STONEBRIDGE SENIOR LLC

A licensure complaint, prompted by #CO34765, was completed on 2/7/24. No deficiencies were cited. Although a complaint allegation was substantiated for #CO34765, the residence was not cited with deficient practice given that on 2/7/24, the residence was operating under the terms of an intermediate condition of a consultant imposed by the department who was in process of assisting the residence to correct the deficient practice identified.

A licensure complaint, prompted by #CO34573, #CO34574, #CO34575, #CO34577, #CO34611, was completed on 1/9/24. Deficiencies were cited. Although a complaint allegation was substantiated for <the complaint allegations #CO34573, #CO34574, #CO34575, #CO34577, #CO34611, the residence was not cited with deficient practice given that on 1/9/24, the residence was operating under the terms of an intermediate condition of a consultant imposed by the department who was in process of assisting the residence to correct the deficient practice identified.

Based on record review and interview, the residence failed to ensure appropriate routine staffing levels considering the acuity and needs of the residents, the services outlined in the care plan, and services set forth in the resident agreement, affecting 88 current residents. (Cross-reference Q1068, Q1192, Q1422)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 8.4, requires that staff shall be sufficient in number to help residents needing or potentially needing assistance, considering individual needs such as the risk of accident, hazards, or other challenging events.b. Chapter VII regulations governing assisted living residences, part 12.9, requires the comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status.c. Chapter VII regulations governing assisted living residences, part 12.11, requires the assisted living residence to be responsible for coordinating resident care services with known external service providers.d. The residence's Staffing policy, dated 3/26/18, read in part that a sufficient number of staff were available 24 hours a day. The residence's staffing ratio complied with the state regulatory requirements. f. The residence's undated assessment plan read in part that the residence assessments were completed by nursing staff when a resident experienced a change in condition.g. The undated Residency Agreement read in part that the residence reassessed the resident when the resident experienced a change in condition and updated the resident's care plan to reflect those changes. 2. Determination of StaffingThe residence failed to base their wellness department staffing level on residents' assessed acuity.a. Record ReviewAn undated residence document entitled Labor Hours-Weekly Calculations read in part that the staffing was based on the number of residents who lived at the residence and not the acuity of residents. Personnel records for the former health and wellness director (HWD) 1 read her hire date was 9/14/23, and the end of her employment at the residence was 11/17/23. Personnel records for the former health and wellness director (HWD) 2 read her hire date was 11/27/23, and the end of her employment at the residence was 12/13/23.b. Interviews On 1/9/24 at 8:34 a.m., the interim HWD stated she began the residence a little less than a week prior to the onsite visit. On 1/9/24 at approximately 2:10 p.m., the administrator stated that she began working at the residence at the end of November 2023, and her last day working at the residence was 1/21/24. She added that the residence based their determination of staffing on the regulatory requirements. After reviewing the regulatory requirement, she affirmed the residence based their staffing on resident acuity, which was determined by the assessments of residents. On 1/9/24 at 2:15 p.m., the vice president of clinical services (VPCS) stated that the residence determined acuity based on a formula that did not include the acuity of residents. In a later interview, on 1/9/24 at 3:15 p.m., the VPCS stated that the residence used assessments prior to the corporate entity taking over in November 2023; the residence used assessments to determine staffing based on acuity. On 1/8/24 at 3:42 p.m., a staff member who wished to remain anonymous said one staff member on each shift created the schedule for staff and that the administrator left it to the staff to decide who was working when. S/he added that when she expressed low staffing concerns to the administrator, s/he rarely responded. 3. AssessmentsThe residence failed to conduct assessments. The wellness staff were solely responsible for completing assessments, and the wellness staff failed to have adequate staffing levels to perform the residents' assessments. Assessments established the acuity of the residents and determined staffing levels. a. Resident #1 was admitted to the residence on 6/1/20 with diagnoses including Parkinson's disease. A progress note, dated 12/20/23, read in part, "Spoke with (family member) regarding fall pattern and med (medication) administration. The resident self-medicated after (family member) sets up medications in his med container. (Family member) states (the resident) might miss one dose a week because he falls asleep. The (family member) does not feel this is an issue, this nurse discussed self med assessment and may need to be done if missing doses continues."A progress note on 12/23/23 revealed Resident #1 was found on the