GOLDEN LODGE ASSISTED LIVING LLC

A licensure complaint revisit was completed on 5/13/25 for all previous deficiencies cited on 10/1/24. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 3/17/25.

A relicensure survey with complaint revisit was completed on 5/25/25 for all previous deficiencies cited on 10/21/24 . The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 3/17/25.

Based on record review and interview, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting five of eight sample residents (#32, #42, #43, #44, #46). This deficiency was previously cited during a relicensure survey on 10/21/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #42 was admitted to the residence on 4/25/25 with diagnoses including Parkinson's dementia. A written practitioner's order, dated 4/25/25, directed the residence to administer the following medications: Lysine 1000 mg once daily. Meloxicam 15 mg once daily. Tizanidine 2 mg once daily. However, the April and May medication administration records (MARs) for Resident #42 read the following medications were not administered because they were not available:Lysine 1000 mg on 4/27-4/29 and 5/1-5/6/25 for a total of nine missed doses. Meloxicam 15 mg on 4/27-4/30 5/1, 5/2, 5/4, 5/6, 5/7, for a total of nine missed doses. Tizanidine 2 mg on 4/27-4/30, 5/1-5/7/25 for a total of 11 missed doses. On 5/13/25 at 9:30 a.m., the administrator confirmed the medications listed above were not administered and were out of stock for Resident #42. On 5/13/25 at 1:05 p.m., the administrator said the reason the citation was not corrected was because of the residence's problems with their external pharmacy. 2. Similar deficient practice was found for Residents #32, #43, #44, #46.

Based on record review and interview, the residence failed to complete progress notes at the end of the shift, which included documentation regarding any out-of-the-ordinary event or issue that affected the resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address that resident's changing needs, affecting one of eight sample residents (#39). This deficiency was previously cited during a relicensure survey on 10/21/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #39 was admitted to the residence on 7/24/23 with a diagnosis of neurocognitive disorder and dysphagia. a. ObservationsOn 5/12/25 at 8:35 a.m., Resident #39 had four pinky-sized flat-round reddish-purple bruises on his forehead. Two were above his right eyebrow, and two smaller ones were near his hairline. On 5/12/25, at approximately 8:51 a.m., Staff #50 asked Resident #39's family member if she knew what had happened to his face. He continued to say that he had not noticed the marks on his face last week and had just returned this morning and saw them. On 5/12/25, at approximately 8:52 a.m., the family member of Resident #39 told Staff #50 she was unaware of what happened and that the residence did not call her about those bruises on his face. On 5/13/25 at 8:29 a.m., Staff #50 asked Resident #39's external hospice representative if the marks on Resident #39's skin were there when she saw him last week. On 5/13/25 at approximately 8:30 a.m., the external hospice representative said that she had not seen the bruises on his face when she was here last week. On 5/13/25 at 12:30 p.m., the administrator acknowledged there was no progress note about Resident #39's bruises.b. Record reviewDuring the on-site survey, the residence provided progress notes dated 2/12/25-5/12/25. The residence staff also wrote two notes in May, 5/4/25 and 5/12/25. Neither of the two notes in May noted the four pinky-sized flat-round reddish-purple bruises on his forehead.c. InterviewsOn 5/13/25 at 12:30 p.m., the administrator stated she expected staff to document when they noticed the injuries. She continued and confirmed that there was no documentation of the bruises observed on Resident #39's face, and now that she had been made aware, she had started an investigation. On 5/13/25 at 1:15 p.m., the administrator stated she thought the residence staff did not document because they assumed the injuries were due to his fall on 5/4/25. On 5/13/25 at approximately 1:20 p.m., the administrator stated she believed this was not corrected because the memory care staff thought the bruising was from the fall from 5/4/25, and failed to document. However, she stated that she expected staff to review the progress notes and incident reports written to verify their assumption.

A revisit survey was completed on 1/23/25 for all previous deficiencies cited on 10/3/24. The facility is in compliance with all deficiencies that were cited.

A complaint revisit was completed on 10/21/24 for the previous deficiency cited on 3/23/23. The residence is in compliance with all regulations surveyed.

A relicensure survey with complaint #CO37942, #CO37978, #CO38007 was completed on 10/21/24. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure at least one staff member was assigned responsibility for overseeing an infection prevention and control program and training; and had completed training from a nationally recognized provider or the Departments training, affecting 59 current residents. Findings include:On 10/16/24 at 1:35 p.m., the residence's completed training certificates for the infection prevention and control officer were requested but not provided. On 10/21/24 at 11:30 a.m., the health services director and the administrator said they were aware of the requirement for a designated infection control officer. However, the stated one had not been assigned nor had any staff at the residence completed training from a nationally recognized provider for the infectious diseases mitigation program.

Based on interview and record review, the residence failed to ensure that residence personnel engaged in the care of at-risk persons shall report suspected sexual abuse to law enforcement within 24 hours of observation or discovery, affecting 59 current residents. (Cross-Reference S1410)Findings include:Chapter VII regulations governing assisted living residences, part 2.1, defines"Abuse" means subjection to sexual conduct or contact that is classified as a crime. Chapter VII regulations governing assisted living residences, part 2.8, defines "At-risk person" means any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: Is a person with a mental health disorder as defined in Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.The residence's Reportable Events policy, dated 7/30/22, read in part that the residence was required to immediately begin an internal investigation once the residence was notified of an allegation of abuse of a resident. Abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The residence's investigation included reporting all allegations to law enforcement (LE). The residence does not contain information regarding reporting of sexual abuse specifically and provides no examples of sexual abuse. Resident #34 was admitted to the residence's secure environment (SE) on 8/31/24 with a diagnosis of Alzheimer's Disease. Progress notes, dated 10/10/24, read in part:At 11:57 a.m., late entry for an incident on 10/9/24 at 5:30 p.m., Resident #34 reported to a family member that another resident who resided in a room near hers (#35) demonstrated inappropriate behavior and had bothered her. The MCC notified the administrator, the resident's representative, and the practitioner. At 11:59 a.m., Resident #34 visited the memory care coordinator (MCC) in her office and was upset. She mentioned a bad man in a nearby room (#35) was bothering her. Typically, Resident #34 was happy and never demonstrated signs of distress prior to the last few days. The MCC contacted the practitioner for Resident #34. At 5:07 p.m., Resident #34 visited the life enrichment director for memory care (LEDMC) in her office. Resident #34 stated that a bad man had gone into her room, showed her something, and pointed to her groin area. She showed the LEDMC her room and stated she did not want to be alone and that the bad man needed to get out. She was very agitated and would not stop crying. She was usually happy and friendly, but she was upset. She pointed to the room of Resident #35 as the bad man. At 8:19 p.m., Resident #34 opened her door and screamed for someone to get out of her room as the person did not belong there. Another resident from a nearby room was in Resident #34's room. Resident #35 from the nearby room raised his fist at Resident #34; however, the MCC redirected the resident to vacate Resident #34's room. The MCC then requested a staff person sit outside of the room of Resident #34 and the Resident #35 for the night. Resident #34 was very upset. On 10/16/24, during the onsite visit, Staff #39, #42, #43 and the LEDMC stated that they reported a sexual abuse allegation made by Resident #34 that identified Resident #35 as the alleged assailant to the MCC; however, the staff members and the residence did not report the allegation to LE.On 10/16/24 at 10:20 a.m., the administrator stated that the MCC reported that Resident #34 reported a sexual abuse allegation to her. The administrator stated that she and other residence staff did not report the allegation to LE as she did not realize that she did not need more evidence than suspected sexual abuse to report the allegation.

Based on record review and interview, the residence failed to ensure at least one staff member was onsite who had certification in first aid from a nationally recognized organization, affecting 59 current residents. Findings include:1. On 10/17/24 staff first aid certifications were reviewed in comparison with the staff schedule for 9/1/24 through 10/31/24 and revealed the following: On 9/2/24 from 6:00 p.m. to 6:30 a.m., Staff #34 was the only staff working who was certified in first aid, however, it was not from a nationally recognized organization. On 10/10/24 from 6:00 p.m. to 6:30 a.m., none of the staff working were certified in first aid. 2. InterviewsOn 10/21/24 at 12:07 p.m., the administrator stated she was aware of the first aid requirement. The administrator stated she was unaware Staff #34 was not certified from a nationally recognized organization and she thought the previous the deficient practice had been corrected.

Based on record review and interview, the residence failed to ensure there was at least one staff member on-site at all times with current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization, affecting 59 residents. Findings include:1. Record ReviewOn 10/17/24, staff CPR certifications were reviewed in comparison with the staff schedule for 9/1/24 through 10/31/24 and revealed the following: On 9/2/24 from 6:00 p.m. to 6:30 a.m., Staff #34 was the only staff working who was certified in CPR, however, it was not from a nationally recognized organization. On 10/10/24 from 6:00 p.m. to 6:30 a.m., none of the staff working were certified in CPR.2. InterviewOn 10/21/24 at 12:09 p.m., the administrator stated she was aware of the CPR requirement. The administrator stated she was unaware Staff #34 was not certified from a nationally recognized organization and she thought the previous deficient practice had been corrected.

Based on record review and interview, the residence failed to identify the highest potential risk, hold, and document routine drills to facilitate staff and resident response to that risk, affecting 59 current residents. (Cross-reference S0918)Findings include:The residence's Fire Safety policy, dated 6/26/20, read in part that the residence conducted fire drills at random on a monthly basis. A drill was conducted on each shift quarterly. The residence documented all fire drills. On 10/17-10/21/24, during the onsite survey, the residence could not provide documented drills for any potential risk requiring evacuation, including fire, flood, earthquake, tornado, or power outage. On 10/16/24 at 8:50 a.m., Staff #5, #46, and #47 stated that the residence had not conducted any emergency drills for at least five or six months. On 10/16/24 at 9:10 a.m., the administrator stated that the residence maintenance director (MD) was responsible for conducting drills and had not conducted them. She added there was no documentation of any drills prior to her start date, which was approximately four weeks prior to the onsite survey. The administrator affirmed that she was ultimately responsible for ensuring that the drills were conducted and the residence had not conducted any since she began working at the residence. She added she was aware of the requirement for routine drills.

