RIDGE PINEHURST LLC

A licensure revisit was completed on 1/7/25 for the previous deficiencies cited on 6/21/23. The residence is in compliance with all regulations surveyed.

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

A complaint revisit was completed on 1/7/25 for all previous deficiencies cited on 6/21/23. A deficiency was 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

Based on record review, interviews, and observations the residence failed to detail in each resident's care plan the individualized approach necessary to address fall risks, affecting two of six sample residents (#44, #50). This deficiency was cited previously during a complaint revisit on 6/21/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #50 was admitted to the residence on 5/9/23 with diagnoses including muscle weakness, osteoarthritis and anemia. The resident fell six times between 10/14 and 12/31/24. Five of these falls resulted in injuries such as bruises, knee pain, head injury, pain in the back, legs, knees and hips, and a skin tear. There were care plans dated 6/1/24, 11/13/24 and 1/2/25, however, the care plans were not updated after falls with individualized approaches necessary to address all the falls the resident experienced. Findings include:1. Residence PolicyThe Residence Fall Reduction and Management policy, undated, read: "Reduction of falls is the responsibility of all associates. The assisted living director or designee will investigate the fall with the intention of reducing the incidents of falls for the person who fell. Changes to service plans will be made, as needed." 2. Resident #50 was admitted to the residence on 5/9/23 with diagnoses of muscle weakness, osteoarthritis, and anemia. a. Record ReviewA residence care plan with fall interventions, revised 6/1/24, read that Resident #50 was not able to ambulate long distances without guidance, used her walker for ambulation, and was independent with ambulation. The care plan read that Resident #50 was educated to lock her brakes on her wheelchair, wear gripper socks, ensure her walker was close by, and call for assistance with the bathroom during the night. The care plan, revised 6/1/24, read that Resident #50 lived with moderate dementia and moderate disorientation with difficulty recalling information. A progress note, dated 10/14/24 read that Resident #50 was "sitting up on her bottom leaning up against her recliner in her living room. Resident (#50) had no shoes on and no socks. Noticed there was a tiny skin tear the size of a grain of rice on Resident's (#50) right foot. Resident ' s wheelchair was next to her unlocked. Resident did not push her pendant."A document labeled Levels of Care Evaluation: Section 9, dated 10/14/24, read that Resident #50 was not showing signs of pain and required safety checks every 1 to 3 hours. A progress note dated 11/11/24 read that Resident #50 was found on the floor hanging onto the sliding bathroom door handle with one hand. Resident #50 had her walker next to her and her wheel chair was in the living room. Resident #50 had her slippers on. There was a bruise on Resident #50 ' s hand. Another progress note dated 11/11/24 read that Resident #50 had a large bruise on her right hand around her thumb and part of her hand, and that Resident #50 stated that her knee hurt. The note stated to increase toilet checks for a fall intervention. A document labeled Levels of Care Evaluation: Section 9, dated 11/11/24, read that Resident #50 was not showing signs of pain and required safety checks every 1 to 3 hours. An incident report dated 11/12/24 read that Resident #50 was found on the floor next to her fridge with a spilled drink on the floor. Resident #50 stated that she could not remember how she fell. The caregiver and the qualified medication administration personnel (QMAP) assisted Resident #50 to her wheelchair. Although Resident #50 was not complaining of pain the incident report noted a closed head injury to the top of Resident #50 ' s scalp with altered consciousness. A residence care plan with fall interventions, revised on 11/13/23, read that Resident #50 had balance issues and weakness. The fall interventions read that Resident #50 needed safety checks but did not specify how frequent and that Resident #50 was encouraged to call for assistance. A progress note dated 11/18/24 read that Resident #50 had a large skin discoloration on her left upper arm and that it was determined to be due to her recent falls and being on blood thinners. An incident report dated 12/8/24 read that Resident #50 was found on her bathroom floor with no clothes on, leaning against her bathroom wall. Resident #50 ' s wheelchair was in her shower with the brakes unlocked. Resident #50 was unable to describe how she fell or if she hit her head when she fell. Resident #50 was complaining of pain in her back, legs, and hips at the time of the fall, however the incident report did not have any injuries marked. A document labeled Levels of Care Evaluation: Section 9, dated 12/9/24, read that Resident #50 was not showing signs of pain and required safety checks every 1 to 3 hours. A progress note dated 12/19/24 read that Resident #50 was found, after pressing her pendant, laying on the floor in front of the foot of her bed on her left side. Resident #50 had her wheelchair and walker located on the other side of the room. Resident #50 was unable to recall how she fell. An incident report dated 12/30/24 read that Resident #50 was found on the floor by the front door of her apartment lying on her right side. Resident #50 complained of pain in both of her knees and was unsure of how she ended up on the floor. A progress note dated 12/31/24 read that Resident #50 was found on the ground during checks laying on her left side with her wheelchair tipped over and that Resident #50 was soiled. After Resident #50 was assisted to the bathroom staff discovered significant bruising along Resident #50 ' s right hip and on both knees. The residence most recent care plan for Resident #50, revised 1/2/24, read that Resident #50 was re-educated to wear nonslip footwear, alert care providers if help was needed, and lock her wheelchair brakes. A document presented to the surveyor, on 1/7/25, showed caregiver tasks. The caregiver tasks showed that the only fall interventions for Resident #50 were to check the resident every one to three hours. This did not correlate with the updated care plan fall interventions revised on 1/2/25. 4. InterviewsOn 1/7/25 at approximately 12:00 p.m., the assisted living director stated that after every fall that a resident had, fall interventions were supposed to be put in place. Additionally, the assisted living director stated that two to three hour checks were used for all residents and were not classified as frequent checks, despite this statement, the assisted living director then stated that two to three hour checks were classified as frequent time checks and that most residents that were independent did not get checked. The assisted living director also stated external care services provided safety checks for Resident #50. On 1/7/25 at approximately 1:00 p.m., Staff #34 stated that Resident #50 had external care services and the external care services managed most of the fall care for Resident #50. She stated that they conducted one to two hour checks for Resident #50. Staff #34 stated fall interventions were found under her task list and that the task list was directly linked to Resident #50 ' s care plan. On 1/7/25 at approximately 2:30 p.m., the administrator stated that he considered a skin tear, a bruise, and a fall an injury, and that interventions for falls were documented in order to determine the reason the resident had the falls. He expected interventions updated in the care plan each time a fall had occurred because the falls could be for different reasons. 5. Similar deficient practice was found with Resident #44.

A licensure complaint, prompted by #CO35454 was completed on 4/3/24. Although a complaint allegation was substantiated for the complaint allegations, the residence was not cited with deficient practice given that on 4/3/24, 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 revisit survey was completed on 3/19/24 for all previous deficiencies cited on 1/2/24. No deficiencies were cited.

A licensure complaint, prompted by #CO34543, was completed on 1/2/24. A deficiency was cited.

5. Resident #47 was admitted to the residence on 6/4/22. The emergency call system response times in December 2023 for Resident #47 revealed he waited more than 20 minutes for staff assistance, as follows:12/1/23 at 2:32 p.m. for 33 minutes12/7/23 at 8:47 p.m. for 23 minutes12/7/23 at 9:22 p.m. for 29 minutes12/9/23 at 8:44 p.m. for 21 minutes12/21/23 at 1:55 p.m. for 22 minutes12/23/23 at 7:30 a.m. for 23 minutes12/23/23 at 10:01 p.m. for 25 minutes12/24/23 at 7:24 a.m. for 24 minutes12/25/23 at 7:30 a.m. for 38 minutes12/26/23 at 7:23 a.m. for 21 minutes 12/26/23 at 5:52 p.m. for 24 minutes12/28/23 at 9:05 p.m. for 32 minutes12/29/23 at 6:22 p.m. for 33 minutesThe care plan for Resident #47, dated 1/2/24 read he required assistance from staff with transfers to and from the bathroom, bed, dressing and mobility. On 1/2/24 at 1:47 p.m., a family member of Resident #47 said when his father requested assistance from staff he had recently waited in bed for 45 minutes and the average wait was up to 30 minutes in the morning. He added staff helped Resident #47 to the bathroom, in and out of bed and assisted him to breakfast. 6. Interviews On 1/2/24 at 10:18 a.m., Staff #32 stated when a resident pushed their pendant for assistance, there should only be a five minute wait time. On 1/2/24 at 2:50 p.m., the administrator said she expected staff to respond to residents' emergency call system requests within 10 minutes and acknowledged a response between 20-30 minutes was a long time. Based on observation, interview and record review, the residence failed to ensure the residents received the cooperation of the residence to achieve the maximum degree of benefit, affecting four of five sample residents (#39, #40, #41, #47) who utilized their emergency call system to summon staff assistance. Findings include 1. Residence PolicyThe residence's Resident Rights policy, dated October 2022, read, in part, "You have the right to choice and personal involvement regarding care and services including ... The right to expect the cooperation of the community in achieving the maximum degree of benefit from those services which are made available by the community." 2. Resident #41 was admitted to the residence on 8/29/23. The December 2023 alarm Response Report for Resident #41 read she pressed her pendant nine times with wait times longer than 20 minutes. 12/1/23 at 2:03 p.m. for 32 minutes12/2/23 at 7:38 p.m. for 32 minutes 12/3/23 at 8:17 a.m. for 3 hours12/12/23 at 1:59 p.m. for 23 minutes 12/17/23 at 7:31 a.m. for 20 minutes12/22/23 at 4:30 p.m. for 31 minutes 12/26/23 at 6:36 p.m. for 37 minutes12/31/23 at 8:16 p.m. for 29 minutesThe care plan for Resident #41 dated 8/29/23 read she required assistance from staff with transfers to and from bed, toileting, changing, mobility, and home management. On 1/2/24 at 8:16 a.m., Resident #41 stated she waited ten to fifteen minutes for staff to assist her after she had pressed her pendant and often calls the front desk for assistance when staff has taken too long. On 1/2/23 at 2:50 p.m., the administrator stated Resident #41 waited long periods of time for staff assistance when she summoned staff for help using her emergency call system. 3. Resident #39 was admitted to the residence on 2/22/23. The December 2023 alarm Response Report for Resident #39 read he pressed his pendant two times with wait times longer than 20 minutes. 12/1/23 at 2:11 p.m. for one hour 12/31/23 at 4:28 p.m for 20 minutesThe care plan for Resident #39 dated 2/18/23 read he needed assistance from staff with toileting, bathing, mobility and partial assistance with grooming and hygiene. On 1/2/24 Resident #39 stated he waited for long periods of time after pressing his pendant to discard his urinal and cleaning after toileting. 4. Resident #40 was admitted to the residence on 12/20/23.a. ObservationsOn 1/2/24 at 10:27 a.m., to 10:37 a.m., Resident #41's pendant was pressed, after ten minutes, Staff #31 came to the room to assist. On 1/2/24 at 11:01 a.m. to 11:32 a.m., Resident #40's pendant was pressed however, not answered.

A licensure complaint, prompted by #CO33417 and #CO33436, was completed on 9/14/23. Deficiencies were cited.

Based on record review and interview, the residence failed to update the comprehensive assessment when a resident's condition changed from baseline status, affecting one former resident (#6). Findings include:1. Residence PolicyThe residence's comprehensive assessment policy, dated January 2023, read in part that the memory support director (MSD) completed and signed a comprehensive assessment when a resident's condition changed from baseline status. The policy did not read that the residence updated the comprehensive assessment only when the change in condition exceeded 14 days. 2. Record ReviewAn assessment, dated 6/26/23, read in part that the resident did not report unmanaged pain or show any signs of pain. It further read that the former resident lived with acute/chronic wrist pain that it was managed at a tolerable level with assistance from staff. Additionally, the former resident did not have any present swelling in her upper extremities. A progress note, dated 8/6/23, read in part that the resident fell and was "unable to identify the pain location." She was holding her right wrist and staff noticed a minor scratch on the resident's right wrist. A progress note, dated 8/7/23, read in part: "The resident did not verbalize pain or discomfort until I held her right hand. No swelling is noted."A progress note, dated 8/8/23, read in part that the resident denied any pain or discomfort. There was no noted swelling to her wrist. A progress note, dated 8/11/23 read: "Please have resident wrist splint for (eight) hours until 8/14 then DC (discontinue) one time a day for support for swollen wrist until 8/14/23." It further read that the external services provider (ESP) nurse stated 8/11/23 was the last day to wear the wrist splint. A progress note, dated 8/12/23, read in part that the wrist splint to support the former resident's swollen wrist was discontinued on 8/11/23. A progress note, dated 8/15/23, read in part: Post fall observation: the resident did not want to get out of bed. She appeared to be in pain, and the ESP nurse ordered new medication to manage the pain. The residence provided no evidence that a comprehensive assessment was updated when Former Resident #6 fell on 8/6/23 and subsequently experienced increased pain and swelling in her right wrist. 3. InterviewOn 9/12/23 at 10:26 a.m., the MSD stated that Former Resident #6 experienced wrist pain and swelling within the days after her fall on 8/6/23. She stated she did not update the comprehensive assessment because the former resident's health declined so quickly. On 9/13/23 at approximately 4:00 p.m., the administrator stated it was the memory support director's responsibility to update assessments when residents had a change in baseline status. She stated the residence's policy required that they update the comprehensive assessment only when the residents' change in baseline exceeded 14 days, so they were not required to update the assessment when they returned to baseline within that 14 day time frame. The administrator stated she considered the swelling and pain in Former Resident #6's wrist to be a change in baseline status. She added that because it was not a long term or permanent change, the staff monitored it for 72 hours but did not update the comprehensive assessment for Former Resident #6.

