tablet five times daily. However, Former Resident #7's September 2023 MAR revealed the medication was not available on 9/20/23 at 6:00 a.m.c. Lorazepam A written practitioner's order dated 9/21/23 directed the residence to administer lorazepam 1 mg concentrate five times daily. However, Former Resident #7's September 2023 MAR revealed the medication was not available on 9/24/23 at 10:00 a.m. 3. Current residents (#1-#5) and former residents (#9, #10) were also part of the record review. Their MARs yielded similar medication not available documentation. 4. InterviewOn 9/29/23 at 7:45 a.m., Staff #1 stated they contacted the pharmacy or external hospice when the former resident ran out of medications. Staff #1 stated she had notified the Director of Health and Wellness (DHW) by telephone on several occasions due to medications being out of stock. However, she stated that the DHW was unable to order the medications as required but could not explain why. On 10/4/23 at approximately 8:45 a.m.,the administrator stated the DHW had resigned due to being overwhelmed with her position and had not performed her job duties for several weeks prior to the onsite visit, therefore, medications were not ordered as required. Further, the administrator confirmed the aforementioned residents had not been administered their medications as required.

Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration event at the time the event was completed, affecting five of five sample residents (#1-#5) and two former residents (#6, #7). (Cross-reference Q1468, Q1514)Findings include 1. References and Residence Policiesa. The residence's Medication Administration policy, dated December 2022, read, "This community complies with all applicable federal and state statutes and regulations, including but not limited to Chapter 7 and Chapter 24 ... The community is responsible for complying with physician orders associated with the administration of medication or treatment unless the resident self-administers such medication or treatment."b. The residence's Medication Administration Policy reads, "The HWD, ALD or designee will regularly review administration and documentation of the QMAPs." 2. Resident #2 was admitted to the residence on 1/13/23 with multiple diagnoses, including essential hypertension and chronic obstructive pulmonary disease.a. Carvedilol A written practitioner's order, dated 7/14/23, directed the residence to administer carvedilol oral tablets 25 mg twice daily. However, the July 2023 medication administration record (MAR) for Resident #2 revealed a blank space or no documentation on 7/14-7/24/23, for a total of 22 inaccurately documented doses.b. GabapentinA written practitioner's order, dated 8/21/23, directed the residence to administer gabapentin oral capsules 100 mg three times a day. However, the July 2023 MAR for Resident #2 revealed a blank space or no documentation on 9/17 and 9/25/23, for a total of two inaccurately documented doses. 3. Current residents (#1, #3-#5) and former residents (#6, #7) were also part of the record review. The MARs for the sample residents and former residents yielded similar blank spaces or no documentation. On 9/29/23 at 4:00 p.m., the administrator stated she was unaware there were blank spaces on the MAR for Residents #1-#5 and Former Residents #6 and #7. She added that QMAPs should have administered the medications or documented that the medication was unavailable, and the QMAP should have notified the DHW. She confirmed the blank on the MAR indicated that the medication administration was not provided or documented accurately. On 10/4/23 at 7:30 a.m., Staff #1 stated that blanks on the MAR meant medication was not given, and staff did not document on the MAR accurately.

Based on record review and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor audited the accuracy and completeness of the medication administration records and medication error reports quarterly, affecting five of five sample residents (#1-#5). (Cross-reference Q1468, Q1510)Findings include:The residence's medication administration policy, dated December 2022, read in part that the community will audit the accuracy and completeness of the medication administration record (MAR), controlled substance list, medication errors, and medication disposal records on a quarterly basis or as needed. On 9/29/23 at 7:36 a.m., Staff #1 stated that the director of health and wellness (DHW) was responsible for the completion of medication audits. She added she had never witnessed anyone complete a medication audit. On 9/29/23 at 9:14 a.m., medication audits were requested from the administrator, however, the residence was unable to provide medication audits. On 9/29/23 at 10:00 a.m., the administrator stated she was unable to locate medication audits in the DHW's office. On 9/29/23 at approximately 1:30 p.m., the administrator stated that medication audits had not been completed, therefore, she was unable to provide them. On 10/4/23 at 1:30 p.m., the administrator acknowledged the failure to complete the medication audits in tandem with the DHW. She confirmed medication audits were not completed as required.