Based on observation, interview, and record review, the residence failed to ensure that the residence's emergency policies included the circumstances and procedures to evacuate the premises, assignment of specific staff duties on each shift using triage to identify the most vulnerable residents, or agreements with other residences in the event of relocation of residents, affecting 59 current residents. (Cross-reference S0918) Specifically, the residence failed to have an effective emergency plan, and staff could not state the procedure for evacuating residents who utilized wheelchairs to ambulate and resided on the second and third floors of the residence. This failure created an immediate jeopardy risk of neglect to all nine current residents residing in the residence. On 10/17/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include: 1. Residence PoliciesOn 10/16/24, the residence provided the residence's Emergency Preparedness Plan policy, dated 4/1/24, read in part that the policy was for a different residence in a different geographical area. The information contained in the plan reflected the risks and resources of a different residence and geographical area. On 10/17/24 at 8:30 a.m., the residence provided the residence's undated Emergency Procedures document that contained the name and contact information for the prior administrator of record from approximately five months prior to the survey and contained no contact information for the current administrator of the residence. Further, it did not contain specific circumstances that the residence was to evacuate, the procedures to evacuate the premises, the assignment of specific staff duties on each shift using triage to identify the most vulnerable residents, or agreements with other residences in the event of relocation of residents. On 10/17/24 at 11:40 a.m., the residence provided the residence's Evacuation policy, dated 6/26/20; it did not contain specific circumstances that the residence was to evacuate, the procedures to evacuate the premises, the assignment of specific staff duties on each shift using triage to identify the most vulnerable residents or agreements with other residences in the event of relocation of residents; however, it read that the residence was required to have and provide an emergency evacuation plan and the policy contained the steps to create an emergency evacuation plan. The residence's Residence and Care Agreement, dated 2/10/21, read in part that fire protection included that the residents' rooms contained sprinklers. 2. ObservationsOn 10/16/24 and 10/17/24, during the onsite survey, the residence's second and third floors were only accessible by elevator and stairs to reach the ground floor. The elevators had postings that read the elevators were not to be used if there was a fire. On 10/17/24, during the onsite visit, Residents #22, #37, and #41 utilized a wheelchair to ambulate and resided on the second and third floors. 3. Record ReviewA care plan for Resident #22, dated 10/9/24, read the resident was unable to evacuate independently and utilized a wheelchair for ambulation. A care plan for Resident #37, dated 8/19/24, read the resident was unable to evacuate independently and utilized a wheelchair for ambulation. A care plan for Resident #41, dated 8/19/24, read the resident was unable to evacuate independently and utilized a wheelchair for ambulation. 4. InterviewsOn 10/16/24, during the onsite visit, Staff #40 and #41 stated a fire alarm sounded approximately two weeks prior to the onsite visit, and the two staff members assisted residents on the basement level and first floor to evacuate as they did not know the cause of the alarm. They added that only the residents on the basement level and first floor were able to evacuate as the basement level and first floor had no stairs. They stated the residents who resided on the second and third floors were not able to evacuate fully, as many of the residents were unable to navigate the stairs. On 10/17/24, during the onsite visit, Staff #5, #46-#48 stated that there were approximately seven residents who required full stand-by assistance from a staff member to navigate any stairs. They added there were three residents (#22, #37, and #41) who exclusively utilized a wheelchair to navigate and were unable to navigate the stairs at all. The staff members stated that approximately two and a half weeks prior to the onsite survey, the fire alarm sounded, and the staff members attempted to assist residents with evacuation from the second and third floors. Staff #5 stated she assisted four residents, three with walkers and one with a cane, down the stairs; however, the residents were at risk for falls as she was not able to stand next to and assist all four of them at the same time. The staff members stated that they did not know how to evacuate Residents #22, #37, or #41 and asked the residence after the event how to do so; however, the residence provided no direction prior to or after the fire alarm occurred. The staff members stated that if they had to evacuate residents in wheelchairs, they might consider using the elevator quickly despite having awareness they may not be able to use the elevator, or they may take the residents in wheelchairs down the stairs despite that method of evacuation putting the residents at significant risk of a fall. On 10/17/24 at 8:30 a.m., the administrator stated that the Emergency Preparedness Plan policy was for a different residence in a different geographical area, contained no local information or resources, and was not an effective plan for the residence. She added that the residence had posted an Emergency Procedure document; however, she could not state what it contained without reviewing it. After she reviewed the Emergency Procedure document, she affirmed it did not contain the required elements of an emergency plan and contained outdated information. In a later interview, at 9:50 a.m., the administrator stated that the residence had a gas leak on 9/30/24, and 10 minutes after staff reported the gas leak, the fire alarm coincidentally went off for an unrelated issue. She stated the local fire authority (LFA) arrived and tested the gas levels, and the residence had a gas leak in the water heater room and had not required the residence to evacuate residents. She added that she was unaware that the residence staff had attempted to evacuate residents due to the alarm. The administrator was unable to state scenarios of risks when the residence was required to evacuate; however, she later affirmed that in some instances, wildfires or gas leaks might lead to a complete evacuation. She stated that the residence staff were unaware of what they were to do when the residence experienced an emergency that led to an evacuation and that if the staff had to evacuate the residence, she was unsure of how the staff could evacuate Residents #22, #37, or #41. In a later interview at approximately 11:40 a.m., the administrator stated that the residence care coordinator (RCC) found the emergency policies; however, they did not contain assignments of specific staff duties on each shift using triage to identify the most vulnerable residents with specific information tailored to the residence. She added the policies contained no procedures for evacuation of residents who resided on the second or third floor and utilized a wheelchair for all ambulation. 3. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the three current residents at immediate jeopardy risk for lack of policies on fire response. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 10/17/24 at 1:10 p.m., the RCC submitted written evidence that read in pertinent part: "(The residence will provide) education to all staff and departments for emergency preparation plans and what to do in the event of emergencies in the local community and who is assigned to what during an event -education to start 10-17-24 and to be completed for all staff by end of day 10-25-24. Education to the residents on what to do in events of emergencies for Awareness- and who is assigned to what. Meeting with residents in AL [assisted living residence] for education of emergency prep to be completed on 10-28-24. Triage tree for emergencies to be completed for binder by end of day 10-18-24. Education to the families of all residents of what the community will do in the event of an emergency and who is assigned to delegate. Email blast to families for emergency prep plan will be sent out by end of day 10-28-24. Get in place 2 local shelter community resources for Golden Lodge residents- have them in writing and on file for the emergency book. Will have in place to community shelters by 10-25-24. Community to order transport sling for stairwell in event of needing to evacuate 2/3 floor residents. The community ordered on 10-17-24- 4 transport slings. Will be delivered by end week (10/18/24). Will complete monthly drills to stay in regulation. The triage tree to be updated as changes occur in leadership and then reposted in emergency binder. Quarterly resident review at town hall meeting with residents to review emergency plan. Going forward for new move ins in the welcome folder will have the most recent emergency plan that would happen for their loved ones. For current families and changes that happen for the emergency plan families will be updated as needed. Will make sure to annually connect with local community shelters and update records as needed. Ongoing verification of slings during the monthly drills."However, the written evidence did not indicate the risk had been removed because it did not include how the residence planned to evacuate Residents #22, #37, and #41 until the transport slings arrived. The administrator was directed to submit additional written evidence. On 10/17/24 at 3:47 p.m., the administrator submitted additional written evidence that read in pertinent part: "inthe meantime until slings arrive if an emergency were to occur the (LFA) approved the community to utilize sheets in place of sling/transfer board in the event of an emergency within the next 48 hours (10/17/24-10/19/24)."