Based on observation, record review, and interview, the residence failed to investigate all allegations of abuse in accordance with Part 5.3 and its written policy, affecting one former resident (#6). Findings include:1. References and Residence Policya. The residence's undated abuse policy read in part that the residence investigated and responded to actual and suspected abuse; the residence met the requirements of state law in its response to actual or suspected abuse. With reports of allegations of abuse, the residence completed an investigation. Furthermore, it read "abuse" was defined as a person knowingly or intentionally causing harm or attempting to cause harm; "harm" was defined a pain, mental anguish, emotional distress, hurt, physical damage or physical injury. The administrator or designee ensured that regulatory agencies were notified of actual or suspected abuse within the timeframe required by the regulation.b. Chapter VII regulations governing assisted living residences, Part 2.1, defines "abuse" as the non-accidental infliction of bodily injury, serious bodily injury, or death. 2. Record ReviewAn incident report, dated 8/6/23 at 7:40 a.m., read in part that residents were preparing for breakfast and were gathered around each other at the round table, and some were showing signs of agitation. Former Resident #6 appeared to enter the crowded area, causing her to lose gait/mobility leading her to fall on the floor onto the right side of her body. A progress note, dated 8/6/23 at 10:18 a.m., read similarly to what was documented in the above incident report. 3. Observations a. Video surveillanceOn 9/13/23 at 11:53 a.m., the Information Technology/Maintenance Assistant (ITMA) brought a laptop computer to play the video surveillance of Former Resident #6's fall. The footage was dated 8/6/23 at 7:39 a.m. The footage revealed that a resident (identified by the memory support director [MSD] as Former Resident #6) was standing facing a wall in the secure environment's dining area. There were no ambulatory devices observed in the area. The wall obstructed the view of another person, who reached out their arm and applied force with her hand to the former resident's chest area. The person's arm became visible in the footage and donned a black long-sleeved shirt. The force of the pressure applied by the person resulted in Former Resident #6 losing her balance and falling backward onto the floor. Former Resident #6 was not walking at this time. A person (identified by the MSD as Resident #4) appeared to walk from behind the wall and away from the scene, immediately after the incident. The person identified as Resident #4 was wearing a long-sleeved black shirt. b. Electronic messagesAn electronic message, dated 8/6/23 at 7:21 p.m. and sent from the administrator to Former Resident #6's family member, read in part: "I got your voicemail. I hear the concern in your voice, which worries me." The administrator provided the email addresses for both herself and the associate executive director (AED). An electronic message, dated 8/6/23 at 8:51 p.m. and sent from Former Resident #6's family member to the administrator, read in part that the family member had left a voicemail message with the administrator. It further read: "I was disappointed in the lack of interaction or concern I received regarding the fall incident by [the former memory support director (MSD)] ... (Former Resident #6's) perception of what happened was she was pushed and beat on then fell. I understand the nature of (the former resident's) disease, and her perceptions may be different than (sic) what did happen but should be considered and checked on."An electronic message, dated 8/6/23 at 8:51 p.m. and sent from Former Resident #6's family member to the MSD read that the family member had forwarded to her the same electronic message that she had sent to the administrator. An electronic message from the AED to the family member read: "Thank you. I will review it upon my arrival."c. Occurrence reportingA review of the department's occurrence database on 9/13/23 revealed that the residence did not report the allegation of abuse that occurred on 8/6/23. On 9/13/23 at 1:41 p.m., an electronic message from a department representative read in part that the event was reportable when the alleged aggressor acted with intent and there was injury and/or risk for serious injury to the alleged victim. 4. Record ReviewA progress note, dated 8/10/23 at 6:56 p.m., included an electronic message that was sent from Former Resident #6's family member to the MSD. It read in part that the family member was requesting to see the video footage from the day the former resident fell (8/6/23). It read that the family member and her siblings were relayed various accounts of the incident from different staff, including that she was pushed or that she tripped on her walker (even though she did not use one). 5. Interviewsa. Interviews upon viewing video surveillanceOn 8/13/23 from approximately 11:53 a.m.to 12:15 p.m., video surveillance was viewed with the ITMA, the MSD, and the administrator. The following were comments made while viewing the footage:At approximately 11:53 a.m., the ITMA stated it "looks like she pushed her. I see it." He added that it looked like a resident caused Former Resident #6 to fall down by pushing her on the shoulder or the chest. He stated that it looked like the resident wanted her out of her way. The ITMA stated, "When the three of us (the administrator, MSD, and himself) watched (in August 2023), we didn't see the hand." He acknowledged that what he saw in the footage on the date of the on site investigation was considered abuse. At approximately 12:00 p.m., the MSD stated that she saw an arm with a dark sleeve on it, adding "someone pushed her." She stated when she and the administrator initially watched the video in early August 2023, neither she nor the administrator saw the arm extend from behind the wall and push Former Resident #6. The MSD stated that it was considered abuse when a resident pushed another resident. She stated that no one initiated an investigation on 8/6/23 because no one saw that Former Resident #6 was pushed in the video footage when they watched it. The MSD stated that the administrator and the associate executive director were responsible for reporting occurrences to the department. At 12:08 p.m., the administrator stated she watched the video surveillance of the incident on 8/10/23. She stated she watched it with the ITMA and she did not see the arm extend from behind the wall when she watched it. She stated she could not tell whether the person was pushing the former resident or reaching out to her, and she assumed her best intentions. The administrator stated it was hard to say whether she was helping her. She added she did not complete an investigation.b. General interviewsOn 9/13/23 at 8:20 a.m., a staff who wished to remain anonymous (#9) stated on 8/6/23, Resident #4 became upset when she heard another resident yelling loudly. S/he stated Resident #4 swung at former Resident #6, who was standing next to her. Anonymous Staff #9 stated Resident #4 either made contact and Former Resident #6 fell or she tripped over her feet trying to get out of her way. The anonymous staff stated that someone from the management team advised Staff #5 to document that she fell, adding that the documentation in the progress note and incident report was not true. On 9/13/23 at 8:38 a.m., Staff #6 stated he did not witness Former Resident #6 fall on 8/6/23. He stated however, that he heard from an unknown staff that Resident #4 may have "swung" at the former resident, which resulted in the fall. On 9/13/23 at 8:07 a.m., Staff #7 stated Former Resident #6 was not unsteady on her feet and did not use any type of ambulatory device before 8/6/23. At 2:47 p.m., Staff #7 stated that on 8/6/23 Staff #5 reported to her that the MSD instructed Staff #5 to document in the progress notes and incident report that Former Resident #6 lost her footing and fell, and not that Resident #4 pushed the former resident which caused her to fall. Staff #7 stated that she reported this to the former MSD. She stated, "I would have expected an investigation. I don't know if (the information) got past (the former MSD)." On 9/13/23 at 10:26 a.m., the MSD stated that on the morning of 8/6/23, Former Resident #6 walked from the dining room of the secure environment, stumbled over her feet, and fell into the chair area. On 9/13/23 at 11:32 a.m., a representative from an external services provider (ESP) stated the clinical notes entered on 8/6/23 by an ESP nurse read in part that the residence staff initially reported that the resident was pushed by another resident, then the former MSD stated that the former resident just got tripped up. Additionally, she stated the note read that per the former MSD, the video footage may have been in a "dead zone" which meant the incident may not have been caught on video. On 9/13/23 at 1:29 p.m., the former MSD stated that she had heard from an unknown person that Staff #5 had informed Former Resident #6's family member that another resident pushed her which caused her to fall. At 3:20 p.m., the former MSD stated that at a meeting on 8/7/23 that included herself, the MSD and the former resident's family member, the MSD stated multiple times that the former resident tripped on her ambulatory device. The former MSD added that Former Resident #6 never used an ambulatory device, never tried to take another resident's ambulatory device, and there were no ambulatory devices in the area she was in when she sustained a fall on 8/6/23. On 9/13/23 at 2:22 p.m., the administrator stated that the MSD and former MSD informed her that the family was upset about the fall she sustained on 8/6/23 at that time. She stated she was unaware that the family member alleged another resident pushed the former resident which resulted in her falling, contrary to the electronic message that the family member sent to the administrator on 8/6/23 at 8:51 p.m. She stated she would have expected the former MSD to have reported it to her that the family member alleged the former resident was pushed. The administrator stated the former resident was not able to communicate effectively due to her diagnosis of dementia, so she found it surprising that the family member would have heard Former Resident #6 state that she was beaten and pushed. She then acknowledged the residence should have completed an investigation any time a resident or family member presented allegations of abuse. On 9/13/23 at 3:02 p.m., Staff #5 stated that on 8/6/23, he did not witness Former Resident #6 fall, adding that he "assumed she overstepped herself, but another resident could have pushed her." He stated that he reported this to the former MSD, who made him "re-think" the situation. He stated the MSD instructed him to document that the former resident lost her footing which resulted in a fall, although the fall was unwitnessed. On 9/13/23 at 3:42 p.m., Former Resident #6's family member stated that on 8/6/23, Staff #5 telephoned to report that the former resident had sustained a fall. The family member stated she arrived at the residence at approximately 8:30 a.m., and when she mentioned the fall to Former Resident #6, the former resident stated, "I did not fall. I was beaten and pushed." The family member stated she informed the MSD and the former MSD of the former resident's statement and her concern that someone pushed her. She stated Staff #5 had told her that no one witnessed her fall so they were not sure how the former resident fell. Former Resident #6's family member stated the ESP nurse arrived at approximately 10:00 a.m., adding that both she and the ESP nurse asked the former MSD to see surveillance video from the morning of 8/6/23 to determine the cause of her fall. She stated that later on in the day on 8/6/23, the former MSD informed her that she and an unknown staff reviewed the footage but could not see the incident, adding that the former MSD stated she was only able to see the tops of people's heads with where the camera was pointed. Former Resident #6's family member continued by stating that she met with the MSD and the former MSD on 8/7/23 (the day after her fall), during which the MSD stated that she saw in the video footage that the former resident tripped over her ambulatory device and fell, contrary to what the video footage actually revealed. The family member stated she verbalized that Former Resident #6 did not use an ambulatory device and the former resident insisted that she did not fall but was pushed. The family member stated neither the MSD nor former MSD stated they would investigate the allegation during this meeting. Former Resident #6's family member continued by stating that Anonymous Staff #9 informed her that someone on the management team advised staff to say, "we're not sure what happened" when asked about the fall Former Resident #6 sustained on 8/6/23. She stated that the anonymous staff member told her that what had actually occurred was that another resident became agitated and pushed the former resident; as a result of the contact, the former resident fell. The family member stated she wanted the residence to address the situation, but they resisted.

Based on record review and interview, the residence failed to ensure that resident records contained progress notes which included information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs. Additionally, 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 of two sample residents (#4, #5) who resided in the secure environment. Findings include: 1. Resident #5 was admitted to the residence on 7/1/22 with diagnoses including dementia. Progress notes in Resident #5's record for August through September 2023 revealed the following:8/1/23: "Resident was behavioral toward another resident and staff" 8/13/23: "Resident has been showing signs of behaviors crying most of shift has been redirected with programming but does not work well with other residents when upset"8/13/23: "The resident is having a hard day today she is visually upset and not redirectable at times refused care" Practitioner notes in Resident #5's record for August through September 2023 revealed the following:8/25/23: "Nursing requested that I see the patient today with increased behaviors. Resident #5 is seen today for follow up on dementia with behaviors. Behaviors continue, worse this week. Very combative, has been playing with her feces and will not let staff shower her or clean her up. Has gotten physically aggressive with both staff and other residents in the last couple days."8/30/23: Follow up on behaviors "Resident #5 is seen today for follow up on dementia with behaviors. Staff reports behaviors are slightly improved this week after recent changes to meds. No further incidents with other residents." 9/6/23: Urinary tract infection (UTI), f/u on behaviors "Staff reports significantly improved behaviors with recent medication changes. Still has difficulty with showers, but otherwise has been redirectable and no longer with any violent behaviors. Urine analysis (UA) shows positive for pseudomonas, recommends treatment with cipro." The residence failed to document progress notes with the information noted in the practitioner's notes from 8/25-9/6/23 about the resident's increased behavioral expressions, nor the diagnosis and the treatment of an UTI, nor the action taken by staff to address Resident #5's changing behavioral needs. On 9/13/23 at 2:47 p.m. Staff #7 stated Resident #5 had exhibited increasing behavioral expressions for six months prior to the onsite investigation. She stated that Resident #5 mainly displayed these behaviors toward Resident #4. Staff #7 stated Resident #5 would say "You're stupid" to Resident #4, which resulted in yelling and arguing. She stated that staff were required to intervene. She added that Resident #5 finished a cycle of antibiotics for a UTI approximately one week prior to the onsite investigation, she added that Resident #5 exhibited an increase in aggressive behavior when she had a UTI.On 9/13/23 at 3:02 p.m., Staff #5 stated that that Resident #5's behavioral expressions had increased over that two months prior to the onsite investigation. He added that her behaviors increased when she suffered from a UTI, adding that she was treated for a UTI within two weeks of the onsite investigation. 2. Resident #4 was admitted to the residence on 12/1/22 with diagnoses including neurocognitive disorder with Lewy bodies and dementia in other diseases classified elsewhere, severe, with other behavioral disturbance.a. Record ReviewA practitioner's note, dated 7/19/23, read in part that Resident #4 had advanced dementia and physical aggression when touched. The note further read: "I am opting to continue seroquel, depakote for the followingindications: physical aggression on staff and residents that are an imminent safety risk to self and others."A practitioner's note, dated 8/9/23, read in part that the staff reported that Resident #4 displayed worsening physical aggression towards other residents. The resident recently was "involved in two aggravated instances where she lashed out physically at other residents." Resident #4 was triggered when touched. The resident was unable to tolerate getting her blood pressure checked without attempting to scratch the practitioner. A practitioner's note, dated 8/13/23, read in part that the residence requested an evaluation of Resident #4's behaviors. The resident was evaluated on 8/9/23 for aggressive behaviors and medications were adjusted. There was no evidence that staff documented in progress notes from 7/19/23 to 8/9/23 for any out of the ordinary events with respect to aggressive behaviors, including the two aggravated instances of physical aggression noted in the practitioner's note on 8/9/23.b. InterviewsOn 9/13/23 at 8:38 a.m., Staff #6 stated that Resident #4 has had quick bursts of aggressive behavior daily since he started working at the residence in July 2023. He added that she was frequently resistant to care, adding that within the last week of the onsite investigation, Resident #4 had grabbed and pulled Staff #6's hair and would not let go. On 9/13/23 at 2:47 p.m., Staff #7 stated that Resident #4 had a tendency to hit other residents. She stated that loud and obnoxious noises triggered this behavior, adding staff were required to intervene or else she could hurt someone. Staff #7 stated that Resident #4 pushed Former Resident #6 on 8/6/23, and she acknowledged that progress notes did not reflect that the incident occurred. On 9/13/23 at 3:02 p.m., Staff #5 stated that Resident #4 frequently displayed physically aggressive behaviors towards staff when they were attempting to assist her with activities of daily living. On 9/13/23 at 3:09 p.m., Staff #9 stated that approximately two months prior to the onsite investigation, Resident #4 dug her fingernails into another resident's skin, which resulted in the resident being transported to the emergency departmentOn 9/13/23 at approximately 4:00 p.m., the administrator stated that staff communicated to each other by entering notes in the "communication board" of the residence's electronic information management system. She stated these notes were not considered progress notes. The administrator stated the staff manually entered documentation into a "shift to shift logbook;" however, she acknowledged she was unable to provide this documentation at the time of the onsite investigation. She stated staff communicated all out of the ordinary events and issues verbally with the former MSD.

Based on record review and interview, the residence failed to ensure the care plan for each resident in the secure environment included a resident's known behavioral expressions along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact, affecting two of two sample residents (#4, #5) who resided in the secure environment. Findings include:1. Residence PolicyThe residence's Comprehensive Resident Assessment and Service Plan, dated January 2023, read in part: "The Health and Wellness Director (HWD)/Assisted Living Director (ALD), or Memory Support Director (MSD) or designee shall conduct a comprehensive resident assessment and develop a written plan of service for each resident ...This shall be completed when a resident's condition changed from base-line status ...The comprehensive resident assessment shall include mood and behavior patterns ...The HWD/ALD or MSD or designee will reassess the resident with a change in condition to address significant changes in the resident's physical, behavioral, cognitive and functional condition to identify the services the Community shall provide to address the resident's changing needs ...the service plan shall be updated to reflect the results of the assessment." 2. Resident #5 was admitted to the residence on 7/1/22 with diagnoses including dementia. a. Record Review The residence's care plan for Resident #5, dated 6/5/22, did not include Resident #5's behavioral expressions or the noted increased behavioral expressions when diagnosed with an UTI, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact, as required. Practitioner notes in Resident #5's record for August through September 2023 revealed the following:8/25/23: "Nursing requested that I see the patient today with increased behaviors. Resident #5 is seen today for follow up on dementia with behaviors. Behaviors continue, worse this week. Very combative, has been playing with her feces and will not let staff shower her or clean her up. Has gotten physically aggressive with both staff and other residents in the last couple days."8/30/23: Follow up on behaviors "Resident #5 is seen today for follow up on dementia with behaviors. Staff reports behaviors are slightly improved this week after recent changes to meds. No further incidents with other residents." 9/6/23: Urinary tract infection (UTI), f/u on behaviors "Staff reports significantly improved behaviors with recent medication changes. Still has difficulty with showers, but otherwise has been redirectable and no longer with any violent behaviors. Urine analysis (UA) shows positive for pseudomonas, recommends treatment with cipro."3. Resident #4 was admitted to the residence on 12/1/22 with diagnoses including neurocognitive disorder with Lewy bodies and dementia in other diseases classified elsewhere, severe, with other behavioral disturbance. A care plan, revised on 5/31/23, read in part that Resident #4 was reluctant to accept care assistance from staff. It read the resident often grabbed at other residents and staff members, and could be redirected with a snack or a doll. The care plan included a list of interventions for staff when the resident was reluctant to care. The care plan did not address the resident's propensity to become physically aggressive toward other residents along with individualized approaches implemented by staff to protect the resident and other residents with whom they have contact. A practitioner's note, dated 7/19/23, read in part that Resident #4 had advanced dementia and physical aggression when touched. The note further read: "I am opting to continue seroquel, depakote for the following indications: physical aggression on staff and residents that are an imminent safety risk to self and others."A practitioner's note, dated 8/9/23, read in part that the staff reported that Resident #4 displayed worsening physical aggression towards other residents. The resident recently was "involved in two aggravated instances where she lashed out physically at other residents." Resident #4 was triggered when touched. The resident was unable to tolerate getting her blood pressure checked without attempting to scratch the practitioner. On 9/13/23 at 2:47 p.m., Staff #7 stated that Resident #4 displayed behavioral aggression toward other residents that were often triggered by loud noises and commotion. She stated Resident #4 had a tendency to clap her hands and pound on tables as signs that she was becoming agitated. She stated staff were required to intervene and remove the resident from the environment or else she could hurt other residents and will "go after somebody." She stated she would have expected Resident #4's behaviors toward other residents and the required staff interventions to be in the resident's care plan. On 9/13/23 at approximately 4:00 p.m., the administrator stated that anything that would benefit the staff to provide individual care to the residents should have been accessible in Resident #4 and #5's care plans. She stated that she and her management team were in the process of updating all resident care plans, but they had not yet updated the care plans for the residents in the secure environment.