floor by his family member and had a scrape on his left wrist. A review of the resident's record revealed no assessments after 12/20/23 after staff noted that the resident was noncompliant with self-administered medications or after 12/23/22 when the resident sustained a fall. On 1/9/24 at 8:42 a.m., the interim HWD stated that a concern she began working on when she started the week before the onsite visit was that the residence failed to complete resident assessments for the majority of residents at the residence. On 1/9/24 at approximately 2:30 p.m., the administrator said she expected the residence nursing department to have reassessed Resident #1 after a noted change in noncompliance with self-medication administration. On 1/9/24 at 3:44 p.m., the VPCS stated that there were no assessments for residents because there had been inconsistent staffing in the nursing department since November 2023, and the residence had failed to complete them. She added that the nursing department staff were solely responsible for assessments of residents. c. Additionally, the residence failed to have a sufficient number of trained staff to assess residents when the resident experienced a change in baseline condition for Residents #2-#4, #36, #37, #39, #40, Former Resident #42.4. Care CoordinationThe residence failed to coordinate care. The wellness staff were solely responsible for care coordination with external service providers (ESPs). The wellness staff failed to have adequate staffing levels to coordinate residents' care with ESPs. a. Resident #36 was admitted to the residence on 9/24/18. On 1/9/24 at 9:51 a.m., Resident #36 was not wearing her oxygen, and two oxygen cylinders were on the floor in her room. A hospital discharge summary, dated 12/18/23, read in part that the resident experienced acute hypoxemic respiratory failure. The requested delivery date for the oxygen was 12/22/23 for one liter per minute when not exerting and one liter per minute during exertion. The resident was discharged back to the residence on 12/22/23. Progress notes in Resident #36's record for December 2023 revealed the following:On 12/18/23, Resident #36 complained of shortness of breath and was sent to the emergency department. On 12/22/23, Resident #36 returned from the residence with orders for one liter of oxygen. "The hospital did not coordinate an O2 (oxygen) delivery." The administrator said to send Resident #36 to the emergency department if she did not have oxygen supplies. On 12/23/23, the oxygen tanks for Resident #36 were still not delivered. The resident's record contained no practitioner order that discontinued oxygen for Resident #36. b. InterviewsOn 1/8/24 at 11:20 a.m., a registered nurse case manager (RNCM) from a hospital stated the residence routinely failed to return telephone calls to coordinate the resident's readmission or discuss the resident's changed care needs. On 1/8/24 at 12:57 p.m., an external agency representative said when she tried to get ahold of someone at the residence, she often could not find anyone to talk to. She added, "I am told no one is in the building, and it's hard to get a hold of management. I will often leave a voicemail."On 1/9/24 at 8:20 a.m., the receptionist stated that she had attempted to get all telephone calls and messages regarding residents to the administrator from the hospital. She added that she sent the telephone calls and messages to the administrator as the residence had no consistent HWD prior to the interim HWD. She added she was unsure whether the hospital was contacted after they called as they continued coordinating the discharge of residents after she relayed the messages. On 1/9/24 at 9:26 a.m., Staff #24 stated she was unsure if Resident #36 required continuous oxygen. She stated that the resident experienced increased unsteadiness since her return to the residence. On 1/9/24 at 10:40 a.m., the interim HWD stated that she had attempted to coordinate with one ESP since she began at the residence the week prior to the onsite visit. She was unaware if the residence had adequate staff trained to coordinate prior to her arrival at the residence. On 1/9/24 at 10:45 a.m., the VPCS stated that she had not conducted coordinated care with the hospital for Resident #36 prior to her readmission. On 1/9/24 at approximately 2:19 p.m., the administrator stated that the nursing staff coordinated care for residents with ESPs such as the hospital. She was unaware that the nursing staff at the residence had not coordinated care for Resident #36 prior to her readmission. On 1/9/24 at 3:44 p.m., in a later interview, the VPCS stated that after reviewing her emails, she learned that the practitioner for Resident #36 stated she required a skilled nursing facility (SNF) prior to returning to the residence on 12/18/23, and that was the last she had heard about the resident. She added she had not spoken to the hospital or coordinated the resident's care prior to the resident's readmission to the residence. She stated she was unaware the resident had returned and stated the residence planned to coordinate care with the hospital prior to the resident's return and that she may currently be at an SNF level of care. She added she planned to reassess the resident immediately. c Additionally, the residence failed to have sufficient trained staff to coordinate resident care services with known external service providers for Resident #21 and Former Resident #41.