Based on observation, interview, and record review, the residence failed to thoroughly investigate all allegations of abuse of a resident, affecting one sample resident (#34) and the 21 other current residents in the secure environment (SE). (Cross-reference S0410). Specifically, Resident #34 reported an allegation of sexual abuse by Resident #35. The residence failed to follow its policy and conduct a thorough investigation that included how the residence protected residents from abuse during the investigation. Resident #34 continued to report allegations of sexual abuse, was repeatedly tearful, and expressed fear of Resident #35. Further, staff reported that Resident #34 consistently reported accurate information regarding events, more so than other residents in the SE, and Resident #35 frequently entered other residents' rooms unsupervised, which put all residents in the SE at risk. On 10/16/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Residence Policya. Chapter II regulations governing assisted living residences, part 4.2.2, requires that the following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department: (D) Any occurrence involving physical, sexual, or verbal abuse of a client, by another client, an employee of the licensee or a visitor to the facility or agency. b. Chapter VII regulations governing assisted living residences, part 2.1, defines"Abuse" means subjection to sexual conduct or contact that is classified as a crime.c. The residence's Reportable Events policy, dated 7/30/22, read in part that the residence was required to immediately begin an internal investigation once the residence was notified of an allegation of abuse of a resident. The investigation was to include documented interviews of witnesses and reporting parties of the allegation, related client records, a summary of relevant documents, a description of the event, the risk of ongoing maltreatment, agencies the residence reported the incident to, summaries of investigative findings and an individual abuse prevention plan. Further, the findings of the investigation were to be available for department review and reported to the Department within five days of the initial report. The report will include all findings of the events leading to the occurrences and all measures put in place to ensure the event or similar events do not occur again. d. The residence's Incident Reports policy, dated 7/30/24, read in part that the residence documented any allegation of abuse registered by residents, visitors, or others in an incident report in addition to the residents' progress notes. Further, if there was more than one resident involved, the residence staff that were on the shift where the allegation was made completed an incident report for each resident. e. The residence's Residence and Care Agreement, dated 2/10/21, read in part that the residence might have residents who had a history of behavioral expressions that included physical combativeness, disruptive behavior, and socially inappropriate behavior. Further, the residence agreed to do what was reasonably within our control to maintain a safe and calm environment. However, due to the nature of the group setting, the residence cannot guarantee that the residents will be free from disruption. 2. ObservationOn 10/16/24 at 8:25 a.m., Resident #34 cried and gestured at Resident #35's room. 3. Record Reviewa. Residence Investigations of AbuseOn 10/15/24 and 10/16/24, a review of the Department's occurrence database revealed the residence had submitted no occurrences after 9/26/24. The list contained no sexual abuse allegations. On 10/16/24, the residence provided all documented investigations of abuse, dated 7/16/24 to 10/16/24; however, the investigations were a printed list fromthe Department's occurrence database and failed to contain the following: the residence's process for investigating abuse allegations, documentation of the investigation process to evidence the required reporting and that a thorough investigation was conducted, how the residence protected residents from potential future abuse while the investigation was conducted, corrective action taken by the residence if abuse was verified, and a copy of the report with the investigation findings available for Department review. On 10/16/24 at 11:10 a.m., all documented investigations of abuse regarding Residents #34 and #35 were requested. On 10/16/34 at 11:40 a.m., the residence provided a handwritten document, dated 10/8/24, the document read in part that a family member of Resident #34 reported that Resident #34 was upset and made a gesture to the legs. The memory care coordinator (MCC) and administrator interviewed Resident #34. Resident #34 stated that Resident #35 was bad and gestured to her legs, and when asked, she stated that the man did not touch her. The administrator instructed staff to watch and make sure the two residents were not by one another. On Friday (undated), the MCC sent a video of Resident #35 going into Resident #34's room, but Resident #35 did not do anything, so the staff got him out. The document contained no staff interviews or interviews with Resident #35 as evidence that the residence conducted a thorough investigation. Further, the date of the document did not correspond with the dates of the incidents listed in the progress notes of Resident #34 or Resident #35.b. Resident #34 was admitted to the residence on 8/31/24 with a diagnosis of Alzheimer's Disease. Progress notes, dated 10/10/24, read in part:At 11:57 a.m., late entry for an incident on 10/9/24 at 5:30 p.m., Resident #34 reported to a family member that another resident who resided in a room near hers demonstrated inappropriate behavior and had bothered her. The MCC notified the administrator, the resident's representative, and the practitioner. At 11:59 a.m., Resident #34 visited the MCC in her office and was upset. She mentioned a bad man in a nearby room was bothering her. Typically, Resident #34 was happy and never demonstrated signs of distress prior to the last few days. The MCC contacted the practitioner for Resident #34. At 5:07 p.m., Resident #34 visited the life enrichment director for memory care (LEDMC) in her office. Resident #34 stated that a bad man had gone into her room, showed her something, and pointed to her groin area. She showed the LEDMC her room and stated she did not want to be alone and that the bad man needed to get out. She was very agitated and would not stop crying. She was usually happy and friendly, but she was upset. She pointed to a nearby room as the bad man. At 8:19 p.m., Resident #34 opened her door and screamed for someone to get out of her room as the person did not belong there. Another resident from a nearby room was in Resident #34's room. The resident from the nearby room raised his fist at Resident #34; however, the MCC redirected the resident to vacate Resident #34's room. The MCC then requested a staff person sit outside of the room of Resident #34 and the resident of the nearby room's door for the night. Resident #34 was very upset. MCC contacted Resident #34's representative and practitioner. A progress note dated, 10/16/24, read in part that Resident #34 expressed to a department representative that there was an incident of inappropriate touching. The residence moved Resident #35 to another hallway from Resident #34 during the investigation of the abuse allegation. The MCC notified the administrator, the resident's practitioner, law enforcement (LE), and adult protection services (APS). However, the progress failed to contain evidence that the residence conducted a thorough investigation, including interviewing Resident #34, Resident #35, or residence staff. The progress notes regarding the incidents read the sexual abuse allegation that occurred on 10/9/24, contrary to the investigation document, dated 10/8/24, provided by the residence. On 10/16-10/21/24, during the onsite survey, the residence provided no further progress notes or incident reports regarding investigations of the abuse allegation made by Resident #34. c. Resident #35 was admitted to the residence on 9/22/24 with a diagnosis of Alzheimer's Disease. Progress notes dated, 9/28/24-10/15/24, read in part:On 9/28/24, late entry for an incident on 9/27/24, Resident #35 went into another resident's room. Staff attempted to redirect the resident; however, he became physically aggressive with staff. The resident then threw another resident's belongings around the other resident's room. The resident attempted to "clip" the staff members with clippers. An incident report was completed for aggressive behavioral expressions by Resident #35. The administrator was contacted. On 10/2/24, late entry for 10/1/24, Resident #35 entered other residents' rooms. On 10/6/24, two residents expressed fear of Resident #35 as he entered their rooms. On 10/10/24, late entry for 10/8/24, Resident #35 entered other residents' rooms uninvited. He entered an unidentified resident's room, attempted to take a shower, and then wandered through the hallways nude, and the resident exposed his backside to others. On 10/10/24, another resident who resided near Resident #35 reported that Resident #35 kept entering her room and exposing his genitalia to her. Resident #35 stated to a staff member, "She is 17. Come with me." On 10/10/24, a resident who resided near Resident #35 screamed at Resident #35 for him to get out of the resident's room and that he did not belong in the other resident's room. Resident #35 raised his fist; however, staff redirected the resident. The staff notified the administrator. On 10/11/24, Resident #35 had been in the room of Resident #34. Resident #34 was distressed and cried. This incident was not the first occurrence of this. The resident became verbally aggressive to staff when staff attempted to redirect the resident. On 10/15/24, Resident #35 entered two different resident rooms. Resident #35 trapped Resident #38 with a walker and would not exit when redirected. An incident report, dated 9/27/24, read in part that Resident #35 entered an unidentified female resident's room, and the staff were unable to redirect the resident. Resident #35 attempted to jump in the bed with the other resident. The resident became physically aggressive toward staff and eventually exited the room. On 10/16/24-10/21/24, during the onsite visit, the residence provided no further progress notes or incident reports regarding investigations of the abuse allegation made about Resident #35. 4. InterviewsOn 10/16/24, during the onsite visit, Staff #38, #39, and #42-#44 and the LEDMC stated that Resident #34 reported that Resident #35 touched her inappropriately, exposed his genitals, or gestured sexually. They stated that Resident #35 frequently entered other residents' rooms unsupervised. They stated that Resident #34 was able to report concerns more accurately than any other resident in the SE. The staff added they were concerned about Resident #34 as she reported feeling scared of Resident #35 and frequently cried. The staff stated they reported the concerns to the MCC and the administrator; however, they were unsure of the outcome on 10/9/24 or 10/10/24. The staff stated they they attempted to keep two residents apart when they saw them together when not assisting other residents. They affirmed that the residence had a staff member stationed at the door of Resident #34 during the overnight shifts since Resident #34 was next door to Resident #35; however, they did not see anyone stationed when beginning their shifts on 10/16/24, and that the staff members continued to provide care and had to leave the area when other residents required assistance. The staff members stated that there was no staff member scheduled with Resident #35 or #34 during the day. The staff members were unable to state what other protections or outcomes occurred from the report. The staff members reported that Resident #34 had never reported any other concerns regarding any staff or other residents aside from Resident #35; however, she continued to report that Resident #35 gestured, exposed his genitals, or sexually touched her repeatedly. The staff members stated they were not interviewed individually by the administrator during the investigation of the sexual abuse allegation. On 10/16/24 at 8:30 a.m., Resident #34 stated that a bad man had done something she did not want. She gestured to the door of Resident #35 and stated the bad man. Resident #34 gestured with her fingers and then placed her fingers near her vaginal area and stated that the bad man touched her there. She stated the incident had not occurred in her room; however, she stated he came in her room often. She stated she was scared of him. On 10/16/24 at 10:12 a.m., the health service director (HSD) stated she was aware that Resident #34 made a report of inappropriate touching and that the MCC and administrator interviewed Resident #34. On 10/16/24 at 10:20 a.m., the administrator stated that a family member reported that Resident #34 reported to her that Resident #35 touched her in a sexually inappropriate way. She stated she could not recall the specific date; however, she affirmed it was sometime during the week of 10/7/24. She added that she interviewed Resident #34 with the residence care coordinator (RCC) and that the resident stated that Resident #34 communicated through gestures and also stated that Resident #35 exposed his genitalia to her. She stated she did not want that to occur. The administrator stated she asked Resident #34 if Resident #35 touched her, and the resident said no. She affirmed Resident #35 exposing his genitals to Resident #34 without consent was also sexually inappropriate. The administrator then stated that the MCC and not the RCC was with her during the interview of Resident #34. The administrator stated that Resident #34 stated that Resident #35 was a bad man and entered her room without consent, and she was fearful. The administrator stated that she requested footage from the representative of Resident #34 and viewed it. The administrator stated that Resident #35 entered Resident #34's room when Resident #34 was not present, so he removed his pants and got into her bed. The administrator stated that she did not interview staff members and that she solely documented the interview with the resident. She added that she planned to move Resident #35 so that he was not next door to Resident #34 and requested that staff members keep them apart. She added that the residence had not yet moved Resident #35, and he continued to remain next door to Resident #34. On 10/16/24 at 10:52 a.m., the MCC stated that Resident #34 reported that Resident #35 touched her to a family member, and the family member reported the concern to the administrator and the MCC. She stated that she and the administrator interviewed Resident #34, and she reported that Resident #35 exposed his genitals to her; however, he did not sexually touch her. The MCC stated that Resident #35, non-consensually exposing his genitals to Resident #34, was still sexually abusive. She stated that the residence requested footage from the camera from the family of Resident #34, and it did not show that anything occurred in the room with the exception of Resident #35 entering when Resident #34 was not initially present, removing his pants, and sitting on the bed of Resident #34. The MCC stated that Resident #34 was a consistent and accurate reporter of facts and was a better reporter than anyone else in the SE. She added that Resident #35 routinely entered the rooms of other residents in the SE who were unable to report concerns. The MCC stated that Resident #34 had expressed daily fear since the initial report. She added she believed Resident #35 did something inappropriate to Resident #34; however, there was no evidence. She added that the staff had not reported further reports from Resident #34 of Resident #35 touching her; however, they may have believed that she already knew. She added that the residence added a staff person to monitor the doors of Residents #34 and #35 at night; however, the staff had to leave at times to assist other residents. She added that Resident #34 continued to reside next door to Resident #34; however, the residence had planned to move them but had not done so yet. She added that the residence discussed a one-on-one external service provider (ESP) to monitor Resident #35; however, the resident's family said they could not pay for the extra care. She added she believed that Resident #35 was not appropriate for the residence. On 10/16/24 at 2:51 p.m., a family member of Resident #34 stated she had visited the resident on 10/9/24, and the resident reported through hand gestures and words that another resident touched her genital area without consent. The family member added that the resident was crying and fearful, and she was not sure why the residence did not move the resident who reportedly touched Resident #34 after the family reported it to the residence. She added the residence should have acted more quickly as Resident #34 continued to be fearful, and the resident that she had identified was next door to her. 5. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed Resident #34 and the other 21 current residents in the SE at immediate jeopardy risk for abuse since the residence failed to follow their policy on investigation of abuse including ensuring the resident's safety during the investigation into the abuse allegation. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 10/16/24 at 3:08 p.m., the RCC submitted written evidence that read in pertinent part: "Starting 10-16 leadership will continue ongoing thorough investigation with all SE staff, and conduct 5 other resident interviewsalong with (#34) and (#35) ... will be completed 10-18-24 at 3 pm. Will contact families of the 5 SE interviews... by 10-18-24 ... will contact APS ... by 10-16-24 ... Will contact the local police, will contact PCPs of (#34, #35), will contact ombudsman, will file an occurrence ... by 10-16-24. Will place a 1:1 with resident (#35) starting effective immediately to protect resident (#34) and other residents ... by 1:30 p.m. on 10-16-24. Resident (#35) will be moved (another hallway) effective 10-16-24. Leadership will train all staff in the community starting 10-16-24 and will complete all training to staff in building by 10-18-24 end of day- this will be conducted 1:1, all staff meeting and groups -training will cover all forms of abuse and when to report and who to report to (HSD)/RCC/(Administrator) to review incidents and progress notes reports daily and take appropriate action if it needs to be investigated and reported Progress notes on (#34),(#35) for 30 days along with RCC progress notes."

