INN AT GREENWOOD VILLAGE, THE

A licensure complaint, prompted by #CO42249 was completed on 5/13/26. A deficiency was cited.

Based on record review and interviews, the residence failed to follow its written emergency procedures to ensure continuation of necessary care to residents by having a backup generator for up to 72 hours during a long-term power failure affecting all 88 current residents. 1. ObservationsOn 5/13/26 at 9:00 a.m. during an environmental tour there was no backup generator. 2. Record ReviewRecord review of the residence ' s Emergency Procedures revealed the residence had a section titled "Self-Reliance Up to 72 Hours." The policy stated the residence would be capable of self-reliance for up to 72 hours during an emergency, including a short-term or long-term power failure. The plan addressed emergency power, food, water, resident call systems, powered wheelchairs, and oxygen. Record review of the Emergency Power section revealed the form did not identify a permanently installed generator, access to portable generators, generator location, vendor information, or what emergency power source could be used during an outage. 3. InterviewsAn interview with the business office manager (BOM), on 5/13/26 at 8:00 a.m. revealed the power went out on 4/23/26 at approximately 10:00 p.m. and was not restored until at approximately 1:15 p.m. on 4/24/26. BOM stated all backup lights went out at approximately 1:00 a.m., staff used flashlights to assist residents with toileting and activities of daily living, and staff planned to contact the fire department for assistance. Residents were placed at risk for unmet oxygen needs, delayed assistance, fear, and distress due to the loss of power, and loss of backup lighting. An interview with the maintenance director, on 5/13/26 at 9:15 a.m. revealed the residence did not have a full-building generator at the time of the outage. The Maintenance Director stated emergency lights lasted approximately two hours after the power outage. The Maintenance Director stated staff used flashlights, and contacted the local energy services for updates. They also contacted the fire department and emergency medical services (EMS) and obtained batteries from the fire department. Interview on 5/13/26 at 2:00 p.m. with Resident #1 ' s Power of Attorney (POA) revealed the POA received a message from the residence at approximately 5:00 a.m. on 4/24/26 informing him there was a power outage at the residence. The POA stated the residence recommended Resident #1 be sent to the emergency room because the residence was having difficulty maintaining oxygen support during the outage. The POA stated he agreed with the recommendation to send Resident #1 to the emergency room. Record review of Resident #1 ' s Notes and Incidents revealed that during the power outage from 4/23/26 to 4/24/26, it was decided the safest option was to send Resident #1 to the emergency room because EMS could only supply the community with limited oxygen tanks and there was no back up generator. Resident #1 agreed to be transported to the hospital. Resident #1 was doing well and had no issues. An interview with the administrator, on 5/13/26 at 10:37 a.m. revealed that the staff waited for a church to open so staff could use the church ' s electricity to send family notifications. The administrator stated emergency lighting was on the backup battery but did not last long. The administrator stated the residence had budgeted for a backup generator, but there was no timeline for the installation of the generator. The administrator also stated residents were checked every two hours, although the emergency plan required at least hourly checks when the call system was unavailable. An interview with Staff #1, on 5/13/26 at 12:00 p.m. revealed staff completed resident rounds approximately every two hours using flashlights. Staff #1 also stated the outage incident did not go as outlined in emergency training.

A revisit survey was completed on 7/30/24 for all previous deficiencies cited on 2/15/24. 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 revisit survey was completed on 7/10/2024 for all previous deficiencies cited on 6/28/2024. 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 #CO34924, was completed on 2/15/24. Deficiencies were cited.

Based on record review and interview the residence failed to comply with Colorado Adult Protective Services (CAPS) Data System, for one of one sample staff (#4). 1. References a. According to Colorado Revised Statutes (2020) Title 26 Human Services Code,"... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult.b. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado Adult Protective Services data system pursuant to section 26-3.1-111.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: (D) Is a person with an intellectual and developmental disability as defined in Section 25.5-10-202, C.R.S.; (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.2. Record ReviewThe face sheet for Former Resident #8 revealed she was 82 years old. The personnel file for Staff #4 revealed no documentation of CAPS requests or reports. Staff #4 was hired and began providing services to residents on 11/14/23. The February 2024 time cards revealed Staff #4 worked from approximately 8:00 a.m. to 4:00 p.m. on the following days:On 2/15/24 at approximately 3:30 p.m., the administrator said he was unable to provide the CAPS check for Staff #4. He added he expected CAPS checks to be initiated for staff prior to being hired.

Based on record review and interview, the residence failed to investigate allegations of abuse in accordance with regulation and written policy, affecting one former resident (#8). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 13.11, requires 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. The residence's Elder Abuse, Neglect and Exploitation policy, dated 12/7/22, read in part, "Should any resident experience abuse by staff, residents, family or others or when any for of abuse is suspected, staff and volunteers are required to immediately provide notification to persons/agencies as described in thai policy ... The assisted living residence shall investigate all allegations of abuse ... The executive director is responsible to report abuse to the appropriate agencies such as the adult protective services of the appropriate county department of social services."2. Former Resident #8 was admitted to the residence on 1/31/24 with diagnoses including history of stroke. The department's database for occurrences read adult protective services (APS) was not notified for the allegation of abuse on 2/4/24. On 2/15/24 at 10:03 a.m., the administrator said on 2/5/24 a family member of Former Resident #8 notified the administrator of possible sexual abuse of Former Resident #8. The administrator stated he initiated an internal investigation into the allegation. On 2/15/24 at 12:26 p.m., an adult protective services representative said APS was notified of the allegation of abuse on 2/13/24 by someone other than the administrator. On 2/15/24 at 2:40 p.m., the administrator said he had not notified APS and was unaware he was required to.