Based on observation, record review, and interview, the residence failed to evaluate a resident transferred to another healthcare entity prior to readmission or discharge, affecting two of two sample residents who were at another healthcare entity (#21, #36) and one former resident (#41). (Cross-reference Q0720) Specifically, the residence failed to evaluate Resident #36 prior to readmission after a hospitalization on 11/14/23 when her care needs changed to include increased monitoring of abnormal breathing or symptoms of a cardiac event, including sweating, nausea, and pain in the chest or shoulder. Subsequently, the resident experienced chest pain, shortness of breath, a fall, stomach pain, and left shoulder pain from 11/20/23-12/17/23, and the residence failed to send the resident to the emergency department (ED). The resident returned to the ED on 12/18/23 and was diagnosed with acute respiratory hypoxemia. The resident was discharged from the hospital and readmitted to the residence on 12/22/23 without the residence conducting an evaluation prior to readmission. The hospital directed the resident to continuously use one liter per minute of oxygen at rest and two liters per minute when exerting. The residence failed to evaluate the resident prior to readmission to the residence, and the resident went without oxygen for an undetermined amount of time between 12/23-12/28/23. Findings include: 1. Residency Agreement and Residence Policy The undated Residency Agreement read in part that the resident's service (care) plan was subject to change according to the resident's condition. The residence reevaluated the resident when the resident experienced a change in condition. The residence's undated assessment plan, read in part that the residence assessments were completed by nursing staff when a resident experienced a change in condition. 2. Resident #36 was admitted to the residence on 9/24/18 with diagnoses that included dementia, osteoarthritis of the knee, pain in the right shoulder, and abnormalities of gait and mobility. The resident was readmitted on 11/15/23 with a diagnosis of deep vein thrombosis and elevated cardiac enzymes. The resident was readmitted to the residence on 12/22/23 with a diagnosis of acute hypoxemic respiratory failure. On 1/9/24 at 9:51 a.m., the resident was not wearing oxygen. Two portable oxygen tanks were present in the resident's apartment. Progress notes for Resident #36, dated 11/14/23-1/4/23, read in part: On 11/14/23, the resident was crying and reported difficulty breathing and chest pain; and stated she felt like she was having a heart attack and wanted to go to the hospital. The residence staff contacted emergency medical services (EMS) and transported the resident to the hospital. On 11/14/23, the residence received a call from the resident's case manager and the resident's representative reconsidered hospice evaluation for the resident. On 11/15/23 at 10:12 a.m., the residence nurse spoke with the resident's representative, and the representative shared information regarding the resident's hospitalization and discharge as follows: The hospital recommended cardiac testing and blood transfusion; however, the resident's representative refused the testing and transfusion. The resident's representative expressed a desire for the resident's practitioner to manage the resident's medical needs upon return to the residence; however, the practitioner could not guarantee that the resident would not sustain another cardiac event. The hospital lab work indicated elevated troponin and dangerously low hemoglobin were present. Hospice was discussed with the resident's representative; however, they refused the evaluation. The residence reported to the resident representative that the residence was unable to monitor or provide the recommended treatment to the resident upon discharge as the level of care exceeded that of an assisted living. The resident's representative and case manager were educated that if the resident had a change of condition, EMS would be contacted, and the resident would be transported to the ED. The hospital would then be responsible for seeking appropriate placement of the resident elsewhere. The resident's case manager and representative confirmed understanding. On 11/15/23 at 4:33 p.m., the resident was alert and oriented, made needs known, and denied pain or discomfort. The residence continued to monitor the resident. On 11/20/23 at 5:08 p.m., the resident reported chest pain and had a systolic blood pressure of 72. The residence notified the practitioner administered clonidine and became asymptomatic. The residence did not contact EMS for transportation to the ED.On 11/20/23 at 7:12 p.m., the resident fell and experienced left shoulder pain. The residence did not contact EMS for