Based on interview and record review the residence failed to comply with authorized practitioner's orders associated with medication administration for four of eight sample residents (#15, #22, #32 and #36). Findings include:1. Resident #36 was admitted to the residence on 1/4/23 with a diagnosis of dementia.a. AcetaminophenA written practitioners order, dated 3/25/23, directed the residence to administer acetaminophen 500 mg two tablets three times daily. However, the June, August, September and October 2024 electronic administration records (eMARs) read that the medication was not available on 6/1 the morning and afternoon dose, 6/2 and 6/3 all three doses, 8/14 and 8/15 the morning and afternoon dose, 9/12 the afternoon dose, 9/13 the morning and afternoon dose, 9/14 the morning dose, 10/1 the afternoon and evening dose and 10/2/24 the morning and afternoon dose, for a total of 20 missed doses. b. Additional deficient practice was found for senna and ibuprofen. 2. There was similar deficient practice for Residents #15, #22 and #32.3. InterviewOn 10/21/24 at 12:10 p.m., the administrator stated the health services director or qualified medication administration persons were responsible for ordering medications from the pharmacy. The administrator further stated she did not know why orders were not being followed and was unsure why the deficiency had not been corrected; however, she expected compliance with orders.

Based on interviews and record review, the residence failed to ensure resident's medication administration record (MAR) contained accurate information, affecting four of eight sample residents (#22, #35, #36 and #38). Findings include:1. Resident #22 was admitted to the residence on 2/5/21.a. RanolazineA written practitioner's order, dated 7/3/24, directed the residence to administer ranolazine 1000 mg twice daily. However, the October 2024 MAR contained circled initials to indicate a medication exception in the morning on 10/9; however, there was no corresponding documentation for the exception. Additionally, the eMAR contained a blank space on 10/9/24 in the evening. b. Additional deficient practice was found for ropinirole, metformin, pantoprazole sodium, senna and calcium carbonate. 2. There was similar deficient practice for Residents #35, #36 and #38.3. InterviewsOn 10/21/24 at 11:38 a.m., the health services director (HSD) stated the resident care coordinator and memory care coordinator were responsible for transcribing medications on and off the eMAR. The HSD stated blank spaces in the eMAR meant that staff did not initial at the time of administration whether a medication was administered, refused or otherwise. On 10/21/24 at 12:11 p.m., the administrator stated she expected staff to accurately document on MARs at the time of administration, and expected there to be corresponding documentation with each circled medication and for the blank spaces to contain documentation to show whether a medication was administered or not. The administrator stated she was unsure why the deficiency had not been corrected.

Based on interview and record review the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting 59 current residents. Findings include:On 10/16/24 at 3:01 p.m., the last three quarterly medication audits were requested from the administrator. However, the only audit provided was dated 9/27/24. On 10/16/24 at 3:15 p.m., the health services director (HSD) stated the medication audit dated 9/27/24 was the only audit that had been completed. On 10/21/24 at 12:15 p.m., the administrator stated herself, the HSD and the resident care coordinator were responsible for completing quarterly medication audits. The administrator stated she was aware of the requirement that medication audits needed to be completed quarterly; however, she had only assumed her role as the administrator a month prior to the onsite investigation. The administrator stated she was unsure why the deficiency had not been corrected.

Based on record review and interviews, the residence failed to complete progress notes at the end of the shift, which included documentation regarding any out-of-the-ordinary event or issue that affected the resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address that resident's changing needs, affecting five of five sample residents (#22, #34, #35, #38, #39) who experienced out of the ordinary events. (Cross-reference S1410)Findings include:Resident #35 was admitted to the residence on 9/22/24 with a diagnosis of Alzheimer's Disease. Progress notes dated 9/24-10/15/24 contained two late entries that were more than a day late. Further, residence staff did not document the sexual abuse allegation that alleged that Resident #35 was the suspected assailant in the resident's progress notes. On 10/21/24 at 11:52 a.m., the health services director (HSD) stated that all staff should complete progress notes at the end of their shifts, and late entries demonstrated that the residence staff were not completing them as required. She added that the residence required staff to document all out-of-the-ordinary events. On 10/21/24 at 12:18 p.m., the administrator stated that all staff should be documenting at the end of their shifts any out-of-the-ordinary events for residents. She added that late entries did not meet her expectations. The administrator did not know why this was not corrected, as she had recently begun employment at the residence. Additionally, there was evidence that residence staff did not document out-of-the-ordinary events at the end of each shift in the residents' progress notes for Residents #22, #34, #38, and #39.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.5.3 An assisted living residence shall comply with all occurrence reporting required by state law and shall follow the reporting procedures set forth in 6 CCR 1011-1, Chapter 2, Part 4.2.14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following: (A) A description of the resident ' s wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact; (B)A description of how the resident will have continuous independent access to his or her individual room, along with the ALR ' s plan to protect the resident from unwanted visitation by other residents;

A licensure revisit was completed on 10/21/24 for the previous deficiencies cited on 3/23/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

Based on record review and interview, the residence failed to ensure at least one staff member was onsite who had certification in first aid from a nationally recognized organization, affecting 59 current residents. This deficiency was previously cited during a survey on 3/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record ReviewOn 10/17/24 staff first aid certifications were reviewed in comparison with the staff schedule for 9/1/24 through 10/31/24 and revealed the following: On 9/2/24 from 6:00 p.m. to 6:30 a.m., Staff #34 was the only staff working who was certified in first aid, however, it was not from a nationally recognized organization. On 10/10/24 from 6:00 p.m. to 6:30 a.m., none of the staff working were certified in first aid. 2. InterviewsOn 10/21/24 at 12:07 p.m., the administrator stated she was aware of the first aid requirement. The administrator stated she was unaware Staff #34 was not certified from a nationally recognized organization and she thought the previous the deficient practice had been corrected.

Based on record review and interview, the residence failed to ensure there was at least one staff member on-site at all times with current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization, affecting 59 residents. This deficiency was previously cited during a survey on 3/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record ReviewOn 10/17/24, staff CPR certifications were reviewed in comparison with the staff schedule for 9/1/24 through 10/31/24 and revealed the following: On 9/2/24 from 6:00 p.m. to 6:30 a.m., Staff #34 was the only staff working who was certified in CPR, however, it was not from a nationally recognized organization. On 10/10/24 from 6:00 p.m. to 6:30 a.m., none of the staff working were certified in CPR.2. InterviewOn 10/21/24 at 12:09 p.m., the administrator stated she was aware of the CPR requirement. The administrator stated she was unaware Staff #34 was not certified from a nationally recognized organization and she thought the previous deficient practice had been corrected.