A licensure complaint, prompted by #CO33151, was completed on 8/16/23. No deficiencies were cited.

A licensure complaint, prompted by #CO32568, was completed on 6/21/23. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 137 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for 12 months. Following the completion of Events TYFQ12 and TPRR11 on 9/19/22, a licensure revisit and licensure complaint, the department imposed a RN consultant for 12 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the consultant was required to complete, during the first month of the contract period:- Review each of the cited deficiencies identified in the Deficiency List, for Events TPRR11 and TYFQ12 both dated September 19, 2022, with the Administrator, and evaluate the residence's current compliance with corresponding regulations as well as regulations as outlined in 6 CCR 1011-1 Chapters 2, 7, and 24, where applicable. The consultant was required to complete, during the first two months of the contract period:- Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Administrator on any additional areas of noncompliance. The consultant would also implement a monitoring program, to be completed at least monthly, to ensure the Residence remains in compliance with previously cited deficiencies. The monitoring program will be incorporated into the Residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, Section 4. The Consultant will make certain that the QMP was designed to improve resident safety and well-being, and promoted continued quality improvement to enhance service delivery. The consultant was required to complete the following, during the first through sixth months of the contract period: - Conduct onsite visits at least weekly. The consultant was required to complete the following, during the seventh through twelfth months of the contract period:- Conduct onsite visits at least twice monthly. - Ensure the administrator had a process to correct identified deficiencies, which includes measures put into place to ensure deficient practice does not reoccur. - Ensure the administrator will monitor the corrective action to ensure deficiencies are remedied. The consultant was required to complete, during the twelfth and final month of the consulting period:- Prepare the administrator to independently manage the residence to ensure compliance with all applicable regulations governing assisted living residences. - Ensure the administrator has tools and resources in place to maintain compliance. Additionally, the consultant was required to ensure, during the entire 12 month contract period, for each of the deficiencies identified in the Deficiency List, for Events TPRR11 and TYFG12 both dated September 19, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 11/24/22.- Submit executed consultant contract to the department, due by 12/2/22.- Submit final consultant report, due by 12/15/23. Department records read the residence had chosen the RN consultant on 1/10/23 and the contract for the RN consultant was received on 1/11/23. Therefore, on the day of the completion of the complaint investigation, (6/20-6/21/23), the consultant would have been in her sixth month as consultant for the residence. 2. Current deficient practiceDuring the 6/20-6/21/23 complaint investigation, the survey established there was current deficient practice. Seven deficiencies were cited, including tags 910, 1180, 1192, 1312, 1428, 1468 and 1510. Tag 1180 was cited at a D level, pattern of actual harm, tag 1192 was cited at an E level, immediate jeopardy and tag 1312 was cited at a C level, actual harm. (Cross-reference Q910, Q1180, Q1192, Q1312, Q1428, Q1468, Q1510). 3. Interviews On 6/21/23 at approximately 7:30 a.m., the administrator stated she was aware of the intermediate condition requirements to maintain compliance. The administrator stated the residence aspired to maintain compliance and tried their best. On 6/21/23 at 10:26 a.m., one of the consultants stated the RN consultant was currently out of town so she would provide the information she had in regards to the residence's compliance. The consultant stated she was aware the residence was currently under an intermediate condition to maintain a consultant. She stated she was aware the residence was required to maintain compliance with all regulations while under the intermediate condition. In regards to tag 910, the consultant stated she was unsure what the residence had done to ensure the roster was correct. In regards to tag 1180, the consultant stated the health and wellness nurse managed the residence's fall program. She stated the residence had residents that had repeatedly fallen and they had discussed approaches. The consultant stated the residence had issues keeping up with implementation of fall interventions. In regards to tag 1192, the consultant stated she was unsure what the residence had done in regards to lift assistance. In regards to tag 1312, the consultant stated she was not aware of any concerns related to neglect. She stated she was unaware if the residence had completed any training in regards to neglect. In regards to tag 1428, the consultant stated she had not seen any concerns with qualified medication administration persons acting outside their scope. In regards to tag 1468, the consultant stated that the residence review medication exception reports every morning and the health and wellness nurse followed up on medications that were unavailable to administer. The consultant stated the residence had improved the tracking of medication but they still had issues with running out of medications. She stated they had completed training with staff. In regards to tag 1510, the consultant stated she had not seen concerns recently in regards to medication administration record documentation.

Based on record review and interview, the residence failed to have a readily available roster which included resident names and emergency contact information, along with a residence diagram showing room locations, affecting 137 current residents. Findings include:On 6/20/23 at approximately 7:00 a.m., a resident roster was requested from the receptionist. However, the resident roster was not accessible by the receptionist. On 6/20/23 at 8:21 a.m., Staff #26 stated she was not sure how to access a resident roster. On 6/20/23 at 8:50 a.m., the resident roster was provided by the administrator. However, the roster did not include emergency contacts or the residence diagram showing room locations as required. On 6/21/23 at 7:19 a.m., the administrator stated all staff, including the receptionist, had access to a resident record. She also stated there was an emergency binder that included a residence diagram showing room locations.

Based on interview and record review, the residence failed to detail in each resident's care plan the individualized approach necessary to address fall risk, affecting two of three sample residents (#12, #36) and one former resident (#20). Specifically, Former Resident #20 sustained a fall on 10/9/22 which resulted in a hospital visit and a second fall on 4/16/23. The residence did not update the care plan to include individualized approaches to address fall risks related to deficits in strength and balance. Subsequently, Former Resident #20 sustained a fall on 6/14/23 that resulted in nondisplaced subacute fractures of the pubic rami. The coroner stated Former Resident #20 was pronounced deceased on 6/20/23 as a direct result of complications related to the pelvic fractures sustained from the fall. Specifically, Resident #36 sustained four falls on 6/6/23. Two falls resulted in injuries which included a bruised foot and scrapes to both shins. The residence did not update the care plan to include individualized approaches to address fall risks related to deficits in strength and balance. Subsequently, Resident #36 sustained a fall on 6/7/23 that resulted in hospitalization. Resident #36 sustained falls on 6/8/23 and 6/10/23 without injuries and a fall on 6/11/23 that resulted in a scratch. The residence did not update the care plan to address individualized approaches to address the resident's fall risks after the four additional falls. Resident #36 sustained two additional falls on 6/12/23 and 6/16/23. Findings include:1. Reference and Residence policy According to Medical News Today, "A pubic ramus fracture describes a type of crack or break in a person ' s pelvis. Pubic ramus fractures are not typically life threatening and typically heal well. However, this kind of fracture can be serious for older people ... low energy trauma accidents may also cause people to sustain a pubic ramus fracture. These accidents can involve slips, or small falls from standing height ..." Medical News Today (2023), What is a Pubis Ramus Fracture, Retrieved from: https://www.medicalnewstoday.com/articles/pubic-ramus-fracture. The residence's Fall Reduction and Management policy, dated January 2022, read in part, when a resident fell, the residence would investigate the fall with the intention of reducing the fall incidents. Changes to the care plan would be implemented, as needed. 2. Former Resident #20 was admitted to the residence on 5/9/22 with diagnoses that included atrial fibrillation, hypertension and centrilobular emphysema. A fax cover sheet from the residence to the practitioner of Former Resident #20, dated 7/11/22 (actual date unknown), read Former Resident #20 sustained an unwitnessed fall on 10/9/22 and was transported by emergency medical services to the hospital. Former Resident #20 returned to the residence on 10/10/22 with no injuries noted. Incident reports for Former Resident #20, dated 4/15/23 and 6/14/23, read in part:On 4/15/23, Former Resident #20 was found on the floor in her room. Former Resident #20 was noted to have been found laying on the floor on her back with a pillow under her head. Former Resident #20 reporting slipping when she got out of bed. No injuries were reported. Contributing factors of the fall were noted to have been poor lighting, rugs/carpeting and furniture. On 6/14/23, Former Resident #20 was found on the floor in her her room. Former Resident #20 was found laying on her back on the floor. Former Resident #20 reported she had slid off the bed. Staff noted Former Resident #20 reported she did not hit her head and denied pain. No injuries were noted. No contributing factors were documented in the incident report. Progress notes for Former Resident #20, dated 4/17-6/18/23, were reviewed and read the following: A progress note, dated 4/17/23, late entry completed on 4/21/23 at 9:43 a.m. by the memory support director (MSD) read; "Resident has no c/o (complaint of) pain at this time. Resident has no change in mobility and is reminded to use her walker in her apartment. Staff to ensure resident has a clutter free apartment. Resident is baseline with intake and fluid with no concerns at this time." A progress note, dated 4/18/23, late entry completed on 4/21/23 at 9:23 a.m. by the MSD read; "Resident has no c/o (complaint of) pain at this time. Resident has no change in mobility and is reminded to use her walker in her apartment. Staff to ensure resident has a clutter free apartment. Resident is baseline with intake and fluid with no concerns at this time." A progress note, dated 4/21/23 at 9:43 a.m., completed by the MSD read; "Resident has no c/o (complaint of) pain at this time. Resident has no change in mobility and is reminded to use her walker in her apartment. Staff to ensure resident has a clutter free apartment. Resident is baseline with intake and fluid with no concerns at this time." A progress note, dated 6/14/23, late entry completed on 6/17/23 at 1:49 p.m. by the MSD read; "Resident had an unwitnessed fall in her apartment at approx(imately) 5:30 a.m. Resident at that time had no c/o pain other than 'my butt check hurts from sitting on the floor.' Family came into (residence) at approx(imately) 9:15 a.m. and requested (emergency medical services) to come out and assess. Resident is on palliative cares, therefore family and resident asked to not be transported. Resident had an x ray completed by mobile x ray. Family has been in apartment with resident most of the day. Family has asked to hold this evening and HS (hour of sleep) medications at this time."A progress note, dated 6/14/23, late entry completed on 6/17/23 at 1:52 p.m. by the MSD read; "This MSD had been in communication with the family throughout the day. Resident has a c/o pain in the hip/groin area on the right side. PA (physician assistant) and (external palliative care nurse) aware. Awaiting x ray results for further care changes. Family has been apartment (sic) all day and has asked staff to assist every (two) hours. Change of condition has started, awaiting hospice orders if family decide before completing and locking assessment." An x ray report for Former Resident #20, dated 6/14/23, read in part; Former Resident #20 sustained nondisplaced subacute fractures of the pubis rami. A fall assessment for Former Resident #20, dated 4/16/23, and completed on 6/14/23, read; Former Resident #20 was a high risk for falling and scored 90 points. The assessment further read Former Resident #20 had impaired gait which included; "difficulty rising from chair, uses chair arms to get up, bounces to rise, keeps head down when walking, watches the ground, grasps furniture, person or aid when ambulating. Cannot walk unassisted."The residence's care plan for Former Resident #20, dated 11/9/22, read in part; Former Resident #20 was able to get in and out of bed independently, demonstrated impaired judgment related to safety, required safety checks at night every two to three hours to monitor oxygen use and was independent with ambulation. The care plan for Former Resident #20 was not updated after the fall on 4/15/23 to include the updated fall assessment information or to include the individualized approaches necessary to address Former Resident #20's risk for falls related to deficits in balance and strength. On 6/20/23 at 7:48 a.m., Staff #29 stated on 6/14/23 when she arrived for her shift Staff #27 had reported Former Resident #20 fell during the overnight shift. She stated emergency medical services came to the residence and completed a mobile x ray. She stated she was unsure of what the results were; however, she was aware she was injured because she (Former Resident #20) had reported pain to her. On 6/20/23 at 11:06 a.m., the family member of Former Resident #20 stated she had received a telephone call from Staff #27 at approximately 5:50 a.m. on 6/14/23 to notify her that Former Resident #20 had fallen. The family member stated Staff #27 reported Former Resident #20 had no injuries. She stated Staff #29 telephoned her approximately 20 minutes later and also reported Former Resident #20 had no injury. The family member stated Former Resident #20's private caregiver arrived at 9:00 a.m. and Former Resident #20 was in pain. The family member stated Staff #29 and the private caregiver attempted to sit Former Resident #20 up and she complained of pain. The family member stated Former Resident #20 was in a lot of pain and emergency medical services were contacted once she requested it. The Family member stated she was aware Former Resident #20 had fallen in October 2022, but she had not been made aware of a fall that occurred in April 2023. The family member stated no measures had been put into place but the residence to prevent additional falls that she was aware of. The family member stated Former Resident #20 was unable to utilize her call pendant in the secure environment and added she (the family member) had pressed the pendant for assistance on 6/17/23; however, staff took 45 minutes to respond. The family member stated that Former Resident #20 had a fractured pelvis as a result of the fall. The family member stated Former Resident #20 moved from the residence to an external inpatient hospice agency on 6/17/23 due to the sustained injuries and the rapid decline in her health. On 6/20/23 at approximately 11:45 a.m., the private caregiver for Former Resident #20 stated she had received a telephone call from the family member of Former Resident #20 on 6/14/23 who the former resident had fallen. She stated when she arrived at the residence Former Resident #20 was laying in bed, propped up and was visibly uncomfortable. The private caregiver stated Former Resident #20 moaned, was in pain and expressed she was not alright. The private caregiver stated Former Resident #20 had a fractured pelvis as a result of the fall. On 6/20/23 at 12:20 p.m., Staff #26 stated Former Resident #20 had fallen on 6/14/23 and complained of pain in her buttocks. On 6/20/23 at 1:38 p.m., the MSD stated Former Resident #20 had fallen on 6/14/23 during the overnight shift. She stated it was reported to her that the former resident had not complained of pain at the time of the fall. The MSD stated she was unsure if Former Resident #20 had previously fallen. The MSD stated Former Resident #20 moved from the residence on 6/17/23 to an external impatient hospice agency due to her increased care needs. The MSD stated even though Former Resident #20 did not utilize her call pendant routinely she felt it was an appropriate intervention to prevent falls. On 6/20/23 at 2:33 p.m., the health and wellness nurse stated on 6/14/23 Former Resident #20 had fallen. She stated the former resident had an x ray after the fall. The health and wellness nurse stated Former Resident #20 had fallen two previous times that she was aware of. She stated she believed the fall interventions for the former resident's falls was to move her to the secure environment. On 6/20/23 at 3:00 p.m., the administrator stated she was notified on 6/14/23 at approximately 1:30 p.m. that Former Resident #20 had fallen. On 6/20/23 at 4:13 p.m., Staff #28 stated Former Resident #20 had fallen on 6/14/23 and staff had reported she had no injuries. Staff #28 stated at approximately 8:30 a.m., when he checked on Former Resident #20, he had attempted to reposition Former Resident #20 in her bed and she was in a lot of pain. Staff #28 stated after Former Resident #20 fell she was bed bound and was able to be moved with two staff and a sheet to transfer due to her pain level. On 6/21/23 at 7:07 a.m., the administrator stated she was aware Former Resident #20 had fallen prior to the fall on 6/14/23; however, she did not know the specific details of the falls. She stated she was not aware of interventions that had been put into place to prevent additional falls other than frequent checks. The administrator acknowledged the former resident was at risk for falling and stated the care plan should have been updated with fall interventions. She added she did not believe it should be updated after a fall. On 6/21/23 at 8:45 a.m., the coroner stated the preliminary cause of death noted for Former Resident #20 was related to the pelvic fracture sustained from her fall on 6/14/23. The coroner stated the death certificate would be issued to read the death was accidental with related complications from a pelvic fracture as a result of the fall sustained. 3. Resident #36 was admitted to the residence on 5/24/23 with diagnoses including dementia and Parkinson's disease. Incident reports for Resident #36, dated 6/6, 6/8, 6/10-6/12, and 6/16/23, read in part:On 6/6/23, Resident #36 fell four times. One fall resulted in bruises on the left foot and another resulted in scrapes to both shins. On 6/7/23, the resident had an unwitnessed fall and required emergency services because he could not move to get off the floor. On 6/8/23, the resident fell in his closet. On 6/10/23, the resident missed his chair while sitting and fell to the ground. On 6/11/23, the resident fell and was found laying in his back. The fall resulted in a scratch on his lower back and an abrasion to the right iliac crest. On 6/12/23, the resident fell and was found on the floor in his bathroom. On 6/16/23, the resident slid out of his wheelchair and fell to the ground. Progress notes for Resident #36, dated 6/12 and 6/17/23, read in part:On 6/12/23, the resident had bruising on his lower back and coccyx area in various stages of healing, as well as a small abrasion scratch on his lower back. On 6/17/23, the resident was assessed for external hospice services due to fall frequency. A care plan for Resident #36, dated 5/23/23, read in part, the resident was at risk for falls due to a parkinson's disease diagnosis and unsteady gait. An updated care plan for Resident #36, dated 6/19/23, read in part, the resident required assistance with mobility and had a history of falls due to ambulating without assistance. Staff were required to do frequent safety checks, encourage the resident to use the wheelchair and encourage the resident to remain in the common areas for staff supervision. However, the care plan did not include individualized approaches necessary to address fall risk after each fall. Additionally, the care plan was not updated after each fall to include necessary fall interventions to address why Resident #36 fell or staff interventions to address the falls. On 6/20/23 at approximately 7:40 a.m., Staff #30 stated Resident #36 fell frequently. She stated the staff interventions in place to prevent falls included two hour safety checks and staff supervision. On 6/20/23 at 8:08 a.m., Staff #27 stated Resident #36 was at risk for falls due to his history of falls. She stated the staff intervention in place to prevent the resident from falling was frequent checks. On 6/20/23 at 8:21 a.m., Staff #26 stated Resident #36 was at risk for falls due to his history of falls. She stated she was not sure what the care plan detailed for individualized approaches necessary to address fall risk. On 6/20/23 at 1:04 p.m., the legal representative for Resident #36 stated the resident fell frequently. She stated staff tried to keep him in a wheelchair to prevent falls. However, he fell out of the wheelchair at times. She also stated staff tried to keep the resident in common areas for supervision; however, he still fell. On 6/20/23 at 2:13 p.m., the MSD stated Resident #36 was at risk for falls due to parkinson's disease and hallucinations. She stated the resident was weak and experienced several falls. She stated the individualized approaches necessary to address fall risk included frequent safety checks, encourage the resident to remain in common areas for staff supervision, physical therapy, encourage the resident to participate in activities, proper footwear and to encourage the resident to use his walker and wheelchair. On 6/21/23 at approximately 7:33 a.m., the administrator stated Resident #36 was at risk for falls and the care plan should have been updated after falls with the individualized approach necessary to address fall risk. However, she stated it was not their policy to update the care plan after every fall that he had. 4. Resident #12 was admitted to the residence on 2/8/21 with diagnoses including unsteady gait. Incident reports for Resident #12, dated 4/12, 5/9, 5/29, and 6/13/23, read in part:On 4/21/23, the resident fell in her bathroom. On 5/9/23, the resident fell out of bed. On 5/29/23, the resident fell in her room and was found laying on her right side on the floor. On 6/13/23, the resident fell out of her chair. Progress notes for Resident #12, dated 5/12 and 6/13/23, read in part:On 5/12/23, the resident was showing signs of weakness and unsteady gait. On 6/13/23, the resident was not capable of using the call pendant for staff assistance. An assessment, dated 6/1/23, read in part, the resident was at risk for falls due to cognitive changes and poor safety awareness. Staff were required to encourage Resident #12 to put on socks and shoes, remind her to use a call pendant, and provide the resident with safety checks every 1-3 hours. A care plan for Resident #12, dated 1/20/23, read in part, the resident was at risk for falls. On 5/11/23 the care plan was updated with the staff intervention of safety checks every 1-3 hours. On 5/14/23 an intervention was added that staff were required to provide safety checks every 1-3 hours to ensure the resident was in bed when sleeping and did not need any extra assistance. On 6/1/23 the staff intervention of a toileting schedule, hydration, staff escorts, and a clutter free apartment were added. However, the care plan was not updated with the individualized approach necessary to address fall risk after the fall on 4/21 and 6/13/23. On 6/20/23 at 8:21 a.m., Staff #26 stated Resident #12 had a history of falls. However, she stated she was not sure of the individualized approach necessary to address fall risk. On 6/20/23 at 1:09 p.m., the legal representative for Resident #12 stated the resident was at risk for falls due to weakness. She stated the intervention in place was for staff to encourage the resident to use a wheelchair to prevent falls. On 6/20/23 at 2:13 p.m., the MSD stated Resident #12 was at risk for falls and staff were required to provide frequent safety checks and ensure the resident wore proper footwear. On 6/20/23 at 2:31 p.m., the health and wellness nurse stated care plans were updated after falls by the MSD.On 6/21/23 at approximately 7:33 a.m., the administrator stated Resident #12 was at risk for falls and the care plan should have been updated after falls with the individualized approach necessary to address fall risk. However, she stated it was not their policy to update the care plan after every fall that she had.