transportation to the ED.On 12/4/23, the resident tested positive for COVID-19. On 12/12/23, the resident reported a stomach ache. On 12/17/23, the resident reported shortness of breath and refused all meals. The residence did not contact EMS for transportation to the ED.On 12/18/23, the resident reported shortness of breath. The residence contacted EMS for transportation to the ED. On 12/22/23 at 6:26 p.m., the resident returned to the residence with a practitioner's order for one liter of oxygen per minute. The hospital failed to coordinate oxygen delivery. Contacted the residence nurse. On 12/22/23 at 6:38 p.m., the unidentified director stated that the residence staff should send the resident to the ED if she was without the required oxygen. The residence staff contacted the resident representative, who contacted the hospital to coordinate the oxygen delivery. The resident representative stated that the resident had a portable oxygen tank in her room. On 12/23/23 at 5:37 a.m., the hospital sent practitioner orders to an external oxygen provider (EOP); however, they were closed. The EOP planned to deliver the oxygen in the evening. The resident's portable oxygen tank would provide the ordered oxygen for approximately five hours. The residence staff reported concern to the next shift's staff. On 12/28/23, the resident refused to keep her oxygen on. On 12/29/23, the resident fell. The care plan was updated. On 12/31/23, the resident screamed for help. The resident reported pain in her left shoulder; however, she denied any prior injury. The residence administered pain medication. On 12/31/23, the resident had an elevated blood pressure of 169/89 and was administered clonidine, and the pain had lessened; however, it was not reported that it had stopped. On 1/1/24, the resident voiced discomfort. On 1/4/24, the resident fell and was incontinent of bowel. The progress notes, dated 11/14/23-1/4/23, contained no documentation of evaluation of the resident prior to her return to the residence on 11/15/23, and 12/22/23, respectively. Further, the progress notes contained no evidence of communication with the discharging hospital regarding the resident's changed care needs. A hospital discharge summary, dated 11/14/23, read in part that the resident experienced chest pain, abnormally elevated cardiac enzymes, which indicated a cardiac problem, anemia, which indicated possible gastrointestinal bleeding, and an acute deep vein thrombosis in the leg. The hospital communicated with the resident's representative and case manager. The aftercare instructions included raising feet five or six inches with a foam wedge while in bed and monitoring abnormal breathing, black or bloody stool, dizziness, leg pain or swelling, or shortness of breath. Signs of a cardiac event to monitor included sweating, nausea, and pain in the chest, shoulder, neck, arms, or jaw. An EMS report, dated 12/18/23 at 11:53 a.m., read in part that the resident was short of breath and skin pain. She had an oxygen saturation of 86% and was placed on oxygen, and her oxygen saturation rose to 98%. The resident had no respiratory concerns after the use of oxygen. The resident was transported to the ED. A second EMS report, dated 12/18/23 at 11:55 a.m., read in part that the resident reported dyspnea and had a cough since earlier in the morning. The resident reported no prior respiratory history. The residence reported that the resident went to the hospital two weeks prior and returned with a diagnosis of pneumonia. Medications were ordered; however, the resident had not received them from that prior hospitalization. The resident was transported to the ED. A hospital discharge summary, dated 12/18/23, read in part that the resident experienced acute hypoxemic respiratory failure and a history of COVID-19. The treatment and equipment for home included oxygen with the instructions that the plan was for the resident to call the EOP after she arrived home. The requested delivery date for the oxygen was 12/22/23 for one liter per minute when not exerting, and one liter per minute during exertion. The resident was discharged back to the residence on 12/22/23. The record for Resident #36 revealed no documented assessments conducted by the residence prior to readmission from the hospital on 11/15/23 and 12/22/23. The care plan, updated 12/29/23, read in part that the care plan was updated approximately five weeks after the resident experienced a fall, and the update solely included that the residence planned to analyze the resident's falls to determine a trend or pattern. The care plan further revealed the residence failed to update it to include after-hospitalization instructions for raising feet five or six inches with a foam wedge while in bed. The residence failed to update the care plan to indicate the residence was monitoring abnormal breathing, black or bloody stool, leg pain or swelling, shortness of breath, and signs related to a heart attack, such as pain in the chest, shoulder, neck, arms, or jaw. The care plan was not updated to include the resident's oxygen use or what to do in the event of the resident's non-compliance with the oxygen. 