Based on interview and record review the residence failed to comply with authorized practitioner's orders associated with medication administration for four of eight sample residents (#15, #22, #32 and #36). This deficiency was cited previously during a state licensure revisit on 3/23/23. 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 #36 was admitted to the residence on 1/4/23 with a diagnosis of dementia.a. AcetaminophenA written practitioners order, dated 3/25/23, directed the residence to administer acetaminophen 500 mg two tablets three times daily. However, the June, August, September and October 2024 electronic administration records (eMARs) read that the medication was not available on 6/1 the morning and afternoon dose, 6/2 and 6/3 all three doses, 8/14 and 8/15 the morning and afternoon dose, 9/12 the afternoon dose, 9/13 the morning and afternoon dose, 9/14 the morning dose, 10/1 the afternoon and evening dose and 10/2/24 the morning and afternoon dose, for a total of 20 missed doses. b. Additional deficient practice was found for senna and ibuprofen. 2. There was similar deficient practice for Residents #15, #22 and #32.3. InterviewOn 10/21/24 at 12:10 p.m., the administrator stated the health services director or qualified medication administration persons were responsible for ordering medications from the pharmacy. The administrator further stated she did not know why orders were not being followed and was unsure why the deficiency had not been corrected; however, she expected compliance with orders.

Based on interviews and record review, the residence failed to ensure resident's medication administration record (MAR) contained accurate information, affecting four of eight sample residents (#22, #35, #36 and #38). This deficiency was cited previously during a state licensure revisit on 3/23/23. 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 #22 was admitted to the residence on 2/5/21.a. RanolazineA written practitioner's order, dated 7/3/24, directed the residence to administer ranolazine 1000 mg twice daily. However, the October 2024 MAR contained circled initials to indicate a medication exception in the morning on 10/9; however, there was no corresponding documentation for the exception. Additionally, the eMAR contained a blank space on 10/9/24 in the evening. b. Additional deficient practice was found for ropinirole, metformin, pantoprazole sodium, senna and calcium carbonate. 2. There was similar deficient practice for Residents #35, #36 and #38.3. InterviewsOn 10/21/24 at 11:38 a.m., the health services director (HSD) stated the resident care coordinator and memory care coordinator were responsible for transcribing medications on and off the eMAR. The HSD stated blank spaces in the eMAR meant that staff did not initial at the time of administration whether a medication was administered, refused or otherwise. On 10/21/24 at 12:11 p.m., the administrator stated she expected staff to accurately document on MARs at the time of administration, and expected there to be corresponding documentation with each circled medication and for the blank spaces to contain documentation to show whether a medication was administered or not. The administrator stated she was unsure why the deficiency had not been corrected.

Based on interview and record review the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting 59 current residents. This deficiency was cited previously during a state licensure revisit on 3/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 10/16/24 at 3:01 p.m., the last three quarterly medication audits were requested from the administrator. However, the only audit provided was dated 9/27/24. On 10/16/24 at 3:15 p.m., the health services director (HSD) stated the medication audit dated 9/27/24 was the only audit that had been completed. On 10/21/24 at 12:15 p.m., the administrator stated herself, the HSD and the resident care coordinator were responsible for completing quarterly medication audits. The administrator stated she was aware of the requirement that medication audits needed to be completed quarterly; however, she had only assumed her role as the administrator a month prior to the onsite investigation. The administrator stated she was unsure why the deficiency had not been corrected.

A licensure revisit was completed on 10/21/24 for the previous deficiencies cited on 3/23/23. The residence is in compliance with all regulations surveyedThe regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

A licensure revisit was completed on 10/21/24 for the previous deficiencies cited on 3/23/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

Based on record review and interview, the residence failed to ensure at least one staff member was onsite who had certification in first aid from a nationally recognized organization, affecting 59 current residents. This deficiency was previously cited during a survey on 3/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. On 10/17/24 staff first aid certifications were reviewed in comparison with the staff schedule for 9/1/24 through 10/31/24 and revealed the following: On 9/2/24 from 6:00 p.m. to 6:30 a.m., Staff #34 was the only staff working who was certified in first aid, however, it was not from a nationally recognized organization. On 10/10/24 from 6:00 p.m. to 6:30 a.m., none of the staff working were certified in first aid. 2. InterviewsOn 10/21/24 at 12:07 p.m., the administrator stated she was aware of the first aid requirement. The administrator stated she was unaware Staff #34 was not certified from a nationally recognized organization and she thought the previous the deficient practice had been corrected.

Based on record review and interview, the residence failed to ensure there was at least one staff member on-site at all times with current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization, affecting 59 residents. This deficiency was previously cited during a survey on 3/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record ReviewOn 10/17/24, staff CPR certifications were reviewed in comparison with the staff schedule for 9/1/24 through 10/31/24 and revealed the following: On 9/2/24 from 6:00 p.m. to 6:30 a.m., Staff #34 was the only staff working who was certified in CPR, however, it was not from a nationally recognized organization. On 10/10/24 from 6:00 p.m. to 6:30 a.m., none of the staff working were certified in CPR.2. InterviewOn 10/21/24 at 12:09 p.m., the administrator stated she was aware of the CPR requirement. The administrator stated she was unaware Staff #34 was not certified from a nationally recognized organization and she thought the previous deficient practice had been corrected.

Based on interview and record review the residence failed to comply with authorized practitioner's orders associated with medication administration for four of eight sample residents (#15, #22, #32 and #36). This deficiency was cited previously during a state licensure revisit on 3/23/23. 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 #36 was admitted to the residence on 1/4/23 with a diagnosis of dementia.a. AcetaminophenA written practitioners order, dated 3/25/23, directed the residence to administer acetaminophen 500 mg two tablets three times daily. However, the June, August, September and October 2024 electronic administration records (eMARs) read that the medication was not available on 6/1 the morning and afternoon dose, 6/2 and 6/3 all three doses, 8/14 and 8/15 the morning and afternoon dose, 9/12 the afternoon dose, 9/13 the morning and afternoon dose, 9/14 the morning dose, 10/1 the afternoon and evening dose and 10/2/24 the morning and afternoon dose, for a total of 20 missed doses. b. Additional deficient practice was found for senna and ibuprofen. 2. There was similar deficient practice for Residents #15, #22 and #32.3. InterviewOn 10/21/24 at 12:10 p.m., the administrator stated the health services director or qualified medication administration persons were responsible for ordering medications from the pharmacy. The administrator further stated she did not know why orders were not being followed and was unsure why the deficiency had not been corrected; however, she expected compliance with orders.

Based on interviews and record review, the residence failed to ensure resident's medication administration record (MAR) contained accurate information, affecting four of eight sample residents (#22, #35, #36 and #38). This deficiency was cited previously during a state licensure revisit on 3/23/23. 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 #22 was admitted to the residence on 2/5/21.a. RanolazineA written practitioner's order, dated 7/3/24, directed the residence to administer ranolazine 1000 mg twice daily. However, the October 2024 MAR contained circled initials to indicate a medication exception in the morning on 10/9; however, there was no corresponding documentation for the exception. Additionally, the eMAR contained a blank space on 10/9/24 in the evening. b. Additional deficient practice was found for ropinirole, metformin, pantoprazole sodium, senna and calcium carbonate. 2. There was similar deficient practice for Residents #35, #36 and #38.3. InterviewsOn 10/21/24 at 11:38 a.m., the health services director (HSD) stated the resident care coordinator and memory care coordinator were responsible for transcribing medications on and off the eMAR. The HSD stated blank spaces in the eMAR meant that staff did not initial at the time of administration whether a medication was administered, refused or otherwise. On 10/21/24 at 12:11 p.m., the administrator stated she expected staff to accurately document on MARs at the time of administration, and expected there to be corresponding documentation with each circled medication and for the blank spaces to contain documentation to show whether a medication was administered or not. The administrator stated she was unsure why the deficiency had not been corrected.

Based on interview and record review the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting 59 current residents. This deficiency was cited previously during a state licensure revisit on 3/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 10/16/24 at 3:01 p.m., the last three quarterly medication audits were requested from the administrator. However, the only audit provided was dated 9/27/24. On 10/16/24 at 3:15 p.m., the health services director (HSD) stated the medication audit dated 9/27/24 was the only audit that had been completed. On 10/21/24 at 12:15 p.m., the administrator stated herself, the HSD and the resident care coordinator were responsible for completing quarterly medication audits. The administrator stated she was aware of the requirement that medication audits needed to be completed quarterly; however, she had only assumed her role as the administrator a month prior to the onsite investigation. The administrator stated she was unsure why the deficiency had not been corrected.

Based on record review and interviews, the residence failed to complete progress notes at the end of the shift, which included documentation regarding any out-of-the-ordinary event or issue that affected the resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address that resident's changing needs, affecting five of five sample residents (#22, #34, #35, #38, #39) who experienced out of the ordinary events. (Cross-reference S1410)This deficiency was previously cited during a survey on 3/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #35 was admitted to the residence on 9/22/24 with a diagnosis of Alzheimer's Disease. Progress notes dated 9/24-10/15/24 contained two late entries that were more than a day late. Further, residence staff did not document the sexual abuse allegation that alleged that Resident #35 was the suspected assailant in the resident's progress notes. On 10/21/24 at 11:52 a.m., the health services director (HSD) stated that all staff should complete progress notes at the end of their shifts, and late entries demonstrated that the residence staff were not completing them as required. She added that the residence required staff to document all out-of-the-ordinary events. On 10/21/24 at 12:18 p.m., the administrator stated that all staff should be documenting at the end of their shifts any out-of-the-ordinary events for residents. She added that late entries did not meet her expectations. The administrator did not know why this was not corrected, as she had recently begun employment at the residence. Additionally, there was evidence that residence staff did not document out-of-the-ordinary events at the end of each shift in the residents' progress notes for Residents #22, #34, #38, and #39.