Based on record review and interview, the residence failed to ensure trained staff were available to evaluate residents who had fallen to determine if the resident could be assisted in a safe manner such as when the resident had no pain and/or there was no change from baseline, affecting 137 current residents. (Cross reference Q1180 and Q1312) Specifically, Former Resident #20 fell on 6/14/23 and reported pain in her buttocks to two overnight staff members (#26 and #27). The two staff proceeded to lift the former resident and place her back into bed without an assessment of the former resident's reported pain. The former resident continued to complain of pain in her buttocks, groin and hip to two additional staff at 6:30 a.m. and 8:30 a.m. It was identified Former Resident #20 had sustained nondisplaced subacute fractures of the pubic rim. The residence had not completed training with the two staff that lifted the former resident, nor had training been completed with any other staff to prevent the incident from occurring again. Staff stated they were not aware the former resident should have been evaluated prior to lifting her from the floor due to the complaint of pain. The two staff continued to work the overnight shift in the residence. Residence staff acknowledged the policy regarding lift assistance was not followed. The administrator confirmed that the former resident had complained of pain in her buttocks prior to being lifted of the floor. This failure created an immediate jeopardy risk of serious injury to all 137 current residents residing in the residence. On 6/20/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include: 1. Residence Policy The residence's Lift Assist policy, dated January 2022, read in part; "In order to protect the safety and well-being of the team member and residents, and to promote quality care, the (residence) team members will use appropriate techniques whenever assistance is provided to lift and transfer residents ... Should the resident require more assistance than the team members can provide or injury is suspected, emergency medical services (EMS) will be notified ... In the event that a resident has fallen, the assisted living director (ALD) or designees will evaluate the resident's functioning and ability to independently get up from the floor ... If the resident is free of pain, able to move all extremities without pain or difficulty, has not hit their head during the fall, responds appropriately to questions, and requests to be assisted to a standing position, team member(s) may assist the resident to a standing position ... Team members will call EMS to evaluate the resident if any of the following occur: complaints of pain, change of baseline condition, experiences difficulty moving ..." 2. Record Review Former Resident #20 was admitted to the residence on 5/9/22 with diagnoses that included atrial fibrillation, hypertension and centrilobular emphysema. An incident report, dated 6/14/23 and completed by Staff #27, read in part; "this writer and (Staff #26)- were doing (every two hour) rounds, we walked into the resident's room and she was laying on her back on the floor ... Resident said she slid off the bed." The incident report further read Former Resident #20 stated she did not hit her head and denied any pain. Staff documented assisting the resident from the floor into bed. An undated investigation of neglect, completed by the administrator and memory support director (MSD), read the following: At approximately 5:30 a.m. Former Resident #20 fell and the overnight staff reported no injuries were noted. Between approximately 6:30 a.m. to 6:45 a.m. Staff #29 administered medication to Former Resident #20 and she complained of pain in her buttocks. Staff #29 went back into Former Resident #20's room at approximately 7:40 a.m. and again Former Resident #20 complained of pain in her buttocks. At approximately 8:30 a.m., Staff #28 entered the room and Former Resident #20 complained of pain in her buttocks, hip and groin area. At 9:00 a.m., Staff #29 went back into the room to administer morning medications and assisted the private caregiver to get Former Resident #20 out of bed. It was documented at this time Former Resident #20 expressed more pain and Staff #29 laid the former resident back down. At approximately 9:20 a.m.the family member of Former Resident #20 and the private caregiver called emergency medical services. When EMS arrived at approximately 10:14 a.m., a mobile x ray was ordered due to the pain. It was determined that Former Resident #20 had nondisplaced fractures of the pelvic rim as a result of the fall. Interviews were conducted by the administrator and MSD as part of the investigation and read the following:On 6/14/23 at approximately 5:30 a.m., Staff #27 and Staff #26 reported during rounds that Former Resident #20 was seated on the floor with her legs extended in front of her, leaning on her bed. "They asked if she was hurt or in pain, resident was talking to them and said no- other than her (buttocks) hurts from sitting on the floor. They asked is it pain, and the resident reported no. They assisted residents up from the floor, resident had weight on both feet and was transferred to bed ..."Training documentation regarding lift assistance training with residence staff was not provided. However, at 3:58 p.m., the administrator provided hand written notes identified as part of her investigation that read in part; "... Brought in current shift, reviewed todays events and how to respond ... spoke about more then likely you will be interviewed by (the department) ... If the resident says anything hurts even if its not pain ... call oncall (sic) for additional directions and/or notify (power of attorney) if moved." 3. InterviewsOn 6/20/23 at 7:48 a.m., Staff #29 stated she had been in formed by Staff #27 that Former Resident #20 had fallen on 6/14/23 at approximately 5:30 a.m. She stated Staff #27 reported the fall resulted in no injuries and the former resident had been lifted and placed in bed. Staff #29 stated when she checked on Former Resident #20 at approximately 6:30 a.m., (30 minutes after being notified of the fall) the former resident complained of pain in her buttocks. Staff #29 stated herself and the private caregiver for Former Resident #20 tried to stand her up at approximately 9:00 a.m. and Former Resident #20 was unable to bear weight on her legs. She stated she was unaware if the residence had completed training with staff in regards to safely lifting residents prior to or after the incident on 6/14/23. Staff #29 stated the health and wellness nurse should have assessed Former Resident #20 prior to staff lifting her off the ground. She stated if a resident fell and had pain medical attention should have been obtained prior to lifting the resident from the floor. On 6/20/23 at 11:06 a.m., the family member of Former Resident #20 stated she had been notified on 6/14/23 at approximately 5:50 a.m. that Former Resident #20 had fallen. She stated she had been informed Former Resident #20 had no injuries at the time of her fall and had been put back into bed. The family member stated at approximately 9:00 a.m. Staff #29 attempted to sit Former Resident #20 up in bed; however, she was in too much pain. The family member stated she had called emergency medical services to evaluate the former resident and upon arrival a mobile x ray was ordered. She stated the mobile x ray determined Former Resident #20 had fractures in her pelvis. The family member stated when Former Resident #20 had previously fallen out of bed she had complained of pain after the fall for a few days. She stated it was out of the ordinary that Former Resident #20 fell out of bed this time and she had no complaint of pain. On 6/20/23 at 11:45 a.m., the private caregiver for Former Resident #20 stated she routinely cameto the residence twice weekly to assist Former Resident #20. She stated she had been notified of the fall on 6/14/23 by the family member of Former Resident #20 prior to her arrival on 6/14/23. The private caregiver stated she had been told the former resident sustained no injuries from the fall. The private caregiver stated when she arrived, at approximately 9:00 a.m., Former Resident #20 was in her bed propped up and appeared uncomfortable. The private caregiver stated staff had informed her after Former Resident #20 had fallen, two staff members picked her up from the floor and placed her back into bed. The private caregiver stated when Staff #29 came in and tried to stand her up she was in so much pain she could not stand. She stated the MSD came to the room and she (the private caregiver) asked how staff were able to assist her off the floor when she was in so much pain she could not stand. The private caregiver stated the family member informed her (the private caregiver) the former resident had a broken pelvis. She added the staff should have contacted emergency medical services when she fell, not lifted her up. On 6/20/23 at 12:20 p.m., Staff #26 stated when Former Resident #20 fell she did not show any signs of pain. Staff #26 stated the former resident only complained of pain in her buttocks. She stated "it didn't dawn on me that it could've been from the fall. Staff #26 stated it "probably would have been good to call (emergency medical services)to have her (Former Resident #20) assessed (prior to lifting), now that I think of it." On 6/20/23 at 1:38 a.m., the MSD stated training on lift assistance had not yet been completed with staff after the incident on 6/14/23 with Former Resident #20. She stated over the weekend (6/16-6/17/23) another resident (Resident #36) had fallen and staff lifted him afterwards as well. She stated he had been sent to the hospital afterwards and she believed he was diagnosed with a urinary tract infection. The MSD confirmed Resident #36 had reported weakness at the time of the fall. The MSD stated on 6/14/23, when Former Resident #20 had fallen, she was notified of a fall with no injury. She stated she was not aware Former Resident #20 had reported pain in her buttocks to the overnight staff prior to them lifting her from the floor. She stated Staff #26 and #27 were on the list of staff that needed to be trained in lift assistance. On 6/20/23 at 2:33 p.m., the health and wellness nurse stated Former Resident #20 had fallen on 6/14/23. She stated she was not involved in what had occurred and was only aware emergency medical services had been contacted to complete a mobile x ray. She stated later that day Former Resident #20 was admitted to external hospice services. The health and wellness nurse stated lift assistance training was ongoing at the residence. She stated if the staff had not been retrained after the incident with Former Resident #20 then there was a continued risk that this would occur again when another resident fell. On 6/20/23 at 3:00 p.m., the administrator stated on 6/14/23 Former Resident #20 fell and Staff #26 and #27 lifted her from the ground, stood her on both legs then swung the former resident into the bed. The administrator stated Former Resident #20 should have been assessed prior to lifting her; however, she was able to stand after the fall. The administrator confirmed both Staff #26 and #27 had worked at the residence since the incident and added no training regarding lift assistance had been provided with any staff after the incident. On 6/20/23 at 4:13 p.m., Staff #28 stated on 6/14/23 at 6:00 a.m. upon arrival to his shift, the overnight staff reported Former Resident #20 had fallen with no injuries overnight. He stated at 8:30 a.m. when he first entered Former Resident #20's room she was in so much pain he had a hard time trying to move her in her bed to prevent her from falling again. Staff #28 stated the amount of pain that Former Resident #20 was in it should have been addressed. He stated staff were not supposed to lift a resident in pain until the family, hospice or emergency medical services was notified and until the QMAP came and determined it was either safe or emergency medical services needed to be contacted. Staff #28 stated after Former Resident #20 sustained her fall she was completely bed bound and required transfers utilizing bed sheets to move her. Staff #28 stated the only training that he recalled was using gait belts for transfers and making sure the secure environment doors remained locked. 4. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 137 current residents at immediate jeopardy risk for further complications of injuries sustained from falling. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 6/20/23 at 4:22 p.m., the administrator submitted written evidence that read in pertinent part: "What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice: Re-education to Care Team Members (Staff) to include Policy#C302-Lift Assist. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Any resident who has a fall, will be screened/questioned/assessed before any lift assistance is offered. Should a resident have any suspected sign/symptom/report of injury or pain - we do not move, call on-call supervisor or EMS as appropriate. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Re-education and continuing education on Policy#C302-Lift Assist. Executive Director and Memory Support Director had closing conversations during the investigation with seven affected team members. They reviewed that state would likely be in, to be honest and candid. The discussion involved the fact that we 'team' cannot determine the level of pain someone living with dementia has. Any comments from our residents, we must hear them. Reminded them that if there is any report or suspicion of pain, we do not move them. How the corrective actions(s) will be monitored to ensure deficient practice will not recur, i.e., what quality assurance program will be put into practice: Additional education to residents and family members about our SafelyYou program to encourage participation. This will help to determine type and severity of fall and potential next steps while contacting on-call supervisor. Will offer continual training opportunities for proper Lift Assist for persons living with dementia for next 30 days. The date for correction and the title of the person responsible for correction of deficiency: Initial re-education was performed during closing comments of the investigation on 14 June 2023. Re- training will continue for those not involved with specified incident. (An organized re-training during All- Staff was planned for today 6/20/23 as well as scheduled Gait Belt Training on 6/20/23). Team members will complete re-training on Policy#C302-Lift Assist on or before 30 June 2023 by Memory Support Director, Assisted Living Director and/or designee."However, the written evidence did not indicate the risk had been removed because it did not contain an acceptable monitoring element, an acceptable training element, how each element would be documented and maintained, what the administrators oversight would be and included tasks that could only be provided by a nurse, however a nurse was not onsite 24 hours a day. The administrator was directed to submit additional written evidence. On 6/20/23 at approximately 5:30 p.m., the administrator submitted additional written evidence that read in pertinent part; "... Re-education to care team members to include policy #C302-Lift Assist and Chapter 7 Assisted Living Regulations 12.17 ... Any resident who was a fall, will be screened/questioned/evaluated before any lift assistance is offered. Should a resident have any suspected sign/symptom/report of injury or pain- we do not move, call on-call supervisor or EMS as appropriate ... (Administrator) and memory support director had closing conversations during the investigation with seven affected team members. They reviewed that state would likely be in , to be honest honest and candid. The discussion involved the fact the we "team" cannot determine the level of pain someone living with dementia has. Any comments from our residents, we must hear them. Reminded them that if there is any report or suspicion of pain, we do not move them ... Additional education to residents and family members about our Safely You program to encourage participation. This will help to determine type and severity of fall and potential next steps while contacting on-call supervisor. Will offer continual training opportunities for proper lift assist for persons living with dementia for the next 30 days. (Administrator) will review all re-training attendance logs during resident at risk meetings, when held. This will continue for a minimum of 30 days. This will also be reviewed at the next QMP meeting ... Initial re-education with seven affected team members was performed during closing comments of the investigation on 14 June 2023. Immediate re-training will begin today (6/20/2023) and will occur before next scheduled shift for those not involved with specified incident. Team members will complete re-training on Policy#C302- Lift Assist on or before 30 June 2023 by memory support director, assisted living director and/or designee ..."