3. InterviewsOn 1/8/24 at 11:20 a.m., a registered nurse case manager (RNCM) from the hospital stated that she was unaware of an instance when the residence evaluated a hospitalized resident prior to readmission to the residence. She added the residence routinely failed to return telephone calls to coordinate the resident's readmission or discuss the resident's changed care needs. On 1/8/24 at 12:57 p.m., an external agency representative said when she tried to contact someone at the residence she often could not find anyone to talk to. She added, "I am told no one is in the building, and it's hard to get ahold of management. I will often leave a voicemail."On 1/8/24 at approximately 1:00 p.m., the interim health and wellness director (HWD) stated that before she worked at the residence, all assessments conducted by the residence were completed on paper and were in the resident's record. On 1/9/24 at 8:20 a.m., the receptionist stated that she had attempted to get all telephone calls and messages to the administrator from the hospital regarding discharging residents. She added that she sent the telephone calls and messages to the administrator as the residence had no consistent HWD prior to the interim HWD who began a little less than the week before the onsite visit. She added she was unsure whether the hospital was contacted after they telephoned as they continued to coordinate the discharge of residents after she relayed the messages. On 1/9/24 at 8:34 a.m., the interim HWD stated she began working at the residence a little less than a week prior to the onsite visit. She stated that one of the most significant issues she identified at the residence was that the residence had not conducted assessments or updated care plans. On 1/9/24 at 8:42 a.m., another external agency representative said it was difficult to contact a manager at the residence when she required questions to be answered. On 1/9/24 at 9:26 a.m., Staff #24 stated that Resident #36had a change in condition after her hospitalization. She added that Resident #36 had not been compliant with wearing oxygen and assumed that she was required to wear it continuously; however, she was unsure if the resident was required to wear oxygen continuously. She stated that the resident experienced increased unsteadiness since her return to the residence. On 1/9/24 at 10:40 a.m., the interim HWD stated that she had not evaluated any resident in person prior to readmission to the residence. She added that only one resident had been readmitted to the residence since she began, and she had attempted to coordinate with the practitioner and the skilled nursing facility (SNF) prior to his readmission but had not evaluated him in person. She stated that the residence expectation was to evaluate residents in person prior to readmission. On 1/9/24 at 10:45 a.m., the vice president of clinical services (VPCS) stated that the residence was required to evaluate residents prior to readmission. She stated that the residence expected to conduct an in-person evaluation when necessary. She affirmed that an in-person evaluation was required if there was a possibility that the resident needed a higher level of care or had changed care needs. She stated she had not evaluated Resident #36 prior to her readmission. On 1/9/24 at 3:44 p.m., the VPCS, in a later interview, stated that after reviewing her emails, she learned that the practitioner for Resident #36 stated she required a skilled nursing facility (SNF) prior to returning to the residence on 12/18/23, and that was the last she had heard about the resident. She was unaware the resident had returned to the residence and stated the residence planned to conduct an assessment as soon as possible to determine her needs. She affirmed the residence should have evaluated the resident prior to her return to the residence. On 1/9/24 at approximately 2:19 p.m., the administrator stated that the nursing staff evaluated residents prior to readmission after the resident was in a different healthcare setting. She added that the nursing staff reviewed the residents' paperwork and evaluated them to see if there was a concern. She was unaware that the nursing staff at the residence had not evaluated Resident #36 prior to her readmission. 4. Additionally, the residence failed to evaluate a resident transferred to another health care entity prior to readmission or discharge for Resident #21 or Former Resident #41.