A revisit survey was completed on 10/8/24 for all previous deficiencies cited on 7/19/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO37406, was completed on 10/2/24. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to notify the department of a change in the administrator, affecting 63 current residents. Findings include:During the onsite visit on 9/30 and 10/1/24., the acting administrator (AA) was acting as the administrator. A review of the department's database on 9/30/24 revealed that the administrator of record was the administrator of the residence. An email from a department representative, dated 9/30/24 at 3:45 p.m., read in part that the residence had not submitted an application to change the administrator from the administrator of record to the AA.On 9/30/24 at 4:08 p.m., the AA stated she was hired on 9/2/24. She added and had been acting as the administrator for approximately two weeks prior to the onsite visit. The AA added the former interim administrator was acting as the administrator after the administrator of record left on an unknown date. On 10/1/24 at 12:30 p.m., the acting administrator stated that she believed the residence's management company was responsible for notifying the department of a change in the administrator of record.

Based on observations, interviews and record review the residence failed to have sufficient ventilation to meet the needs of four of eight sample residents (#13, #30-#32). Findings Include:1. Reference The residence's undated resident handbook read in part that all residents had access to individual air conditioning, heating, and thermostats. 2. ObservationsOn 9/30/24 at approximately 1:29 p.m., Resident #32's room temperature measured 86 degrees fahrenheit. On 9/30/24 at approximately 1:58 p.m., Resident #13's room temperature measured 83 degrees fahrenheit. 3. Record ReviewA heating, ventilation, and air conditioning (HVAC) document, dated 12/1/23, read in part that an HVAC company provided the residence with a quote to repair the air conditioner unit. Another HVAC document, dated 8/21/24, was another quote to repair the air conditioning unit. 4. InterviewsOn 9/30/24 at 1:29 p.m., Resident #32 stated that she had experienced discomfort due to the heatin her room and that it was too hot in her room. On 9/30/24 at 1:30 p.m., Resident #31 stated that she was not happy with the heat. She stated that shewas unable to open her windows and did not have circulation in her room. On 9/30/24 at 1:58 p.m., Resident #13 stated that he had complained about the heat. On 10/1/24, at 7:51 a.m., the acting administrator stated the air conditioner had been broken before she began as AA with the residence and that she had been in contact with upper management and the owner about the broken unit. She stated she was unsure why it had not been fixed. On 10/1/24 at approximately 8:08 a.m., the maintenance director said that the air conditioner was not workingbecause it was leaking freon and that eventually all of the other floors' units would need to be replaced. He added that the residence's heat was also affected because the air conditioning unit was the same as the heating unit.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.13.1 The assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items:(D) The right to choice and personal involvement regarding care and services, including:(8) The right to receive services in accordance with the resident agreement and the care plan7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows:(A) The assisted living residence shall ensure each staff member or volunteer completes an initial orientation prior to providing any care or services to a resident. Such orientation shall include, at a minimum, all of the following topics:(1) The care and services provided by the assisted living residence;(2) Assignment of duties and responsibilities, specific to the staff member or volunteer;(3) Hand Hygiene and infection control;(4) Emergency response policies and procedures, including:(a) Recognizing emergencies,(b) Relevant emergency contact numbers,(c) Fire response, including facility evacuation procedures(d) Basic first aid,(e) Automated external defibrillator (AED) use, if applicable,(f) Practitioner assessment, and(g) Serious illness injury, and/or death of a resident.(5) Reporting requirements, including occurrence reporting procedures within the facility;(6) Resident rights;(7) House rules;(8) Where to immediately locate a resident's advance directive; and(9) An overview of the assisted living residence's policies and procedures and how to access them for reference.

An appeal of an involuntary discharge survey prompted by #CO37112 was completed on 10/3/24. A deficiency was cited.

Based on interview and record review, the residence failed to develop and implement an involuntary discharge grievance policy affecting one former resident. Findings include:The residence's discharge policy, dated 7/22/22, failed to include the following required elements:(A) The individual designated by the assisted living residence to receive involuntary discharge grievances. (B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence. (C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence. (D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows: (1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. (a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness's name and contact information, and shall keep that information as part of the grievance documentation. (E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows:(1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman. (2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. (3) The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation." (F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S. (G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part. (H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. (I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply: (1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. The residence-issued 30-day involuntary discharge notice for Resident #1, dated 8/5/24, did not contain the required information regarding the resident's right to appeal, to whom, nor the timeline of such an appeal. On 9/24/24 at approximately 1:33 p.m., the administrator stated that the resident was given a 30-day notice. On 9/24/24 at 3:32 p.m., the administrator provided all requested documentation including the residence discharge policy and the administrator stated these were the most current and updated policies for the residence.

A licensure complaint, prompted by #CO35371, #CO36399, #CO36551, and #CO36753 was completed on 7/19/24. Deficiencies were cited.

Based on observation, record review and interview, the residence that is licensed for 20 beds or more failed to comply with regulations concerning Colorado Retail Food Establishments at 6 CCR 1010-2 affecting 72 current residents. Findings include:1. Referencesa. Colorado Retail Food Establishment Regulations 6 CCR 1010-2, part 2-301.14, requires that food employees clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. After handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, before donning gloves to initiate a task that involves working with food and after engaging in other activities that contaminate the hands.b. Colorado Retail Food Establishment Regulations 6 CCR 1010-2, part 3-501.17, requires that ready-to-eat foods are labeled with time/temperature control for safety food, date marking. Open and hold cold refrigerated, ready-to-eattime/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours,to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations by:(1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine;(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or(4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the regulatory authority upon request.c. Colorado Retail Food Establishment Regulations 6 CCR 1010-2, part 4-204.112 requires that cold or hot holding equipment used for time/temperature control for food safety be designed to include and be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the device's temperature display. 2. Observations a. On 7/18/24 at 11:04 a.m., the pantry in the residence's commercial kitchen contained large opened containers of sauces, pasta, tortilla chips, and cereal. The residence's kitchen staff did not label any of the open containers with the dates that they had opened these containers. The refrigerator contained five one-gallon cartons of milk, two were labeled with an expiration date of 7/3/24, and three cartons were labeled with an expiration date of 7/9/24. Additionally, there was a carton of pre-made macaroni salad and an open can of condensed milk with plastic wrap draped over the top of each of them. There was a jar of beef base paste that had been opened, a jar of garlic sauce that had been opened, an unwrapped bowl of fruit parfait containing peaches and yogurt, and multiple uncovered yogurt parfaits with fruit. The refrigerator also contained an undated open container of lunch meat, a large zipper bag of raw chicken breast, trays with cooked chicken breast wrapped in plastic wrap, two unlabeled beef briskets in clear packaging, three large packages of ground beef, and two individually wrapped pork tenderloin. The residence did not label any of the above foods in the refrigerator with the date opened, the date it was to be used by, nor the date that the food was required to be discarded. B. On 7/18/24 at approximately 2:15 p.m., a small refrigerator unit located under a counter in the center of the kitchen contained a plastic container, labeled 7/11/24, with cooked shrimp inside. Additionally, the refrigerator contained a container of open plain yogurt with an expiration date of 7/17/24, an opened cottage cheese container, a plastic container with what looked to be shredded cheese, and four plastic containers with lunch meats inside. The kitchen staff had not labeled any of the above listed food items found in the small refrigerator with any dates. The unit did not have a temperature gauge or dial to adjust the temperature inside. The temperature inside the small refrigerator measured 45 degrees fahrenheit.c. On 7/18/24 at 5:25 p.m., Staff #2 wore large disposable gloves while she prepared a resident's plate of shrimp. After retrieving shrimp from an unmarked plastic container she also touched and retrieved fruit and potato chips from the bag, then put everything away. Staff #4 retrieved an order ticket for a cheeseburger. She placed a hamburger patty from a tray onto the grill, then placed tomato slices, lettuce and onions onto the hamburger bun. Staff #4 went back to the grill, grabbed a dirty spatula and flipped the hamburger. When Staff #2 disposed of an empty bag of potato chips into the trash can, she touched the trash can lip and side then pushed the trash down to fit more. She then grabbed a new bag of potato chips and took a handful of chips and placed them on the plate next to the hamburger bun. She retrieved the hamburger patty with the same gloved hand and placed it on top of the bun. Staff #2 did not change her gloves or wash throughout the observation. During this time, Staff #6 served milk to residents; the milk she served had an expiration date of 7/9/24.3. Interviewsa. On 7/18/24 at 1:48 p.m., the culinary supervisor stated that the kitchen staff were required to label all food containers with the date the package arrived, the date it was opened, and a date by which the food should be discarded, but they did not. She stated the staff knew when the residence received a shipment and when foods were used. She acknowledged staff did not label any food items with dates as required, and they had stored some foods improperly. b. On 7/18/24 at 3:12 p.m., Staff #4 and Staff #5 stated they did not label food containers with dates. They stated that they primarily took food to the residents; however, they did not look at the dates on food packages. They acknowledged they needed to label all opened food packages. c. On 7/18/24 at approximately 5:25 p.m., the interim executive director stated she expected staff to label all opened food containers with the date received, the date opened, and a discard date. She acknowledged the kitchen staff were not trained in food safety and had not been trained to label food containers as required. She stated she planned to observe the upcoming meal preparation and service to understand where more support is needed and will train all kitchen staff in the appropriate courses.

Based on record review and interview, the residence failed to establish a weekly menu that was readily available for resident and public viewing, affecting 72 current residents. Findings include:1. Record Review On 7/18/24 during the onsite investigation from approximately 7:15 a.m. to 6:00 p.m., the residence had no menus readily available anywhere in the residence. 2. InterviewsOn 7/18/24 at 1:48 p.m., the culinary supervisor stated the residence did not have any menus but was working on creating monthly menus for the residents and planned to ask residents about some food items they would like incorporated into the menu. On 7/18/24 at 5:30 p.m., the interim executive director stated she was aware of the regulation for a dining menu, and she will work with the culinary supervisor to ensure updated menus were available to everyone.