Based on record review and interview, the residence failed to ensure residents had the right to be free from neglect, affecting one former resident (#20). (Cross reference Q1180, Q1192)Specifically, Former Resident #20 sustained a fall on 6/14/23 and complained of pain in her buttocks, hip and groin. Former Resident #20 reported pain to four staff members between 5:30 a.m. and 9:20 a.m., approximately 3 hours and 50 minutes, prior to emergency medical services (EMS) or the practitioner being contacted to have the former resident assessed. The family member of Former Resident #20 arrived at the residence at 9:20 a.m. and contacted EMS to have the former resident assessed due to her increased pain. Additionally, Former Resident #20 was not administered pain medication, despite having an order for as needed pain medication, until approximately 10:14 a.m., when EMS arrived and administered the medication. An x ray was completed and revealed Former Resident #20 had sustained nondisplaced subacute fractures of the pubic rim as a result of the fall. Findings include: 1. ReferencesChapter 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. Chapter VII regulations governing assisted living residences, part 2.38, defines Protective oversight as guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following: Being aware of a resident's general whereabouts, although the resident may travel independently in the community; and Monitoring the activities of the resident while on the premises to ensure the resident's health, safety and well-being, including monitoring the resident's needs and ensuring that the resident receives the services and care necessary to protect the resident's health, safety and well-being. Chapter VII regulations governing assisted living residences, part 2.43, defines Secure environment as any grounds, building or part thereof, method or device that prohibits free egress of residents. An environment is secure when the right of any resident thereof to move outside the environment during any hours is limited. 2. Record ReviewFormer Resident #20 was admitted to the residence on 5/9/22 with diagnoses that included atrial fibrillation, hypertension and centrilobular emphysema. An undated investigation of neglect, completed by the administrator and memory support director (MSD) was reviewed and read the following: On 6/14/23 Former Resident #20 fell during the overnight shift at approximately 5:30 a.m. and staff reported no injuries were noted. On 6/14/23 between approximately 6:30 a.m. to 6:45 a.m., Former Resident #20 reported pain in her buttocks to Staff #29 and the staff member left the room. No notification to the practitioner or EMS was documented. On 6/14/23 at approximately 7:40 a.m., Former Resident #20 complained of pain in her buttocks for a second time to Staff #29. No notification to the practitioner or EMS was documented. On 6/14/23 at approximately 8:30 a.m., Former Resident #20 complained of pain in her buttocks, hip and groin area to Staff #28. Staff #28 reported the complaint of pain to Staff #29. No notification to the practitioner or EMS was documented. On 6/14/23 at 9:00 a.m., Staff #29 went back into the room to administer morning medications and assist Former Resident #20 out of bed with her private caregiver. Former Resident #20 expressed more pain and Staff #29 laid the former resident back down. No notification to the practitioner or EMS was documented. On 6/14/23 at approximately 9:20 a.m., the family member of Former Resident #20 arrived at the residence. The family member and the private caregiver telephoned EMS due to the level of pain Former Resident #20 reported. Additionally, the family member notified Former Resident #20's practitioner. On 6/14/23 at approximately 10:14 a.m., EMS arrived at the residence to assess Former Resident #20. EMS provided pain medication, inserted a catheter and ordered a mobile x ray for Former Resident #20. On 6/14/23 a practitioner's order for pain medication was written because the residence only had a current order for as needed tylenol. The family member filled the prescription and self managed the medication for Former Resident #20. "In closing- there will be reeducation completed for when to (telephone), residents reporting pain, addressing pain and residents needs. Documented disciplinary action for (Staff #29)." Interviews were conducted by the administrator and MSD as part of the investigation and read the following:"Overnight QMAP (qualified medication administration person) (Staff #27) and (Staff #26) both reported during rounds that they noted (Former Resident #20) on the floor, sitting with legs extended in front of her, leaning on her bed about 5:30 a.m. They asked if she was hurt or in pain, resident was talking to them and said no - other than her (buttocks) hurts from sitting on the floor. They asked is it pain, and the resident reported no ...""Interview with (Staff #29) and timeline of events and why she did not address the resident's pain. (Staff #29) said she did not think of it, did not associate pain and the fall, and continued about her duties. After reviewing the timeline from 6 am (6:00 a.m.) reporting until 9 am (9:00 a.m.) when family arrived, and how she did not address resident care/pain after she too noted residents' pain and was told by a (staff member) ... she did not notify supervisor, nursing, or address residents reported pain in a timely manner. (Staff #28) acknowledged she should have properly addressed any concerns of reported pain, felt 'bad' and wanted to apologize to the family as she meant no harm ..." An EMS report, dated 6/14/23, read in part; "Arrival- (upon arrival) to (residence) found a geriatric female patient lying in bed, complaining of hip pain ... family stated that (one) hour ago they found the (resident) lying in bed, not responding as usual, answering questions with one word and displaying a droop of the right side of the face. The (resident) had fallen (four) hours prior and was brought back to bed by (residence) staff at that time the (resident) was complaining of pain in the right hip ... (resident) was lethargic and oriented to person only ... (Resident) was evaluated and treated by (EMS) for hip pain ... An order was made for a x ray of the hip and pelvis and the (resident) was administered (one) tablet of 5/325 mg Vicodin tablet. The (resident) attempted to get up to go to the bathroom and after experiencing too much pain was willing to have a foley catheter placed ..."3. Interviews On 6/20/23 at 7:48 a.m., Staff #29 stated Former Resident #29 had reported pain in her buttocks to her on 6/14/23 between 6:30 a.m. and 6:45 a.m.. She stated she left her in bed. Staff #29 stated at approximately 8:00 a.m., Staff #28 informed her Former Resident #20 had complained of pain in her groin area. Staff #29 stated at approximately 9:00 a.m., she went into Former Resident #20's room to administer her morning medications. She stated she attempted to assist Former Resident #20 to stand but she was unable to stand or bear weight because of her pain. Staff #29 stated Former Resident #20 was visibly in pain. She stated the family member of Former Resident #20 requested EMS be called and that was when EMS was called and notified of the pain for the first time. Staff #29 stated she had not provided as needed tylenol to Former Resident #20 despite her complaints of pains because the residence did not have the tylenol available that she was aware of. She stated the MSD added the ordered medication to the medication administration record that day and she administered the medication as soon as she was able to, which was in the afternoon. Staff #29 stated it was neglectful that Former Resident #20 was put back into bed in pain after she had fallen. She stated if Former Resident #20 was in pain, medical attention should have been obtained. Staff #29 also stated if she could go back she would have sent Former Resident #20 out to the hospital for an assessment when she first complained of pain. On 6/20/23 at 11:06 a.m., the family member of Former Resident #20 stated after the fall that occurred on 6/14/23 Former Resident #20 experienced pain in her buttocks, hip and groin. She stated when she arrived at the residence at approximately 9:00 a.m. she called EMS herself due the level of pain Former Resident #20 experienced. She stated Former Resident #20 began to shake, had her eyes closed and was non-responsive. The family member stated when EMS arrived at the residence they reported Former Resident #20 had sustained a neurological change. She stated because Former Resident #20 was on external palliative care services at the time, EMS ordered a mobile x ray. The family member stated a physician's assistant (PA) from EMS arrived at the residence and administered pain medication to Former Resident #20 and inserted a catheter. She stated she had never been notified by the residence that Former Resident #20 reported pain after her fall. The family member stated the practitioner had written orders for tylenol for the residence to administer for pain and they had not administered the tylenol when she was in pain. The family member stated herself and another family member had reported concerns of neglect to the administrator because Former Resident #20 was left in consistent, excruciating pain. The family member stated after Former Resident #20 was admitted to external hospice services on 6/16/23 pain medication was ordered; however, she was unable to determine if the residence had received the medication so she obtained the medication and administered it herself. The family member stated the external hospice nurse reported to her that Former Resident #20's pain had still not been managed two days after she had fallen. The family member stated Former Resident #20 was moved out of the residence into an external inpatient hospice agency. The family member of Former Resident #20 stated she felt Former Resident #20 had been neglected by staff because they had done nothing to ensure she was comfortable and not injured. On 6/20/23 at 11:45 a.m., the private caregiver for Former Resident #20 stated when she arrived at the residence on 6/14/23 Former Resident #20 was in a lot of pain. She stated it was visible that she had pain and she was moaning. The private caregiver stated the residence did nothing after Former Resident #20 fell and began complaining pain. She stated the residence had not addressed the former resident's complaints of pain until the family arrived and contacted EMS themselves, approximately three to four hours after she had fallen. The private caregiver stated the residence had neglected Former Resident #20 by not addressing her complaints of pain and added they should have contacted EMS because Former Resident #20 had a fractured pelvis. On 6/20/23 at 1:38 p.m., the MSD stated Former Resident #20 had sustained a fall on 6/14/23 and Staff #29 had not reported any complaints of pain to her. The MSD stated she believed neglect was defined as "somebody who is intentionally not providing care to a resident." She stated she did not believe Staff #29 had not addressed Former Resident #20's pain intentionally or maliciously. The MSD stated it surprised her that Staff #29 believed what she had done was neglectful. The MSD stated she was not aware the former resident had reported pain to the overnight staff prior to them lifting her from the ground. The MSD stated "persons living with dementia cannot always report pain," and added she believed the situation was not handled appropriately. On 6/20/23 at 2:33 p.m., the health and wellness nurse stated neglect was when a person failed to meet a resident's needs. She stated if Former Resident #20 verbalized pain and was put in bed, after she fell, that was a failure to take care of the former resident. On 6/20/23 at 3:00 p.m., the administrator stated Former Resident #20 had fallen on 6/14/23 and she was notified at 1:30 p.m., approximately eight hours after the fall occurred. She stated Staff #29 had been written up for not addressing the former resident's pain needs. The administrator stated she defined neglect as "intentional wrong doing". The administrator stated, after hearing the definition on caretaker neglect, that the former resident's needs were not met and confirmed, based on the definition, Former Resident #20 had been neglected. On 6/20/23 at 4:13 p.m., Staff #28 stated after Former Resident #20 had fallen she was in so much pain he had a hard time moving her in bed. He stated after she had fallen she was bed bound and required assistance moving in bed. He stated he had reported the former resident's complaints of pain to Staff #29 and later found out that the complaints had never been addressed. Staff #28 stated he considered the incident with Former Resident #20 neglectful and added the level of pain she was in should have been addressed and she should have been checked on.

Based on record review and interview, the residence failed to ensure qualified medication administration persons (QMAPs) did not assess a resident's pain or use judgment to determine a resident's injury, affecting one former resident (#20). (Cross-reference Q1312)Findings include: An undated investigation report provided by the administrator read in part; Staff #29 had checked on Former Resident #20 on 6/14/23 at approximately 6:30 a.m. and 7:40 a.m. The investigation read that Former Resident #20 had complained of pain both times to Staff #29. On 6/20/23 at 7:48 a.m., Staff #29 stated she had checked on Former Resident #20 on 6/14/23 after she had fallen. Staff #29 stated when she checked on the former resident she had used her hands to apply pressure to both of Former Resident #20's hips and tried to determine her level of pain. Staff #29 stated she was not a nurse or a practitioner and she should have sent the former resident out to be assessed by a professional. On 6/20/23 at approximately 1:48 p.m., the memory support director stated she was unsure if QMAPs were allowed to assess a resident for injury after a fall and added she would have had to ask other management if it was allowed. On 6/21/23 at approximately 7:07 a.m., the administrator stated QMAPs were not allowed to assess a resident; however, they could evaluate and look at injuries. She stated the QMAP should not have pushed on anything or palpated any area. The administrator stated a QMAP could have only completed a light touch to understand where it may have hurt or just asked a resident questions.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of four sample residents (#37) and one former resident (#20). Findings include:1. Residence policyThe residence's Medication Administration policy, dated January 2022, read in part, the residence ensured all medications were administered according to the practitioner's orders. 2. Former Resident #20 was admitted to the residence on 5/9/22 with diagnoses that included atrial fibrillation, hypertension and centrilobular emphysema. a. Atorvastin A written practitioner's order, dated 10/10/22, directed the residence to administer atorvastatin 40 mg one tablet daily. However, the May and June 2023 MARs read the medication was not administered as ordered from 5/1-6/16/23 due to the medication not being on the MARs, for a total of 47 missed doses. b. Cetirizine A written practitioner's order, dated 2/12/23, directed the residence to administer Cetirizine 10 mg every daily. However, the May and June 2023 MARs read the medication was not administered as ordered on 5/4-5/5/23, 5/9/23, 5/11-5/14/23, 5/17-5/20/23,5/26-5/28/23, 6/1/23, 6/3-6/4/23- due to the medication being unavailable and on 6/15/23 due to the family refusing, for a total of 18 missed doses. c. Imodium A written practitioner's order, dated 4/29/23, directed the residence to administer imodium 2 mg one tablet every morning. However, the May and June 2023 MARs read the following:Two tablets were administered daily on 5/1-5/5/23, 5/25/23, 5/31/23, 6/1/23, 6/5-6/7/23 and 6/14/23, due to the MAR reading to administer two tablets daily, for a total of 12 incorrect doses. Imodium 2 mg was not administered on 5/13-5/14/23, 5/19-5/21/23, 5/23-5/24/23, 5/26-5/30/23, 6/2-6/4/23, 6/8-6/13/23 due to the medication not being available and on 6/15/23 due to the family refusing, for a total of 22 missed doses.d. Potassium A written practitioner's order, dated 11/3/22, directed the residence to administer potassium 10 MEQ one tablet daily. However, the May and June 2023 MARs read the medication was not administered as ordered on 5/21/23, 5/26/23 and 6/15/23 due to the medication being unavailable and on 6/14/23 due to the family requesting the medication be held, for a total of four missed doses. e. Probiotic multi enzyme A written practitioner's order, dated 5/2/22, directed the residence to administer probiotic multi enzyme one tablet daily. However, the May and June 2023 MARs read the medication was not administered as ordered on 5/21/23 and 6/15/23 due to the medication being unavailable and on 6/14/23 due to the family requesting the medication be held, for a total of three missed doses. f. Pramipexole A written practitioner's order, dated 11/3/22, directed the residence to administer pramipexole 0.75 mg two tablets daily. However, the June 2023 MARs read the medication was not administered as ordered on 6/14/23 because the medication was held at the family member's request and on 6/15/23 because the medication was unavailable, for a total of two missed doses. g. Trospium ChlorideA written practitioner's order, dated 11/3/22, directed the residence to administer trospium chloride one capsule daily. However, the June 2023 MARs read the medication was not administered as ordered on 6/14/23 because the medication was held at the family member's request and on 6/15/23 because the medication was unavailable, for a total of two missed doses. h. Vitamin D3A written practitioner's order, dated 5/2/22, directed the residence to administer vitamin D3 25 mcg two tablets daily. However, the June 2023 MARs read the medication was not administered as ordered on 6/14/23 because the medication was held at the family member's request and on 6/15/23 because the medication was unavailable, for a total of two missed doses. i. Xarelto A written practitioner's order, dated 5/2/22, directed the residence to administer xarelto 20 mg one tablet daily. However, the June 2023 MARs read the medication was not administered as ordered on 6/14/23 because the medication was held at the family member's request and on 6/15/23 because the medication was unavailable, for a total of two missed doses. j. Irbesartan A written practitioner's order, dated 11/3/22, directed the residence to administer Irbesartan 8300 mg one tablet daily. However, the June 2023 MAR read the medication was not administered as ordered on 6/14/23 because the medication was held at the family member's request and on 6/15/23 because the medication was unavailable, for a total of two missed doses. k. Aspirin A written practitioner's order, dated 10/11/22, directed the residence to administer aspirin 81 mg one tablet daily. However, the June 2023 MAR read the medication was not administered on 6/15/23 due to the medication being refused by the family, for a total of one missed dose. l. Calcium A written practitioner's order, dated 5/2/22, directed the residence to administer calcium 600-200 mg one tablet daily. However the June 2023 MAR read the medication was not administered on 6/15/23 due to the the medication being refused by the family, for a total of one missed dose. m. Duloxetine A written practitioner's order, dated 11/3/22, directed the residence to administer Duloxetine 60 mg one tablet daily. However, the June 2023 MAR read the medication was not administered on 6/15/23 due to the medication being refused by the family, for a total of one missed dose. n. FurosemideA written practitioner's order, dated 11/3/22, directed the residence to administer furosemide 20 mg two tablets daily. However, the June 2023 MAR read the medication was not administered on 6/15/23 due to the medication being refused by the family, for a total of one missed dose. o. GlipizideA written practitioner's order, dated 10/10/22, directed the residence to administer glipizide 5 mg two tablets daily. However, the June 2023 MAR read the medication was not administered on 6/15/23 due to the medication being refused by the family, for a total of one missed dose. p. Jardiance A written practitioner's order, dated 11/3/22, directed the residence to administer Jardiance 25 mg one tablet daily. However, the June 2023 MAR read the medication was not administered as ordered on 6/15/23 due to the family refusing the medication, for a total of one missed dose. q. Metoprolol A written practitioner's order, dated 11/3/22, directed the residence to administer metoprolol 50 mg one tablet daily. However, the June 2023 MAR read the medication was not administered as ordered on 6/15/23 due to the family refusing the medication, for a total of one missed dose. On 6/20/23 at 11:06 a.m., the family member of Former Resident #20 stated after Former Resident #20 had fallen she had difficulty swallowing her medication and staff did not administer the medications because she informed them the former resident was unable to swallow the medications. The family member stated the doctor had not been aware the former resident had swallowing difficulties or that medication was refused by her on behalf of the former resident. She stated on 6/15/23 the external hospice agency wrote medication orders and she began to administer the medications to Former Resident #20. She stated she was not aware of the missed medications and that she believed all medications were supplied through the residence's external pharmacy. On 6/20/23 at approximately 1:48 p.m., the memory support director (MSD) stated the medication should have been available to administer if there was a written practitioner's order. She stated she was aware medications had not been administered on 6/14/23 or 6/15/23 due to Former Resident #20's family refusing medication. The MSD stated the residence had not notified the practitioner nor was a hold order received to hold the medications. The MSD stated she believed the family could refuse the medication on behalf of the former resident and was not aware the former resident had to refuse medications themself. On 6/21/23 at 7:07 a.m., the administrator stated if a resident had orders for medication to be administered the medication should have been available to administer. She stated she believed Former Resident #20's practitioner had written a hold order to hold the former resident's medication. The administrator stated she was aware the family member had refused the medications and added she was unsure why the medications were refused. 3. Resident #37 was admitted to the residence on 2/5/22 with diagnoses including major depressive disorder. A written practitioner's order, dated 2/15/23, directed the residence to administer sertraline HCL oral concentrate 20 mg/ml for 0.5 ml every morning. However, the June 2023 medication administration record (MAR) read the medication was not administered on 6/18/23 due to the medication not being available, for a total of one missed doses. A written practitioner's order, dated 2/3/23, directed the residence to administer acetaminophen 500 mg three times daily. However, the June 2023 MAR read the medication was not administered on the morning of 6/2/23 due to the medication not being available, for a total of one missed dose. On 6/20/23 at 2:31 p.m., the MSD confirmed there was a discrepancy with the resident's sertraline and she was not administered the medication as ordered. She also stated when the MAR read a medication was not available, it meant it was out of stock and the resident was not administered the medication as ordered.

Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented information in the medication administration record (MAR), affecting two of four sample residents (#36, #37). Findings include: 1. Residence policyThe residence's Medication Administration policy, dated January 2022, read in part, QMAPs would accurately document medication administration in the MAR.2. Resident #36 was admitted to the residence on 5/24/23 with diagnoses including Parkinson's disease. A written practitioner order, dated 6/6/23, directed the residence to administer seroquel 25 mg twice daily. However, the June 2023 MAR read the medication was not available on the evening of 6/7/23. However, a progress note, dated 6/7/23, read in part the resident refused the medication, for a total of one inaccurately documented dose. A written practitioner order, dated 5/22/23, directed the residence to administer sinemet 25-100 mg three times daily. However, the June 2023 MAR read the medication was not available on the evening of 6/7/23. However, a progress note, dated 6/7/23, read in part the resident refused the medication, for a total of one inaccurately documented dose. 3. Resident #37 was admitted to the residence on 2/5/22. A written practitioner order, dated 2/3/23, directed the residence to administer acetaminophen 500 mg three times daily. However, the June 2023 MAR read the medication was not available midday on 6/6/23. However, a progress note, dated 6/6/23, read in part the medication was refused by the resident. On 6/20/23 at approximately 7:18 a.m., the administrator stated the medications for Resident #36 and #37 were not administered due to refusals and that the QMAP inaccurately documented the medication refusals on the MAR.

A licensure revisit was completed on 6/21/23 for the previous deficiency cited on 9/19/22. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 137 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for 12 months. Following the completion of Events TYFQ12 and TPRR11 on 9/19/22, a licensure revisit and licensure complaint, the department imposed a RN consultant for 12 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the consultant was required to complete, during the first month of the contract period:- Review each of the cited deficiencies identified in the Deficiency List, for Events TPRR11 and TYFQ12 both dated September 19, 2022, with the Administrator, and evaluate the residence's current compliance with corresponding regulations as well as regulations as outlined in 6 CCR 1011-1 Chapters 2, 7, and 24, where applicable. The consultant was required to complete, during the first two months of the contract period:- Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Administrator on any additional areas of noncompliance. The consultant would also implement a monitoring program, to be completed at least monthly, to ensure the Residence remains in compliance with previously cited deficiencies. The monitoring program will be incorporated into the Residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, Section 4. The Consultant will make certain that the QMP was designed to improve resident safety and well-being, and promoted continued quality improvement to enhance service delivery. The consultant was required to complete the following, during the first through sixth months of the contract period: - Conduct onsite visits at least weekly. The consultant was required to complete the following, during the seventh through twelfth months of the contract period:- Conduct onsite visits at least twice monthly. - Ensure the administrator had a process to correct identified deficiencies, which includes measures put into place to ensure deficient practice does not reoccur. - Ensure the administrator will monitor the corrective action to ensure deficiencies are remedied. The consultant was required to complete, during the twelfth and final month of the consulting period:- Prepare the administrator to independently manage the residence to ensure compliance with all applicable regulations governing assisted living residences. - Ensure the administrator has tools and resources in place to maintain compliance. Additionally, the consultant was required to ensure, during the entire 12 month contract period, for each of the deficiencies identified in the Deficiency List, for Events TPRR11 and TYFG12 both dated September 19, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 11/24/22.- Submit executed consultant contract to the department, due by 12/2/22.- Submit final consultant report, due by 12/15/23. Department records read the residence had chosen the RN consultant on 1/10/23 and the contract for the RN consultant was received on 1/11/23. Therefore, on the day of the completion of the licensure revisit, (6/20-6/21/23), the consultant would have been in her sixth month as consultant for the residence. 2. Current deficient practiceDuring the 6/20-6/21/23 licensure revisit, the revisit established there was current deficient practice. One deficiency was recited,including tag 1110. (Cross-reference Q1110) 3. Interviews On 6/21/23 at approximately 7:30 a.m., the administrator stated she was aware of the intermediate condition requirements to maintain compliance. The administrator stated the residence aspired to maintain compliance and tried their best. On 6/21/23 at 10:26 a.m., one of the consultants stated the RN consultant was currently out of town so she would provide the information she had in regards to the residence's compliance. The consultant stated she was aware the residence was currently under an intermediate condition to maintain a consultant. She stated she was aware the residence was required to maintain compliance with all regulations while under the intermediate condition. In regards to tag 1110, the consultant stated the memory support director had completed staff training related to oxygen. She stated the residence had a written training plan for oxygen services.

Based on observation, interview, and record review, the residence failed to make available, either directly or indirectly through a resident agreement, personal services, affecting one of three sample residents (#38). This deficiency was cited previously during a state licensure survey 9/19/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Resident Agreement and Referencea. The undated sample resident agreement, read in part, the residence was responsible for providing residents with personal care services.b. Chapter VII regulations governing assisted living residences, section two, defines "Personal services" as those services that an assisted living residence and its staff provide for each resident. 2. Resident #38 was admitted to the residence on 12/15/22 with diagnoses including heart failure. On 6/20/23 at 3:29 p.m., the oxygen concentrator was set to approximately 3.25 L (liters). A written practitioner order, dated 12/1/22, directed the residence to administer 2-3 L of oxygen continuously. On 6/20/23 at approximately 7:40 a.m., Staff #30 stated Resident #38 required 4L of continuous oxygen. On 6/20/23 at 8:08 a.m., Staff #27 stated Resident #38 required 4L of continuous oxygen. On 6/20/23 at 8:21 a.m., Staff #26 stated Resident #38 required 4L of continuous oxygen. On 6/20/23 at 3:48 p.m., the memory support director stated the resident required 3L of continuous oxygen. On 6/21/23 at approximately 7:33 a.m.,, the administrator stated staff were required to know how many liters of oxygen Resident #38 needed. She stated she was not sure why staff were not aware. Further, she stated the previous deficient practice was not corrected because staff were improperly monitoring the resident's oxygen intake.

A licensure revisit was completed on 6/21/23 for all previous deficiencies cited on 9/19/22. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 137 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for 12 months. Following the completion of Events TYFQ12 and TPRR11 on 9/19/22, a licensure revisit and licensure complaint, the department imposed a RN consultant for 12 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the consultant was required to complete, during the first month of the contract period:- Review each of the cited deficiencies identified in the Deficiency List, for Events TPRR11 and TYFQ12 both dated September 19, 2022, with the Administrator, and evaluate the residence's current compliance with corresponding regulations as well as regulations as outlined in 6 CCR 1011-1 Chapters 2, 7, and 24, where applicable. The consultant was required to complete, during the first two months of the contract period:- Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Administrator on any additional areas of noncompliance. The consultant would also implement a monitoring program, to be completed at least monthly, to ensure the Residence remains in compliance with previously cited deficiencies. The monitoring program will be incorporated into the Residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, Section 4. The Consultant will make certain that the QMP was designed to improve resident safety and well-being, and promoted continued quality improvement to enhance service delivery. The consultant was required to complete the following, during the first through sixth months of the contract period: - Conduct onsite visits at least weekly. The consultant was required to complete the following, during the seventh through twelfth months of the contract period:- Conduct onsite visits at least twice monthly. - Ensure the administrator had a process to correct identified deficiencies, which includes measures put into place to ensure deficient practice does not reoccur. - Ensure the administrator will monitor the corrective action to ensure deficiencies are remedied. The consultant was required to complete, during the twelfth and final month of the consulting period:- Prepare the administrator to independently manage the residence to ensure compliance with all applicable regulations governing assisted living residences. - Ensure the administrator has tools and resources in place to maintain compliance. Additionally, the consultant was required to ensure, during the entire 12 month contract period, for each of the deficiencies identified in the Deficiency List, for Events TPRR11 and TYFG12 both dated September 19, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 11/24/22.- Submit executed consultant contract to the department, due by 12/2/22.- Submit final consultant report, due by 12/15/23. Department records read the residence had chosen the RN consultant on 1/10/23 and the contract for the RN consultant was received on 1/11/23. Therefore, on the day of the completion of the licensure revisit, (6/20-6/21/23), the consultant would have been in her sixth month as consultant for the residence. 2. Current deficient practiceDuring the 6/20-6/21/23 licensure revisit, the revisit established there was current deficient practice. Two deficiencies were recited, including tags 1110 and 1180. Tag 1180 was cited at a D level, pattern of actual harm. (Cross-reference Q1110, Q1180) 3. Interviews On 6/21/23 at approximately 7:30 a.m., the administrator stated she was aware of the intermediate condition requirements to maintain compliance. The administrator stated the residence aspired to maintain compliance and tried their best. On 6/21/23 at 10:26 a.m., one of the consultants stated the RN consultant was currently out of town so she would provide the information she had in regards to the residence's compliance. The consultant stated she was aware the residence was currently under an intermediate condition to maintain a consultant. She stated she was aware the residence was required to maintain compliance with all regulations while under the intermediate condition. In regards to tag 1110, the consultant stated the memory support director had completed staff training related to oxygen. She stated the residence had a written training plan for oxygen services. In regards to tag 1180, the consultant stated the health and wellness nurse managed the residence's fall program. She stated the residence had residents that had repeatedly fallen and they had discussed approaches. The consultant stated the residence had issues keeping up with implementation of fall interventions.

Based on observation, interview, and record review, the residence failed to make available, either directly or indirectly through a resident agreement, personal services, affecting one of three sample residents (#38). This deficiency was cited previously during a state licensure survey 9/19/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Resident Agreement and Referencea. The undated sample resident agreement, read in part, the residence was responsible for providing residents with personal care services.b. Chapter VII regulations governing assisted living residences, section two, defines "Personal services" as those services that an assisted living residence and its staff provide for each resident. 2. Resident #38 was admitted to the residence on 12/15/22 with diagnoses including heart failure. On 6/20/23 at 3:29 p.m., the oxygen concentrator was set to approximately 3.25 L (liters). A written practitioner order, dated 12/1/22, directed the residence to administer 2-3 L of oxygen continuously. On 6/20/23 at approximately 7:40 a.m., Staff #30 stated Resident #38 required 4L of continuous oxygen. On 6/20/23 at 8:08 a.m., Staff #27 stated Resident #38 required 4L of continuous oxygen. On 6/20/23 at 8:21 a.m., Staff #26 stated Resident #38 required 4L of continuous oxygen. On 6/20/23 at 3:48 p.m., the memory support director stated the resident required 3L of continuous oxygen. On 6/21/23 at approximately 7:33 a.m.,, the administrator stated staff were required to know how many liters of oxygen Resident #38 needed. She stated she was not sure why staff were not aware. Further, she stated the previous deficient practice was not corrected because staff were improperly monitoring the resident's oxygen intake.