Based on record review and interview, the residence failed to ensure trained staff evaluated residents who had fallen to determine if the resident could be assisted safely, affecting two of two sample residents who experienced head trauma and reported pain (#21, #37). (Cross-reference Q0720)Specifically, Resident #21 fell on 12/28/23, hit her head, sustained a raised bump above her left eye, and reported significant pain. The residence staff lifted the resident despite the direction from the residence's lift assistance policy that read the staff were not to lift a resident when the resident experienced head trauma. The resident subsequently experienced increased swelling around her eye and was sent to the emergency department. At the emergency department, she was diagnosed with multiple rib fractures and a subdermal hematoma. Specifically, Resident #37 fell on 12/29/23; the resident hit his head after he waited approximately one hour for a staff response. Once staff responded, the resident reported he hit his head when he fell and felt continued pain. The residence staff lifted him, and the resident reported continued pain during the onsite visit on 1/9/24. Findings include: 1. Residence Policy The residence's Accidents and Incidents No Lift Policy, dated 3/26/18, read in part that the residence provided a safe environment and ensured emergency care for residents when necessary. The residence summoned emergency medical services when a resident experienced head trauma. After a resident sustained a fall, the residence contacted the resident's practitioner for further instruction and provided frequent checks. Further, the residence completed an incident report, and updated the resident's care plan after the resident fell. 2. Resident #21 was admitted to the residence on 5/19/22 with a diagnosis of dementia. A progress note, dated 12/28/23, read in part: At 6:16 a.m., the resident fell at approximately 5:30 a.m. The residence staff conducted an evaluation. The resident had a bump above her left eye, left knee soreness, and a reported pain level of 8/10 from the fall. The residence staff lifted the resident and placed her back in bed. The residence notified the resident's representative and the administrator. At 12:23 p.m., the resident's left eye had increased swelling. The resident had not eaten breakfast or lunch. The resident reported pain on the left side of her body. The residence notified the resident representative, and the representative requested that the residence send the resident to the emergency department (ED). A hospital occupational therapy evaluation, dated 12/29/23, read in part that the resident presented at the ED from the residence after a witnessed fall. The resident fell forward and hit her head. The patient experienced several acute rib fractures, injury to the left orbital, and a subdural hematoma. The resident reported continued pain. 3. Staff TrainingA personnel file for Staff #21 contained no hire date or documented lift-assistance training. A residence in-service for community procedures, including lift assistance, dated 12/13/24, revealed that Staff #21 and #23 were absent. 4. InterviewsOn 1/8/24 at 7:50 a.m., Staff #22 stated that Resident #21 fell with an injury approximately two weeks prior to the onsite visit and went to the hospital. On 1/8/24 at 8:03 a.m., Staff #6 stated that Resident #21 fell approximately one or two weeks prior to the onsite visit. She stated she was absent during the fall, as it occurred before the morning shift began. She added that the resident was injured and went to the hospital. On 1/9/24 at 7:50 a.m., Staff #8 stated Resident #21 had a fall during the overnight shift. She said she was told that Resident #1 fell out of bed but noticed when she administered her medications in the morning that Resident #21 "didn't seem right," complained of pain in her shoulder, and had a knot on her head. On 1/8/24 at 11:20 a.m., a registered nurse case manager (RNCM) from the hospital stated that Resident #21 fell, hit her head, and sustained a subdural hematoma and fractured ribs on 12/28/23. On 1/8/23 at approximately 12:00 p.m., the representative for Resident #21 stated that the residence contacted a different family member listed as an emergency contact when Resident #21 fell on 12/28/23. On 1/8/24 at approximately 12:15 p.m., a family member of Resident #21 stated that she received a telephone call from the residence at approximately 6:30 a.m. the staff reported that the resident fell. She stated that the residence failed to report the bump above the resident's eye or the pain the resident felt. She added that she would have advised sending the resident to the ED if the residence told her that the resident had an injury and pain. She added the residence reported that they lifted the resident and assisted her back into her bed after the fall. On 1/8/24 at 12:29 p.m., Staff #21 stated that Resident #21 fell on 12/28/23. Staff #21 affirmed that the resident fell at about 5:30 a.m. He added that he entered the room, and an unidentified staff member and Staff #23 were present. He added he saw that the resident had fallen and that she was on the floor. He stated that the resident had a new bump above her eye. He stated that they evaluated the resident, and she reported pain but had no visible injury, contrary to the stated observation of the bump above the resident's eye. He added that he, the unidentified staff, and Staff #23 lifted the resident. He stated that Staff #23 notified the resident's representative. He stated that he was unaware of any management notification since the residence had no regular nurse. On 1/9/24 at approximately 10:20 a.m., the interim health and wellness director (HWD) stated that residence staff should have never lifted any resident who reported pain or hit their head. She added she was unaware it occurred to Resident #21 as she began working at the residence a little less than a week prior to the onsite visit. On 1/9/24 at approximately 10:40 a.m., the vice president of clinical services (VPCS) stated she was unaware that residence staff lifted Resident #21 while she was injured or in pain. She added that the residence staff should have contacted her or the other corporate-level nurse to advise the staff. She stated that if the staff could not reach them, they should have contacted the resident's practitioner for direction on lifting the resident. She added that, at the very least, the staff should have contacted emergency medical services (EMS) to advise and assist. She added the residence staff should never lift a resident who reported pain or was injured. On 1/9/24 at approximately 2:19 p.m., the administrator stated that residence staff should not lift a resident when the resident experienced pain or bumped her head. 4. Additionally, the residence failed to ensure that trained staff evaluated residents who had fallen to determine if the resident could be assisted safely for Resident #37 after he fell and hit his head.