A licensure revisit was completed on 3/23/23 for all previous deficiencies cited on 10/5/22. Deficiencies were cited

Based on observation and interview, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire, for two of three sample staff (#9, #11) affecting 52 current residents. This deficiency was cited previously during a complaint investigation 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's Background Check Policy, dated 1/16/22, read in part: "In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer.(A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the assisted living residence shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI)."Staff #9's personnel file revealed a hire date of 9/5/22. There was no evidence in the personnel file that a name-based criminal history report was conducted by the CBI. Staff #9 was observed on 3/21/23 providing care and services to residents. Staff #11's personnel file revealed a hire date of 12/15/23. However, the CBI criminal history report was dated 3/21/23, the date of the onsite investigation. There was no evidence in the personnel file that a name-based criminal history report was conducted by the CBI prior to Staff #11's hire date. On 3/22/22 at 4:22 p.m., the assisted living and memory care director stated that the administrator was responsible for ensuring that each personnel file contained the required documentation prior to hiring staff. On 3/22/23 at 5:46 p.m., the administrator stated that Staff #9 had worked at the residence previously, so her CBI criminal history report was located in another file and she therefore was unable to provide it. She acknowledged the date on the CBI criminal history report for Staff #11 was the date of the onsite investigation, and she stated that the report had been run prior to hire but the residence was unable to provide the documentation. The administrator stated she could not answer as to why this deficiency that was previously cited was not corrected.

Based on interview and record review, the residence failed to have at least one staff member onsite who has current certification in first aid from a nationally recognized organization, affecting 52 current residents (Cross-reference Q734). This deficiency was cited previously during a complaint investigation completed on 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 3/21/23, a review of staff first aid certifications revealed that Staff #12 had a first aid certification from an organization that was not nationally recognized, and Staff #3 and #13 had no first aid certifications at all. On 3/21/23, the residence's staff schedule and staff time card documents from 3/7/23 to 3/21/23 revealed the following shifts did not have at least one staff member at all times who was certified in basic first aid from a nationally recognized organization:3/7/23 6:00 p.m. to 6:00 a.m. 3/8/23 6:00 p.m. to 6:00 a.m. 3/9/23 6:00 p.m. to 6:00 a.m. 3/12/23 6:00 p.m. to 6:00 a.m. 3/13/23 6:00 p.m. to 6:00 a.m. 3/14/23 6:00 p.m. to 6:00 a.m. 3/15/23 6:00 p.m. to 6:00 a.m. 3/16/23 6:00 p.m. to 6:00 a.m. 3/17/23 6:00 p.m. to 6:00 a.m. On 3/22/23 at 5:46 p.m., the administrator stated the assisted living and memory care director was responsible for ensuring there was a staff certified in first aid at the residence on each shift. She stated she was not aware that the certifications for Staff #3 nor Staff #13 did not include first aid certification. The administrator stated that she thought that all current staff with CPR certifications also had first aid certifications and that they received first aid certification through a nationally recognized organization. The administrator stated that this deficiency that was previously cited was not corrected because she thought that all current staff with CPR certifications also had first aid certifications and that they received first aid certification through a nationally recognized organization.

Based on interview and record review, the residence failed to have at least one staff member onsite who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 52 current residents (Cross-reference Q732). This deficiency was cited previously during a complaint investigation completed on 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's CPR policy, dated 6/26/20, read in part that the residence had personnel with certification in CPR at the residence. Staff CPR certifications revealed that Staff #12 had certification in CPR and obstructed airway technique from an organization that was not nationally recognized. On 3/21/23, the residence's staff schedule and staff time card documents from 3/7/23 to 3/21/23 revealed the following shifts did not have at least one staff member at all times who was certified in CPR and obstructed airway technique from a nationally recognized organization: 3/13/23 6:00 p.m. to 6:00 a.m. 3/14/23 6:00 p.m. to 6:00 a.m. On 3/22/23 at 5:46 p.m., the administrator stated that this deficiency that was previously cited was not corrected because she thought that all current staff with CPR certifications received them through a nationally recognized organization.

Based on observation and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation), so that the information was readily available to staff at all times, affecting 52 current residents. This deficiency was cited previously during a complaint investigation completed on 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 3/21/23 from 7:00 a.m. to 5:45 p.m. and 3/22/23 from 7:00 a.m. to 7:00 p.m., throughout the onsite investigation, there was no list of all staff who had current certification in first aid or CPR placed in a visible location, so that the information was readily available to all staff at all times. On 3/21/23 at 7:08 a.m., Staff #13 stated she had worked at the residence for approximately three months, and she had not seen a list posted anywhere within this time frame. On 3/21/23 at approximately 7:10 a.m., the resident care coordinator for memory care stated there was no list of staff with current certification in first aid or CPR posted at the residence, adding that there may have been a list at the front desk. On 3/22/23 at 4:22 p.m., the assisted living and memory care director stated she was not aware of the requirement to post a visible list of staff with current certification in CPR and first aid. She stated that when she created the staff schedules, she highlighted those with current CPR and first aid certification in red. On 3/22/23 at 5:46 p.m., the administrator stated that staff checked the schedule every day to see which staff were highlighted in red. She acknowledged that a visible list was not readily available to staff in the secure environment. The administrator stated that that this deficiency that was previously cited was not corrected because she thought that noting which staff had current certifications in CPR and first aid on the staff schedule was adequate.