Based on record review and interview, the residence failed to ensure that the resident's legal representative was promptly notified of a decline from a resident's baseline status, affecting one former resident (#8). Findings include:1. Residence PolicyThe residence's Change in Resident Status policy, dated 5/9/22, read in part, "Community staff have the responsibility to provide care to each resident and summon medical attention when the resident has a change in status ... Notify the director of health services or med tech on duty whenever there is a change in resident status. Examples of change would include, but not be limited to ... decreased coordination ... decreased communication/responsiveness, decreased ability to communicate ... hallucinations or other unusual behavior ... Notify the residents family/responsible party of the change in status and community action taken."2. Former Resident #8 was admitted to the residence on 1/31/24 with diagnoses including history of stroke. Progress notes in Former Resident #8's record for February 2024 revealed the following:On 2/4/24 at 1:44 a.m. "Care staff heard resident opening her door around 12:30 a.m. ... HSA (Staff #3) entered resident's apartment and found resident using her walker backwards. HSA (Staff #3) aided resident in property (sic) using her walker and assisted her to the chair in her living room. Resident was visibly confused and kept on repeating "I need help, help me," and that she doesn't understand what's happening ... Resident did not appear to understand what care staff was saying and continued to repeat that she needed help and that "this has never happened before."On 2/4/24 at 7:06 a.m., Former Resident #8 was up at 2:00 a.m. and needed assistance using the restroom. Former Resident #8 was unable to walk straight and ran into walls and furniture. On 2/15/24 at 11:42 a.m., two ambulance reports were provided by the department and revealed that on 2/4/24 emergency services were contacted and the report revealed, "Upon arrival, I found an 82-year-old female patient sitting upright, alert but not oriented, in the care of one of the staff in the assisted living facility as well as family. The patient was not able to articulate what was wrong. She just kept repeating the same phrase, and it was difficult to understand what she was saying, but it was clear that she was repeating the same thing over and over again. The patient's speech was extremely abnormal, and both family and the staff stated that she was normally alert and oriented x4, and spoke normally. She was also normally able to ambulate using her walker well ... Again, the patient was not able to be understood but was obviously dealing with some sort of a neurologic or cognitive issue at that time, and the patient did have a history of strokes ... The staff member from the night before said that the patient had acted more confused than normal but did not mention anything about the way that she was acting now and how extreme it was. The staff member from today stated that she felt as though if it were as bad as it was currently, it would have been brought to her attention. Due to that unknown timeframe of when this could have happened, EMS (emergency medical services) went with an unknown time of onset for those stroke symptoms ... Neurologic: The patient had a positive Cincinnati Stroke Scale due to speech. Impression: Stroke."The second report, dated 2/5/24, read Former Resident #8 was admitted to the emergency department for a stroke. On 2/15/24 at 11:17 a.m., a family member of Former Resident #8 stated three days after Former Resident #8 moved into the residence and started having behaviors, the family member was not notified until the next day. She added, "From her symptoms I think she had a stroke and I told them to call the ambulance. (Staff #5) told me she was acting that way the (night prior to being sent to the emergency department). I asked how come we were not notified. (Staff #5) didn't say anything."On 2/15/24 at 1:53 p.m., Staff #5 stated she arrived to work at 6:30 a.m. on Sunday 2/4/24 and was not notified by staff that Former Resident #8 was confused or behaving inappropriately the evening before. On 2/15/24 at 2:00 p.m., another family member of Former Resident #8 said Former Resident #8 moved into the residence and three days later, at 10:00 p.m., she was behaving oddly. He added, "They didn't call us then and then come 6:00 a.m. the next day staff came in and they still didn't call us. She had gotten worse. Behaved worse. She wasn't speaking properly. Was out of it. They didn't notify me until 11:20 a.m., almost 5 and a half hours later ... She had a stroke ..."On 2/15/24 at 2:30 p.m., the director of health services said staff should have notified her and the responsible party the night (2/3/24) of Former Resident #8's change in baseline status. On 2/15/24 at 2:30 p.m., the administrator acknowledged the residence staff should have notified Former Resident #8's responsible party after her change from baseline status.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer.(A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the assisted living residence shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI).(B) If the applicant has lived in Colorado for three years or less at the time of application, the assisted living residence shall obtain a name-based criminal history report for each state in which the applicant has lived for the past three years, conducted by the respective states ' bureaus of investigation or equivalent state-level law enforcement agency or other name-based report as determined by the Department.(C) The cost of obtaining such information shall be borne by the assisted living residence, the contract staffing agency or the individual who is the subject of such check, as appropriate.

A relicensure survey was completed on 6/28/23. A deficiency was cited.

Based on observation and interview, the residence failed to ensure resident rooms occupied by smokers had fire resistant wastebaskets, affecting four residents (#4-#7). Findings include: On 6/28/23 at 9:50 a.m., the health and services coordinator provided a list that identified residents #4-#7 as smokers. On 6/28/23 at 10:00 a.m., an environmental tour revealed the rooms occupied by residents #4-#7 did not contain fire resistant wastebaskets. On 6/28/23 at 10:30 a.m., the administrator stated that smoking in resident rooms was prohibited; however, he was not aware that rooms occupied by smokers were required to contain fire resistant wastebaskets.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.