A licensure complaint, prompted by #CO34378, #CO34387, #CO34391, #CO34406 and #CO34409, was completed on 12/13/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure each staff member received all required training prior to providing any care or services to residents, affecting two of three sample staff (#16, #17). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" means employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.b. The residence's Staffing and Basic Training policy, dated July 2021 read, in part, "All employees will have sufficient orientation and training to provide for the needs of the residents including those with dementia as outlined in specific requirements. The employee will have basic training on the following prior to beginning their job responsibilities: resident rights and the values of community-based care, abuse reporting requirements, fire safety and emergency procedures, standard precautions for infection control, their specific job description with specific duties and responsibilities."2. Record ReviewThe December 2023 contracted staffing schedule revealed the following:Staff #16 and #17 worked on 12/7/23. Staff #16 worked on 12/8/23. Personnel files for Staff #16 and #17 revealed no initial orientation training prior to providing any care or services to residents. 3. ObservationOn 12/12/23 from approximately 7:00 a.m. to 5:00 p.m., Staff #16 and Staff #17 were observed providing care and services to residents. 4. InterviewsOn 12/12/23 at 7:54 a.m., Staff #17 said she was considered contracted staff and that another contracted staff member trained her on resident specific duties only and no other training was provided. She added she was unsure where resident care plans were located and had access to the residence's electronic documentation system but never used it. On 12/12/23 at 8:16 a.m., Staff #16 stated she was a contracted staff member and that the training she received was from another contracted staff member who had trained her on resident specific duties only. She confirmed that no other training was provided, as required. She added that she was given a daily task sheet for the residents whom she was assigned to. On 12/13/23 at 1:16 p.m., the administrator said contracted staff were the same as the residence staff and expected them to have orientation training, as required.

Based on interview and record review, the residence failed to ensure residents had the right to be free from neglect, affecting one of eight sample residents (#30). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.10, defines "Caretaker Neglect" as: neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person.b. The residence's undated posted Resident Rights read, in part, "To be free of abuse from staff, family, visitors, or other residents. This includes ... neglect."2. Resident #30 was admitted to the residence on 1/14/23 with diagnoses including vascular dementia, anxiety, osteoporosis, glaucoma and hypertension. Progress notes for November 2023 in Resident #30's record revealed the following:On 11/29/23 at 4:51 a.m.: Resident #30 was found on the floor of her bedroom in front of her bed. Resident #30 said she slid onto the floor. On 11/29/23 at 6:40 p.m.: Resident #30 was sent to the emergency department. A care plan for Resident #30, dated 6/6/23, read Resident #30 was at risk for falls related to her dementia diagnoses and required routine safety checks. An external email communication from Resident #30's family member to the residence on 11/29/23 at 8:59 a.m., read, Resident #30 was on the floor on 11/28/23 at 8:30 p.m. and was found to still be on the floor on 11/29/23 at 4:13 a.m. and was not checked on by staff for over eight hours. The family member provided screen shots of the camera that was in Resident #30's room as evidence and revealed the following:On 11/28/23 at 8:31 p.m. Resident #30 was seated on the floor in front of her recliner. On 11/28/23 Resident #30 was still seated on the floor at 9:55 p.m. On 11/29/23 Resident #30 was still seated on the floor at 3:40 a.m. and 4:02 a.m. At 4:13 a.m., Former Staff #20 entered Resident #30's room. The residence's neglect investigation documents and interviews from 11/29/23 revealed Former Staff #20 did not conduct safety checks (at least once during that time period), as required on 11/28 and 11/29/23 from approximately 8:30 p.m. to 4:13 a.m. 3. InterviewsOn 12/12/23 at 1:54 p.m., a family member of Resident #30 said on 11/29/23 in the morning she received a telephone call that her mother was found on the floor. She added she reviewed the camera footage in Resident #30's room and saw Resident #30 was on the floor for eight hours and no staff member checked on her. On 12/13/23 at 12:56 p.m., the director of nursing services said she expected Resident #30 to be checked on every two hours. On 12/13/23 at 1:16 p.m., the administrator acknowledged Resident #30 was neglected and left on the floor for eight hours and expected staff to check on her, as required.