Based on interview and record review, the residence failed to detail in each resident's care plan the individualized approach necessary to address fall risk, affecting two of three sample residents (#12, #36) and one former resident (#20). This deficiency was cited previously during a state licensure survey 9/19/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #20 sustained a fall on 10/9/22 which resulted in a hospital visit and a second fall on 4/16/23. The residence did not update the care plan to include individualized approaches to address fall risks related to deficits in strength and balance. Subsequently, Former Resident #20 sustained a fall on 6/14/23 that resulted in nondisplaced subacute fractures of the pubic rami. The coroner stated Former Resident #20 was pronounced deceased on 6/20/23 as a direct result of complications related to the pelvic fractures sustained from the fall. Specifically, Resident #36 sustained four falls on 6/6/23. Two falls resulted in injuries which included a bruised foot and scrapes to both shins. The residence did not update the care plan to include individualized approaches to address fall risks related to deficits in strength and balance. Subsequently, Resident #36 sustained a fall on 6/7/23 that resulted in hospitalization. Resident #36 sustained falls on 6/8/23 and 6/10/23 without injuries and a fall on 6/11/23 that resulted in a scratch. The residence did not update the care plan to address individualized approaches to address the resident's fall risks after the four additional falls. Resident #36 sustained two additional falls on 6/12/23 and 6/16/23. Findings include:1. Reference and Residence policy According to Medical News Today, "A pubic ramus fracture describes a type of crack or break in a person ' s pelvis. Pubic ramus fractures are not typically life threatening and typically heal well. However, this kind of fracture can be serious for older people ... low energy trauma accidents may also cause people to sustain a pubic ramus fracture. These accidents can involve slips, or small falls from standing height ..." Medical News Today (2023), What is a Pubis Ramus Fracture, Retrieved from: https://www.medicalnewstoday.com/articles/pubic-ramus-fracture. The residence's Fall Reduction and Management policy, dated January 2022, read in part, when a resident fell, the residence would investigate the fall with the intention of reducing the fall incidents. Changes to the care plan would be implemented, as needed. 2. Former Resident #20 was admitted to the residence on 5/9/22 with diagnoses that included atrial fibrillation, hypertension and centrilobular emphysema. A fax cover sheet from the residence to the practitioner of Former Resident #20, dated 7/11/22 (actual date unknown), read Former Resident #20 sustained an unwitnessed fall on 10/9/22 and was transported by emergency medical services to the hospital. Former Resident #20 returned to the residence on 10/10/22 with no injuries noted. Incident reports for Former Resident #20, dated 4/15/23 and 6/14/23, read in part:On 4/15/23, Former Resident #20 was found on the floor in her room. Former Resident #20 was noted to have been found laying on the floor on her back with a pillow under her head. Former Resident #20 reporting slipping when she got out of bed. No injuries were reported. Contributing factors of the fall were noted to have been poor lighting, rugs/carpeting and furniture. On 6/14/23, Former Resident #20 was found on the floor in her her room. Former Resident #20 was found laying on her back on the floor. Former Resident #20 reported she had slid off the bed. Staff noted Former Resident #20 reported she did not hit her head and denied pain. No injuries were noted. No contributing factors were documented in the incident report. Progress notes for Former Resident #20, dated 4/17-6/18/23, were reviewed and read the following: A progress note, dated 4/17/23, late entry completed on 4/21/23 at 9:43 a.m. by the memory support director (MSD) read; "Resident has no c/o (complaint of) pain at this time. Resident has no change in mobility and is reminded to use her walker in her apartment. Staff to ensure resident has a clutter free apartment. Resident is baseline with intake and fluid with no concerns at this time." A progress note, dated 4/18/23, late entry completed on 4/21/23 at 9:23 a.m. by the MSD read; "Resident has no c/o (complaint of) pain at this time. Resident has no change in mobility and is reminded to use her walker in her apartment. Staff to ensure resident has a clutter free apartment. Resident is baseline with intake and fluid with no concerns at this time." A progress note, dated 4/21/23 at 9:43 a.m., completed by the MSD read; "Resident has no c/o (complaint of) pain at this time. Resident has no change in mobility and is reminded to use her walker in her apartment. Staff to ensure resident has a clutter free apartment. Resident is baseline with intake and fluid with no concerns at this time." A progress note, dated 6/14/23, late entry completed on 6/17/23 at 1:49 p.m. by the MSD read; "Resident had an unwitnessed fall in her apartment at approx(imately) 5:30 a.m. Resident at that time had no c/o pain other than 'my butt check hurts from sitting on the floor.' Family came into (residence) at approx(imately) 9:15 a.m. and requested (emergency medical services) to come out and assess. Resident is on palliative cares, therefore family and resident asked to not be transported. Resident had an x ray completed by mobile x ray. Family has been in apartment with resident most of the day. Family has asked to hold this evening and HS (hour of sleep) medications at this time."A progress note, dated 6/14/23, late entry completed on 6/17/23 at 1:52 p.m. by the MSD read; "This MSD had been in communication with the family throughout the day. Resident has a c/o pain in the hip/groin area on the right side. PA (physician assistant) and (external palliative care nurse) aware. Awaiting x ray results for further care changes. Family has been apartment (sic) all day and has asked staff to assist every (two) hours. Change of condition has started, awaiting hospice orders if family decide before completing and locking assessment." An x ray report for Former Resident #20, dated 6/14/23, read in part; Former Resident #20 sustained nondisplaced subacute fractures of the pubis rami. A fall assessment for Former Resident #20, dated 4/16/23, and completed on 6/14/23, read; Former Resident #20 was a high risk for falling and scored 90 points. The assessment further read Former Resident #20 had impaired gait which included; "difficulty rising from chair, uses chair arms to get up, bounces to rise, keeps head down when walking, watches the ground, grasps furniture, person or aid when ambulating. Cannot walk unassisted."The residence's care plan for Former Resident #20, dated 11/9/22, read in part; Former Resident #20 was able to get in and out of bed independently, demonstrated impaired judgment related to safety, required safety checks at night every two to three hours to monitor oxygen use and was independent with ambulation. The care plan for Former Resident #20 was not updated after the fall on 4/15/23 to include the updated fall assessment information or to include the individualized approaches necessary to address Former Resident #20's risk for falls related to deficits in balance and strength. On 6/20/23 at 7:48 a.m., Staff #29 stated on 6/14/23 when she arrived for her shift Staff #27 had reported Former Resident #20 fell during the overnight shift. She stated emergency medical services came to the residence and completed a mobile x ray. She stated she was unsure of what the results were; however, she was aware she was injured because she (Former Resident #20) had reported pain to her. On 6/20/23 at 11:06 a.m., the family member of Former Resident #20 stated she had received a telephone call from Staff #27 at approximately 5:50 a.m. on 6/14/23 to notify her that Former Resident #20 had fallen. The family member stated Staff #27 reported Former Resident #20 had no injuries. She stated Staff #29 telephoned her approximately 20 minutes later and also reported Former Resident #20 had no injury. The family member stated Former Resident #20's private caregiver arrived at 9:00 a.m. and Former Resident #20 was in pain. The family member stated Staff #29 and the private caregiver attempted to sit Former Resident #20 up and she complained of pain. The family member stated Former Resident #20 was in a lot of pain and emergency medical services were contacted once she requested it. The Family member stated she was aware Former Resident #20 had fallen in October 2022, but she had not been made aware of a fall that occurred in April 2023. The family member stated no measures had been put into place but the residence to prevent additional falls that she was aware of. The family member stated Former Resident #20 was unable to utilize her call pendant in the secure environment and added she (the family member) had pressed the pendant for assistance on 6/17/23; however, staff took 45 minutes to respond. The family member stated that Former Resident #20 had a fractured pelvis as a result of the fall. The family member stated Former Resident #20 moved from the residence to an external inpatient hospice agency on 6/17/23 due to the sustained injuries and the rapid decline in her health. On 6/20/23 at approximately 11:45 a.m., the private caregiver for Former Resident #20 stated she had received a telephone call from the family member of Former Resident #20 on 6/14/23 who the former resident had fallen. She stated when she arrived at the residence Former Resident #20 was laying in bed, propped up and was visibly uncomfortable. The private caregiver stated Former Resident #20 moaned, was in pain and expressed she was not alright. The private caregiver stated Former Resident #20 had a fractured pelvis as a result of the fall. On 6/20/23 at 12:20 p.m., Staff #26 stated Former Resident #20 had fallen on 6/14/23 and complained of pain in her buttocks. On 6/20/23 at 1:38 p.m., the MSD stated Former Resident #20 had fallen on 6/14/23 during the overnight shift. She stated it was reported to her that the former resident had not complained of pain at the time of the fall. The MSD stated she was unsure if Former Resident #20 had previously fallen. The MSD stated Former Resident #20 moved from the residence on 6/17/23 to an external impatient hospice agency due to her increased care needs. The MSD stated even though Former Resident #20 did not utilize her call pendant routinely she felt it was an appropriate intervention to prevent falls. On 6/20/23 at 2:33 p.m., the health and wellness nurse stated on 6/14/23 Former Resident #20 had fallen. She stated the former resident had an x ray after the fall. The health and wellness nurse stated Former Resident #20 had fallen two previous times that she was aware of. She stated she believed the fall interventions for the former resident's falls was to move her to the secure environment. On 6/20/23 at 3:00 p.m., the administrator stated she was notified on 6/14/23 at approximately 1:30 p.m. that Former Resident #20 had fallen. On 6/20/23 at 4:13 p.m., Staff #28 stated Former Resident #20 had fallen on 6/14/23 and staff had reported she had no injuries. Staff #28 stated at approximately 8:30 a.m., when he checked on Former Resident #20, he had attempted to reposition Former Resident #20 in her bed and she was in a lot of pain. Staff #28 stated after Former Resident #20 fell she was bed bound and was able to be moved with two staff and a sheet to transfer due to her pain level. On 6/21/23 at 7:07 a.m., the administrator stated she was aware Former Resident #20 had fallen prior to the fall on 6/14/23; however, she did not know the specific details of the falls. She stated she was not aware of interventions that had been put into place to prevent additional falls other than frequent checks. The administrator acknowledged the former resident was at risk for falling and stated the care plan should have been updated with fall interventions. She added she did not believe it should be updated after a fall. On 6/21/23 at 8:45 a.m., the coroner stated the preliminary cause of death noted for Former Resident #20 was related to the pelvic fracture sustained from her fall on 6/14/23. The coroner stated the death certificate would be issued to read the death was accidental with related complications from a pelvic fracture as a result of the fall sustained. 3. Resident #36 was admitted to the residence on 5/24/23 with diagnoses including dementia and Parkinson's disease. Incident reports for Resident #36, dated 6/6, 6/8, 6/10-6/12, and 6/16/23, read in part:On 6/6/23, Resident #36 fell four times. One fall resulted in bruises on the left foot and another resulted in scrapes to both shins. On 6/7/23, the resident had an unwitnessed fall and required emergency services because he could not move to get off the floor. On 6/8/23, the resident fell in his closet. On 6/10/23, the resident missed his chair while sitting and fell to the ground. On 6/11/23, the resident fell and was found laying in his back. The fall resulted in a scratch on his lower back and an abrasion to the right iliac crest. On 6/12/23, the resident fell and was found on the floor in his bathroom. On 6/16/23, the resident slid out of his wheelchair and fell to the ground. Progress notes for Resident #36, dated 6/12 and 6/17/23, read in part:On 6/12/23, the resident had bruising on his lower back and coccyx area in various stages of healing, as well as a small abrasion scratch on his lower back. On 6/17/23, the resident was assessed for external hospice services due to fall frequency. A care plan for Resident #36, dated 5/23/23, read in part, the resident was at risk for falls due to a parkinson's disease diagnosis and unsteady gait. An updated care plan for Resident #36, dated 6/19/23, read in part, the resident required assistance with mobility and had a history of falls due to ambulating without assistance. Staff were required to do frequent safety checks, encourage the resident to use the wheelchair and encourage the resident to remain in the common areas for staff supervision. However, the care plan did not include individualized approaches necessary to address fall risk after each fall. Additionally, the care plan was not updated after each fall to include necessary fall interventions to address why Resident #36 fell or staff interventions to address the falls. On 6/20/23 at approximately 7:40 a.m., Staff #30 stated Resident #36 fell frequently. She stated the staff interventions in place to prevent falls included two hour safety checks and staff supervision. On 6/20/23 at 8:08 a.m., Staff #27 stated Resident #36 was at risk for falls due to his history of falls. She stated the staff intervention in place to prevent the resident from falling was frequent checks. On 6/20/23 at 8:21 a.m., Staff #26 stated Resident #36 was at risk for falls due to his history of falls. She stated she was not sure what the care plan detailed for individualized approaches necessary to address fall risk. On 6/20/23 at 1:04 p.m., the legal representative for Resident #36 stated the resident fell frequently. She stated staff tried to keep him in a wheelchair to prevent falls. However, he fell out of the wheelchair at times. She also stated staff tried to keep the resident in common areas for supervision; however, he still fell. On 6/20/23 at 2:13 p.m., the MSD stated Resident #36 was at risk for falls due to parkinson's disease and hallucinations. She stated the resident was weak and experienced several falls. She stated the individualized approaches necessary to address fall risk included frequent safety checks, encourage the resident to remain in common areas for staff supervision, physical therapy, encourage the resident to participate in activities, proper footwear and to encourage the resident to use his walker and wheelchair. On 6/21/23 at approximately 7:33 a.m., the administrator stated Resident #36 was at risk for falls and the care plan should have been updated after falls with the individualized approach necessary to address fall risk. However, she stated it was not their policy to update the care plan after every fall that he had. 4. Resident #12 was admitted to the residence on 2/8/21 with diagnoses including unsteady gait. Incident reports for Resident #12, dated 4/12, 5/9, 5/29, and 6/13/23, read in part:On 4/21/23, the resident fell in her bathroom. On 5/9/23, the resident fell out of bed. On 5/29/23, the resident fell in her room and was found laying on her right side on the floor. On 6/13/23, the resident fell out of her chair. Progress notes for Resident #12, dated 5/12 and 6/13/23, read in part:On 5/12/23, the resident was showing signs of weakness and unsteady gait. On 6/13/23, the resident was not capable of using the call pendant for staff assistance. An assessment, dated 6/1/23, read in part, the resident was at risk for falls due to cognitive changes and poor safety awareness. Staff were required to encourage Resident #12 to put on socks and shoes, remind her to use a call pendant, and provide the resident with safety checks every 1-3 hours. A care plan for Resident #12, dated 1/20/23, read in part, the resident was at risk for falls. On 5/11/23 the care plan was updated with the staff intervention of safety checks every 1-3 hours. On 5/14/23 an intervention was added that staff were required to provide safety checks every 1-3 hours to ensure the resident was in bed when sleeping and did not need any extra assistance. On 6/1/23 the staff intervention of a toileting schedule, hydration, staff escorts, and a clutter free apartment were added. However, the care plan was not updated with the individualized approach necessary to address fall risk after the fall on 4/21 and 6/13/23. On 6/20/23 at 8:21 a.m., Staff #26 stated Resident #12 had a history of falls. However, she stated she was not sure of the individualized approach necessary to address fall risk. On 6/20/23 at 1:09 p.m., the legal representative for Resident #12 stated the resident was at risk for falls due to weakness. She stated the intervention in place was for staff to encourage the resident to use a wheelchair to prevent falls. On 6/20/23 at 2:13 p.m., the MSD stated Resident #12 was at risk for falls and staff were required to provide frequent safety checks and ensure the resident wore proper footwear. On 6/20/23 at 2:31 p.m., the health and wellness nurse stated care plans were updated after falls by the MSD.On 6/21/23 at approximately 7:33 a.m., the administrator stated Resident #12 was at risk for falls and the care plan should have been updated after falls with the individualized approach necessary to address fall risk. However, she stated it was not their policy to update the care plan after every fall that she had.

A licensure revisit was completed on 6/21/23 for all previous deficiencies cited on 9/19/22. The residence is in compliance with all regulations surveyed.

A licensure revisit was completed on 6/21/23 for all previous deficiencies cited on 12/13/22. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 137 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for 12 months. Following the completion of Events TYFQ12 and TPRR11 on 9/19/22, a licensure revisit and licensure complaint, the department imposed a RN consultant for 12 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the consultant was required to complete, during the first month of the contract period:- Review each of the cited deficiencies identified in the Deficiency List, for Events TPRR11 and TYFQ12 both dated September 19, 2022, with the Administrator, and evaluate the residence's current compliance with corresponding regulations as well as regulations as outlined in 6 CCR 1011-1 Chapters 2, 7, and 24, where applicable. The consultant was required to complete, during the first two months of the contract period:- Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Administrator on any additional areas of noncompliance. The consultant would also implement a monitoring program, to be completed at least monthly, to ensure the Residence remains in compliance with previously cited deficiencies. The monitoring program will be incorporated into the Residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, Section 4. The Consultant will make certain that the QMP was designed to improve resident safety and well-being, and promoted continued quality improvement to enhance service delivery. The consultant was required to complete the following, during the first through sixth months of the contract period: - Conduct onsite visits at least weekly. The consultant was required to complete the following, during the seventh through twelfth months of the contract period:- Conduct onsite visits at least twice monthly. - Ensure the administrator had a process to correct identified deficiencies, which includes measures put into place to ensure deficient practice does not reoccur. - Ensure the administrator will monitor the corrective action to ensure deficiencies are remedied. The consultant was required to complete, during the twelfth and final month of the consulting period:- Prepare the administrator to independently manage the residence to ensure compliance with all applicable regulations governing assisted living residences. - Ensure the administrator has tools and resources in place to maintain compliance. Additionally, the consultant was required to ensure, during the entire 12 month contract period, for each of the deficiencies identified in the Deficiency List, for Events TPRR11 and TYFG12 both dated September 19, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 11/24/22.- Submit executed consultant contract to the department, due by 12/2/22.- Submit final consultant report, due by 12/15/23. Department records read the residence had chosen the RN consultant on 1/10/23 and the contract for the RN consultant was received on 1/11/23. Therefore, on the day of the completion of the licensure revisit, (6/20-6/21/23), the consultant would have been in her sixth month as consultant for the residence. 2. Current deficient practiceDuring the 6/20-6/21/23 licensure revisit, the revisit established there was current deficient practice. One deficiency was recited,including tags 1180. Tag 1180 was cited at a D level, pattern of actual harm. (Cross-reference Q1180) 3. Interviews On 6/21/23 at approximately 7:30 a.m., the administrator stated she was aware of the intermediate condition requirements to maintain compliance. The administrator stated the residence aspired to maintain compliance and tried their best. On 6/21/23 at 10:26 a.m., one of the consultants stated the RN consultant was currently out of town so she would provide the information she had in regards to the residence's compliance. The consultant stated she was aware the residence was currently under an intermediate condition to maintain a consultant. She stated she was aware the residence was required to maintain compliance with all regulations while under the intermediate condition. In regards to tag 1180, the consultant stated the health and wellness nurse managed the residence's fall program. She stated the residence had residents that had repeatedly fallen and they had discussed approaches. The consultant stated the residence had issues keeping up with implementation of fall interventions.