Based on observations, interviews and record review, the residence failed to ensure meals included a variety of foods, were nutritionally balanced and that appealing substitutes of similar nutritive value were available, affecting 103 current residents. Findings include: 1. Reference According to Healthline, "eating a healthy diet consists of not consuming a high amount of 'empty calories', this means they have little nutritional value. Instead they give your body mostly solid fats and added sugars, which can lead to weight gain and nutritional deficiencies ... these foods provide nothing of value to your body beyond calories that create excess pounds ... avoid cakes, cookies, donuts, cheese, ice cream, meats like sausage, bacon, pizza, burgers, and french fries ... instead try fresh fruits, vegetables, whole grain bread and pasta, eggs, beans, fish, poultry and low-fat milk cheeses and yogurt." Healthline (5/7/19) Recognizing and Avoiding Empty Calories, retrieved from: https://www.healthline.com/health/food-nutrition/empty-calories#what-to-eat 2. Record Review The residence's weekly menu, dated 12/10-12/16/23, read in part: Breakfast: DonutsHowever, there were no other varieties of food that were nutritionally balanced or appealing substitutes of similar nutritive value were included. 4. ObservationsOn 12/12/23 from approximately 7:00 a.m. - 9:00 a.m., during breakfast meal service in the assisted living, staff served donuts. Additionally, staff did not serve or offer any other food. On 12/12/23 from approximately 7:30 a.m. to 9:00 a.m., during breakfast in the residence's secure environment, staff served donuts, sausage patties, sausage links and bacon. On 12/12/23 at 8:00 a.m, Resident #28 had two donuts served to him on a plate. On 12/12/23 at 8:10 a.m., Resident #33 had one donut served to her on a plate. On 12/12/23 at 8:39 a.m., Resident #29 had two donuts on a plate for breakfast. 5. InterviewsOn 12/12/23 at 7:30 a.m, Staff #18 stated the breakfast was a donut special that included one donut unless otherwise requested. On 12/12/23 at 7:56 a.m., Resident #20 stated that the options and choices provided on the residence's menu were sparse and that it was a 'hit and miss' for nourishing meals. On 12/12/23 at 8:07 a.m., Staff #19 said it would have been a good idea to offer fruit, when asked if there was fresh fruit available for residents in addition to the donut and pork offerings. On 12/12/23 at 1:54 p.m., a family member of Resident #30 said the residence did not offer fresh fruit to residents at meals. On 12/12/23 at 10:09 a.m., a family member of Resident #31 said the residence did not have consistent nutritious foods offered to residents at meals. On 12/13/23 at 1:17 p.m., the administrator stated that the five food groups should be represented in all three meals. She added donuts are 'fun'; however, acknowledged they are not nutritious in value, as required.

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 7.7.8 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows:(B) The assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self-study courses, or on-the-job training, and shall include, but is not limited to, the following topics:(1) Overview of state regulatory oversight applicable to the assisted living residence;(2) Person-centered care;(3) The role of and communication with external service providers;(4) Recognizing behavioral expression and management techniques, as appropriate for the population being served;(5) How to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, as appropriate for the population being served;(6) Training related to fall prevention and ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobility;(7) How to safely provide lift assistance, accompaniment, and transport of residents;(8) Maintenance of a clean, safe and healthy environment including appropriate cleaning techniques;(9) Food safety; and(10) Understanding the staff or volunteer ' s role in end of life care including hospice and palliative care. 12.12 The assisted living residence shall notify the resident's representative whenever the resident experiences a significant change from baseline status.