Based on interview and record review, the residence failed to detail in each resident's care plan the individualized approach necessary to address fall risk, affecting two of three sample residents (#12, #36) and one former resident (#20). This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #20 sustained a fall on 10/9/22 which resulted in a hospital visit and a second fall on 4/16/23. The residence did not update the care plan to include individualized approaches to address fall risks related to deficits in strength and balance. Subsequently, Former Resident #20 sustained a fall on 6/14/23 that resulted in nondisplaced subacute fractures of the pubic rami. The coroner stated Former Resident #20 was pronounced deceased on 6/20/23 as a direct result of complications related to the pelvic fractures sustained from the fall. Specifically, Resident #36 sustained four falls on 6/6/23. Two falls resulted in injuries which included a bruised foot and scrapes to both shins. The residence did not update the care plan to include individualized approaches to address fall risks related to deficits in strength and balance. Subsequently, Resident #36 sustained a fall on 6/7/23 that resulted in hospitalization. Resident #36 sustained falls on 6/8/23 and 6/10/23 without injuries and a fall on 6/11/23 that resulted in a scratch. The residence did not update the care plan to address individualized approaches to address the resident's fall risks after the four additional falls. Resident #36 sustained two additional falls on 6/12/23 and 6/16/23. Findings include:1. Reference and Residence policy According to Medical News Today, "A pubic ramus fracture describes a type of crack or break in a person ' s pelvis. Pubic ramus fractures are not typically life threatening and typically heal well. However, this kind of fracture can be serious for older people ... low energy trauma accidents may also cause people to sustain a pubic ramus fracture. These accidents can involve slips, or small falls from standing height ..." Medical News Today (2023), What is a Pubis Ramus Fracture, Retrieved from: https://www.medicalnewstoday.com/articles/pubic-ramus-fracture. The residence's Fall Reduction and Management policy, dated January 2022, read in part, when a resident fell, the residence would investigate the fall with the intention of reducing the fall incidents. Changes to the care plan would be implemented, as needed. 2. Former Resident #20 was admitted to the residence on 5/9/22 with diagnoses that included atrial fibrillation, hypertension and centrilobular emphysema. A fax cover sheet from the residence to the practitioner of Former Resident #20, dated 7/11/22 (actual date unknown), read Former Resident #20 sustained an unwitnessed fall on 10/9/22 and was transported by emergency medical services to the hospital. Former Resident #20 returned to the residence on 10/10/22 with no injuries noted. Incident reports for Former Resident #20, dated 4/15/23 and 6/14/23, read in part:On 4/15/23, Former Resident #20 was found on the floor in her room. Former Resident #20 was noted to have been found laying on the floor on her back with a pillow under her head. Former Resident #20 reporting slipping when she got out of bed. No injuries were reported. Contributing factors of the fall were noted to have been poor lighting, rugs/carpeting and furniture. On 6/14/23, Former Resident #20 was found on the floor in her her room. Former Resident #20 was found laying on her back on the floor. Former Resident #20 reported she had slid off the bed. Staff noted Former Resident #20 reported she did not hit her head and denied pain. No injuries were noted. No contributing factors were documented in the incident report. Progress notes for Former Resident #20, dated 4/17-6/18/23, were reviewed and read the following: A progress note, dated 4/17/23, late entry completed on 4/21/23 at 9:43 a.m. by the memory support director (MSD) read; "Resident has no c/o (complaint of) pain at this time. Resident has no change in mobility and is reminded to use her walker in her apartment. Staff to ensure resident has a clutter free apartment. Resident is baseline with intake and fluid with no concerns at this time." A progress note, dated 4/18/23, late entry completed on 4/21/23 at 9:23 a.m. by the MSD read; "Resident has no c/o (complaint of) pain at this time. Resident has no change in mobility and is reminded to use her walker in her apartment. Staff to ensure resident has a clutter free apartment. Resident is baseline with intake and fluid with no concerns at this time." A progress note, dated 4/21/23 at 9:43 a.m., completed by the MSD read; "Resident has no c/o (complaint of) pain at this time. Resident has no change in mobility and is reminded to use her walker in her apartment. Staff to ensure resident has a clutter free apartment. Resident is baseline with intake and fluid with no concerns at this time." A progress note, dated 6/14/23, late entry completed on 6/17/23 at 1:49 p.m. by the MSD read; "Resident had an unwitnessed fall in her apartment at approx(imately) 5:30 a.m. Resident at that time had no c/o pain other than 'my butt check hurts from sitting on the floor.' Family came into (residence) at approx(imately) 9:15 a.m. and requested (emergency medical services) to come out and assess. Resident is on palliative cares, therefore family and resident asked to not be transported. Resident had an x ray completed by mobile x ray. Family has been in apartment with resident most of the day. Family has asked to hold this evening and HS (hour of sleep) medications at this time."A progress note, dated 6/14/23, late entry completed on 6/17/23 at 1:52 p.m. by the MSD read; "This MSD had been in communication with the family throughout the day. Resident has a c/o pain in the hip/groin area on the right side. PA (physician assistant) and (external palliative care nurse) aware. Awaiting x ray results for further care changes. Family has been apartment (sic) all day and has asked staff to assist every (two) hours. Change of condition has started, awaiting hospice orders if family decide before completing and locking assessment." An x ray report for Former Resident #20, dated 6/14/23, read in part; Former Resident #20 sustained nondisplaced subacute fractures of the pubis rami. A fall assessment for Former Resident #20, dated 4/16/23, and completed on 6/14/23, read; Former Resident #20 was a high risk for falling and scored 90 points. The assessment further read Former Resident #20 had impaired gait which included; "difficulty rising from chair, uses chair arms to get up, bounces to rise, keeps head down when walking, watches the ground, grasps furniture, person or aid when ambulating. Cannot walk unassisted."The residence's care plan for Former Resident #20, dated 11/9/22, read in part; Former Resident #20 was able to get in and out of bed independently, demonstrated impaired judgment related to safety, required safety checks at night every two to three hours to monitor oxygen use and was independent with ambulation. The care plan for Former Resident #20 was not updated after the fall on 4/15/23 to include the updated fall assessment information or to include the individualized approaches necessary to address Former Resident #20's risk for falls related to deficits in balance and strength. On 6/20/23 at 7:48 a.m., Staff #29 stated on 6/14/23 when she arrived for her shift Staff #27 had reported Former Resident #20 fell during the overnight shift. She stated emergency medical services came to the residence and completed a mobile x ray. She stated she was unsure of what the results were; however, she was aware she was injured because she (Former Resident #20) had reported pain to her. On 6/20/23 at 11:06 a.m., the familymember of Former Resident #20 stated she had received a telephone call from Staff #27 at approximately 5:50 a.m. on 6/14/23 to notify her that Former Resident #20 had fallen. The family member stated Staff #27 reported Former Resident #20 had no injuries. She stated Staff #29 telephoned her approximately 20 minutes later and also reported Former Resident #20 had no injury. The family member stated Former Resident #20's private caregiver arrived at 9:00 a.m. and Former Resident #20 was in pain. The family member stated Staff #29 and the private caregiver attempted to sit Former Resident #20 up and she complained of pain. The family member stated Former Resident #20 was in a lot of pain and emergency medical services were contacted once she requested it. The Family member stated she was aware Former Resident #20 had fallen in October 2022, but she had not been made aware of a fall that occurred in April 2023. The family member stated no measures had been put into place but the residence to prevent additional falls that she was aware of. The family member stated Former Resident #20 was unable to utilize her call pendant in the secure environment and added she (the family member) had pressed the pendant for assistance on 6/17/23; however, staff took 45 minutes to respond. The family member stated that Former Resident #20 had a fractured pelvis as a result of the fall. The family member stated Former Resident #20 moved from the residence to an external inpatient hospice agency on 6/17/23 due to the sustained injuries and the rapid decline in her health. On 6/20/23 at approximately 11:45 a.m., the private caregiver for Former Resident #20 stated she had received a telephone call from the family member of Former Resident #20 on 6/14/23 who the former resident had fallen. She stated when she arrived at the residence Former Resident #20 was laying in bed, propped up and was visibly uncomfortable. The private caregiver stated Former Resident #20 moaned, was in pain and expressed she was not alright. The private caregiver stated Former Resident #20 had a fractured pelvis as a result of the fall. On 6/20/23 at 12:20 p.m., Staff #26 stated Former Resident #20 had fallen on 6/14/23 and complained of pain in her buttocks. On 6/20/23 at 1:38 p.m., the MSD stated Former Resident #20 had fallen on 6/14/23 during the overnight shift. She stated it was reported to her that the former resident had not complained of pain at the time of the fall. The MSD stated she was unsure if Former Resident #20 had previously fallen. The MSD stated Former Resident #20 moved from the residence on 6/17/23 to an external impatient hospice agency due to her increased care needs. The MSD stated even though Former Resident #20 did not utilize her call pendant routinely she felt it was an appropriate intervention to prevent falls. On 6/20/23 at 2:33 p.m., the health and wellness nurse stated on 6/14/23 Former Resident #20 had fallen. She stated the former resident had an x ray after the fall. The health and wellness nurse stated Former Resident #20 had fallen two previous times that she was aware of. She stated she believed the fall interventions for the former resident's falls was to move her to the secure environment. On 6/20/23 at 3:00 p.m., the administrator stated she was notified on 6/14/23 at approximately 1:30 p.m. that Former Resident #20 had fallen. On 6/20/23 at 4:13 p.m., Staff #28 stated Former Resident #20 had fallen on 6/14/23 and staff had reported she had no injuries. Staff #28 stated at approximately 8:30 a.m., when he checked on Former Resident #20, he had attempted to reposition Former Resident #20 in her bed and she was in a lot of pain. Staff #28 stated after Former Resident #20 fell she was bed bound and was able to be moved with two staff and a sheet to transfer due to her pain level. On 6/21/23 at 7:07 a.m., the administrator stated she was aware Former Resident #20 had fallen prior to the fall on 6/14/23; however, she did not know the specific details of the falls. She stated she was not aware of interventions that had been put into place to prevent additional falls other than frequent checks. The administrator acknowledged the former resident was at risk for falling and stated the care plan should have been updated with fall interventions. She added she did not believe it should be updated after a fall. On 6/21/23 at 8:45 a.m., the coroner stated the preliminary cause of death noted for Former Resident #20 was related to the pelvic fracture sustained from her fall on 6/14/23. The coroner stated the death certificate would be issued to read the death was accidental with related complications from a pelvic fracture as a result of the fall sustained. 3. Resident #36 was admitted to the residence on 5/24/23 with diagnoses including dementia and Parkinson's disease. Incident reports for Resident #36, dated 6/6, 6/8, 6/10-6/12, and 6/16/23, read in part:On 6/6/23, Resident #36 fell four times. One fall resulted in bruises on the left foot and another resulted in scrapes to both shins. On 6/7/23, the resident had an unwitnessed fall and required emergency services because he could not move to get off the floor. On 6/8/23, the resident fell in his closet. On 6/10/23, the resident missed his chair while sitting and fell to the ground. On 6/11/23, the resident fell and was found laying in his back. The fall resulted in a scratch on his lower back and an abrasion to the right iliac crest. On 6/12/23, the resident fell and was found on the floor in his bathroom. On 6/16/23, the resident slid out of his wheelchair and fell to the ground. Progress notes for Resident #36, dated 6/12 and 6/17/23, read in part:On 6/12/23, the resident had bruising on his lower back and coccyx area in various stages of healing, as well as a small abrasion scratch on his lower back. On 6/17/23, the resident was assessed for external hospice services due to fall frequency. A care plan for Resident #36, dated 5/23/23, read in part, the resident was at risk for falls due to a parkinson's disease diagnosis and unsteady gait. An updated care plan for Resident #36, dated 6/19/23, read in part, the resident required assistance with mobility and had a history of falls due to ambulating without assistance. Staff were required to do frequent safety checks, encourage the resident to use the wheelchair and encourage the resident to remain in the common areas for staff supervision. However, the care plan did not include individualized approaches necessary to address fall risk after each fall. Additionally, the care plan was not updated after each fall to include necessary fall interventions to address why Resident #36 fell or staff interventions to address the falls. On 6/20/23 at approximately 7:40 a.m., Staff #30 stated Resident #36 fell frequently. She stated the staff interventions in place to prevent falls included two hour safety checks and staff supervision. On 6/20/23 at 8:08 a.m., Staff #27 stated Resident #36 was at risk for falls due to his history of falls. She stated the staff intervention in place to prevent the resident from falling was frequent checks. On 6/20/23 at 8:21 a.m., Staff #26 stated Resident #36 was at risk for falls due to his history of falls. She stated she was not sure what the care plan detailed for individualized approaches necessary to address fall risk. On 6/20/23 at 1:04 p.m., the legal representative for Resident #36 stated the resident fell frequently. She stated staff tried to keep him in a wheelchair to prevent falls. However, he fell out of the wheelchair at times. She also stated staff tried to keep the resident in common areas for supervision; however, he still fell. On 6/20/23 at 2:13 p.m., the MSD stated Resident #36 was at risk for falls due to parkinson's disease and hallucinations. She stated the resident was weak and experienced several falls. She stated the individualized approaches necessary to address fall risk included frequent safety checks, encourage the resident to remain in common areas for staff supervision, physical therapy, encourage the resident to participate in activities, proper footwear and to encourage the resident to use his walker and wheelchair. On 6/21/23 at approximately 7:33 a.m., the administrator stated Resident #36 was at risk for falls and the care plan should have been updated after falls with the individualized approach necessary to address fall risk. However, she stated it was not their policy to update the care plan after every fall that he had. 4. Resident #12 was admitted to the residence on 2/8/21 with diagnoses including unsteady gait. Incident reports for Resident #12, dated 4/12, 5/9, 5/29, and 6/13/23, read in part:On 4/21/23, the resident fell in her bathroom. On 5/9/23, the resident fell out of bed. On 5/29/23, the resident fell in her room and was found laying on her right side on the floor. On 6/13/23, the resident fell out of her chair. Progress notes for Resident #12, dated 5/12 and 6/13/23, read in part:On 5/12/23, the resident was showing signs of weakness and unsteady gait. On 6/13/23, the resident was not capable of using the call pendant for staff assistance. An assessment, dated 6/1/23, read in part, the resident was at risk for falls due to cognitive changes and poor safety awareness. Staff were required to encourage Resident #12 to put on socks and shoes, remind her to use a call pendant, and provide the resident with safety checks every 1-3 hours. A care plan for Resident #12, dated 1/20/23, read in part, the resident was at risk for falls. On 5/11/23 the care plan was updated with the staff intervention of safety checks every 1-3 hours. On 5/14/23 an intervention was added that staff were required to provide safety checks every 1-3 hours to ensure the resident was in bed when sleeping and did not need any extra assistance. On 6/1/23 the staff intervention of a toileting schedule, hydration, staff escorts, and a clutter free apartment were added. However, the care plan was not updated with the individualized approach necessary to address fall risk after the fall on 4/21 and 6/13/23. On 6/20/23 at 8:21 a.m., Staff #26 stated Resident #12 had a history of falls. However, she stated she was not sure of the individualized approach necessary to address fall risk. On 6/20/23 at 1:09 p.m., the legal representative for Resident #12 stated the resident was at risk for falls due to weakness. She stated the intervention in place was for staff to encourage the resident to use a wheelchair to prevent falls. On 6/20/23 at 2:13 p.m., the MSD stated Resident #12 was at risk for falls and staff were required to provide frequent safety checks and ensure the resident wore proper footwear. On 6/20/23 at 2:31 p.m., the health and wellness nurse stated care plans were updated after falls by the MSD.On 6/21/23 at approximately 7:33 a.m., the administrator stated Resident #12 was at risk for falls and the care plan should have been updated after falls with the individualized approach necessary to address fall risk. However, she stated it was not their policy to update the care plan after every fall that she had.