Based on record review and interview the residence failed to develop a fall management program that included, fall management education and materials to residents and family members, detail in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or the effects of medication, routinely inspect and maintain a safe environment, and provide staff training related to fall prevention, affecting three of three sample residents (#7, #22 and #27) who had sustained recent falls. This deficiency was cited previously during a complaint investigation completed on 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #27 sustained a fall in November 2022, which resulted in a fractured hip. The resident sustained at least three subsequent falls following readmission after her surgery to repair her hip. The residence failed to provide fall management education and materials to the resident's family member, detail in the care plan the individualized approach necessary to address fall risk, and provide all staff with training related to fall prevention. The resident sustained a fall on 3/17/23 which resulted in a hospitalization due to several broken ribs and a requirement for an external services provider. Specifically, Resident #7 sustained falls on 1/9/23, 2/13/23, and 3/12/23. Staff reminded the resident to use a call pendant for assistance, but the resident did not comply. A private sitter was with the resident seven days per week from 2:00 p.m. to 10:00 p.m. However, Resident #7 still sustained a fall while a private sitter was on duty. The residence failed to update the resident's care plan with new individual approaches necessary to address fall risk after each fall on the above dates, and on the morning of 3/21/23, and the resident again was found on the floor with a skin tear on his elbow. Findings include:1. Residence Policya. The residence's fall management policy, dated 6/26/20, read in part that the residence observed the resident's living area for hazards and potential problems and inspected the environment for trip hazards, clutter, proper lighting, and any other items that placed residents at risk for falls. The residence created a care plan to help prevent falls utilizing a fall risk assessment form which included interventions that addressed specific identified deficits and specific activities to help maintain the resident's strength and balance. Further, the residence provided staff training related to fall prevention within 30 days of hire and provided family members and residents with education on fall prevention.b. The residence's undated care plan policy read in part that the program director and the resident care director completed a care plan on admission to address fall prevention. The care plan addressed resident goals, actual and potential problems, needs, and strengths. 2. Resident #27 was admitted to the residence on 6/24/22 with diagnoses including vascular dementia.a. Record ReviewA care plan, dated 7/1/22, read in part that the resident maintained her ability to ambulate and transfer independently without devices. A fall risk assessment, dated 11/25/22, read in part that the resident sustained one or two falls in one month/quarter, and had a fall-related fracture to her right hip. A hospital discharge document, dated 11/26/22, read in part that Resident #27 was admitted to the hospital from 11/22-11/28/22. Resident #27 presented from the residence with a fall and was found to have a right femoral neck fracture. She underwent right hip hemiarthroplasty on 11/23/23. A progress note, dated 2/2/29, read in part that staff observed Resident #27 exit her room, When the staff member approached her, the resident's head was down and she was leaning against the railing, Resident #27 stated she felt dizzy and weak. Two staff members assisted the resident to bed and noticed she had difficulty when walking. A progress note, dated 2/16/23, read in part that Resident #27 was very tired and weak. An incident report, dated 2/24/23, read in part that staff found Resident #27 on the floor. Resident #27 stated she fell and hit her head; the resident later stated she did not hit her head. A hospital discharge document, dated 2/25/23, read in part that the resident was seen because she fell and was experiencing arm and back pain. An incident report, dated 3/5/23, read in part that Resident #27 sustained an unwitnessed fall in her room. An incident report, dated 3/18/23, read in part that Resident #27 sustained an unwitnessed fall in another resident's room. The resident stated she lost her balance and fell. Resident #27's head was against the wall by the chair. There was no evidence that the care plan was updated with any fall interventions following the resident's falls on approximately 11/22/23, 2/24/23, or 3/5/23. The care plan did not address the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or the effects of medication.b. InterviewsOn 3/21/23, a family member for Resident #27 stated that the resident sustained a fall at the residence for the first time in November 2022. She stated this fall resulted in a hip injury that required a partial hip replacement, adding that the resident had fallen four times since then. The family member stated that Resident #27 had been admitted to the hospital since the night of 2/17/23 due to a fall that resulted in five broken ribs. She stated that the residence failed to provide fall management education and materials to her at any time. The family member stated the residence informed her that Resident #27 was on the maximum level of care that the residence provided so there was nothing more they could do for fall prevention. On 3/21/23 at 4:05 p.m., the administrator stated that Resident #27 was not currently at the residence because she recently fell and broke three ribs. On 3/22/23 at 9:40 a.m., Staff #13 stated Resident #27 often forgot to use her walker when ambulating. She stated staff reminded her to use it several times per day but the resident would become distracted, forget to use it, and walk without it. Staff #13 stated Resident #27 did not fall when she used the walker. Staff #13 stated the residence did not provide her any training for fall mitigation; she added the resident's room was not evaluated or changed in any way after any falls since she had worked at the residence (approximately three months). Staff #13 stated she needed one on one care for fall prevention but she did not have it. On 3/22/23 at 10:05 a.m., Staff #8 stated that Resident #27 fell because she would trip herself up or would not sit properly on her bed and slid down to the floor. She stated the resident had a walker but regularly did not use it. Staff #8 stated Resident #27 would exit seek, and she did not know what to do except provide reminders and redirection. She added that the residence did not provide any other training to prevent Resident #27 from falling. Staff #8 stated the resident's family member rearranged the furniture in the room approximately two months prior to the on site visit, and she acknowledged this did not prevent the resident from falling. 3. Resident #7 was admitted to the residence on 11/1/20 with diagnoses including mild cognitive impairment and unsteadiness on his feet.a. Record ReviewA care plan, dated 9/8/22, read in part that staff encouraged the resident to call for assistance when rising from his chair and to use his walker when walking to the restroom. Resident #7 required staff assistance with transferring as well as a safety check every two hours. A care plan, update 11/4/23, read in in part that Resident #7 was admitted to an external services provider. When the resident fell, staff were to notify the external services provider. Anincident report, dated 1/19/23, read in part that upon entering Resident #7's room staff found Resident #7 lying on his back in front of his dresser between the dresser and the recliner. He sustained two skin tears on his left elbow: one was dime-sized and one was about two inches in length. The resident stated he rose from his chair and did not have slippers on, lost his footing, and he fell. An incident report, dated 2/13/23, read in part that staff found Resident #7 lying on his back on the floor in front of his dresser which was in front of his bed. A private sitter stated that the resident had been seated in his recliner, and she went to use the bathroom. Upon her return to the room, the private sitter found the resident on the floor. The resident stated he had a little back pain. A progress note, dated 3/12/23, read in part that Resident #7 had a fall. He stated his back was sore. The resident did not use his call pendant to request assistance for toileting prior to falling. Instead, he used it to call for assistance when he fell. Staff provided a reminder to Resident #7 to use the call pendant when he needed help to prevent him from falling. A progress note, dated 3/13/23, read in part that Resident #7 was not using his call pendant to request assistance despite staff reminders. Resident #7 complained of quite a bit of back pain. A progress note, dated 3/15/23 read in part that Resident #7 stated that he was in tremendous pain in his back from a previous fall that was reported. He expressed pain when moving in his bed, walking, and sitting up in his bed. He stated several times that something was broken. There was no evidence that the care plan was updated with any fall interventions following the resident's falls on 1/19/23, 2/13/23, and 3/12/23. The care plan did not address the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or the effects of medication.b. InterviewsOn 3/21/23 at 9:04 a.m., an external agency nurse (EAN) stated that emergency responders had just left that morning of the on site visit on 3/21/23 because Resident #7 tried to get out of bed, fell, and sustained a skin tear to his right arm. On 3/22/23 at 9:40 a.m., Staff #13 stated that Resident #7 had a private sitter with him at all times from 2:00 p.m. to 10:00 p.m., seven days per week, because that was the timeframe when the likelihood for a fall was higher. She stated Resident #7 sustained a fall on the morning of 3/21/23. Staff #13 stated she did not know how he fell because she administered his medications in his room and approximately ten minutes later, Staff #8 found him on the floor. She added that without staff being able to keep an eye on him at all times, the residence was unable to prevent him from falling. On 3/22/23 at 9:46 a.m., the resident care coordinator for memory care (RCCMC) stated that Resident #7 did not request assistance when he needed it. She stated a private sitter that stayed with him from 2:00 p.m. to 10:00 p.m., and she acknowledged that having the private sitter in place for that time frame did not prevent Resident #7 from falling the morning of 3/21/23. The RCCMC stated the care plan did not reflect Resident #7's fall risk nor any individualized approaches to mitigate falls, adding that the care plan should have been updated. On 3/22/23 at 10:05 a.m., Staff #8 stated Resident #7 pushed his call pendant when he wanted food, drink, or someone to find his remote control. However, she added, he did not push the call pendant for assistance to walk, including to go to the bathroom. She stated he did this because he did not think he required assistance with walking, adding the resident knew he was going to stand up but did not tell staff. Staff #8 stated Resident #7 fell the morning of 3/21/23, adding that Staff #13 administered his medications to him in his room. She stated a few minutes later, she walked past his room and observed the resident on the floor, he had reopened a skin tear on his right elbow that was a result of a prior fall approximately one and one-half months prior to the on site visit. On 3/22/23 at 4:22 p.m., the assisted living and memory care director (ALMCD) stated Resident #7 had a private sitter with him at all times from 2:00 p.m. to 10:00 p.m. She acknowledged that the resident fell the morning of 3/21/23, adding that nothing was implemented to prevent him from sustaining another fall in the mornings before the private sitter's arrival. 4. Resident #22 was admitted to the residence on 2/5/21 with diagnoses including syncope and collapse.a. Record ReviewA care plan, dated 9/30/22, read in part that staff encouraged the resident to exercise, keep up mobility, and decrease falls by attending activities. A fall risk assessment, dated 11/7/23, read in part that Resident #22 had a fall related injury which required brain surgery. It further read that a score above eight points meant that the resident was at a high risk for falls. The resident's score was 10 points. A hospital discharge document, dated 1/11/23, read that Resident #22 was seen in the neuro-critical care department by a surgeon in relation to a subdural hematoma. A progress note, dated 2/7/23, read in part that the resident was readmitted to the residence after an inpatient stay at a rehabilitation facility. The administrator had a discussion with the resident's family member regarding a private sitter to eliminate future concerns. An Assessment, dated 2/10/23, read in part that the resident had a change in condition which included a fall that resulted in being transported to the emergency department, a hospitalization, and an inpatient stay at a rehabilitation center. A fall risk assessment, dated 3/2/23 read the resident had a history of falling one to two times per month/quarter. It further read that a score above eight points meant that the resident was at a high risk for falls. The resident's score was 12 points. There was no evidence that the care plan was updated with any fall interventions following the resident's readmission to the residence on 2/7/23 after rehabilitation necessary as a result of a fall. b. InterviewsOn 3/22/23 at 2:56 p.m., the resident care manager (RCM) stated that when a resident fell, staff completed an incident report and would brainstorm interventions to keep the residents from falling again. She acknowledged, however, that interventions were not included in the incident reports and resident care plans were not updated with individual approaches necessary to address falls. The RCM stated it was the residence's management team's responsibility to follow up with fall interventions and discuss fall prevention with family members. On 3/22/23 at 4:22 p.m., the ALMCD stated when a resident fell, she was responsible for updating the care plans. She stated when staff completed safety checks every one to two hours, residents still fell. On 3/22/23 at 5:46 p.m., the administrator stated the residence's fall policy included ensuring spaces were free from clutter and fall hazards, obtaining a referral for physical and occupational therapies, and providing additional strength training. The administrator stated she expected the care plan to reflect the fall risk and the individual approaches necessary to address fall risks. She stated that this deficiency that was previously cited was not corrected because a former memory care director did not update the care plans for Resident #7 and #27 as required. Additionally, the administrator acknowledged that she needed assistance with fall management because she thought the residence had improved.

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Based on observation, interview and record review the residence failed to have an accurate medication administration record (MAR) affecting three of ten sample residents (#1, #9) and one former resident (#24). This deficiency was cited previously during a complaint investigation completed on 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. References and Residence Policy:a. The residence's medication administration policy, dated 7/9/20, read in part: For residents whose medications are monitored or administered by residence staff, a current record shall be maintained of the resident's medications including name of drug, dosage, route of administration and directions for administration of medication. The administration of medication should be documented at the time of administration. 2. Resident #1 was admitted to the residence on 6/22/22, with a diagnosis of type 1 diabetes.a. LantusA written practitioner's order, dated 1/16/23, directed the residence to administer 14 units of 100 unit/ml solution of lantus twice daily. However, the March 2023 eMAR contained "x's" on 3/9/23 in the evening, and 3/10/23 in the morning. On 3/22/23 at 5:15 p.m., the assisted living and memory care director (ALMCD) stated that did not know what blanks or "x's" in the eMAR meant; however, it should have been documented why the medication was not given. On 3/22/23 at 6:42 p.m., the administrator stated that she did not know what "x's" in the eMAR meant and stated that it should have been documented. 3. Resident #9 was admitted to the residence on 8/1/21, with diagnoses including type 2 diabetes and hypertension.a. LatanoprostA written practitioner's order, dated 1/27/23, directed the residence to instill one drop of latanoprost ophthalmic solution 4% in each eye at bedtime. However, the February 2023 eMAR read that latanoprost was administered three times on 2/4 once during the p.m. and twice at bedtime, once in the the p.m. and once at bedtime 2/1-2/3/23, and twice at bedtime on 2/5-2/25/23, for a total of twenty-four inaccurate documentations. b. ClaritinA written practitioner's order, dated 1/27/23, directed the residence to administer Claritin 10 mg once daily. However, the February 2023 eMAR read that Claritin was administered twice on 2/2, 2/8-2/10, 2/12, 2/13, 2/15, 2/17, 2/18, and 2/23-2/26/23 for a total of twelve inaccurate documentations. c. TramadolA written practitioner's order, dated 1/27/23, directed the residence to administer tramadol 50 mg one half tablet twice daily. However, the February 2023 eMAR revealed no evidence of documentation on 2/9/23 in the morning.d. OmeprazoleA written practitioner's order, dated 1/27/23, directed the residence to administer omeprazole 20 mg once daily. However, the February 2023 eMAR revealed no evidence of documentation on 2/6/23.e. SennaA written practitioner's order, dated 1/27/23, directed the residence to administer one 8.6 mg tablet of senna once daily. However, the February 2023 eMAR read that senna was administered twice on 2/4/23, for a total of one inaccurate documentation. f. AcetaminophenA written practitioner's order, dated 1/27/23, directed the residence to administer acetaminophen 1000 mg three times daily. However, the February 2023 eMAR read that acetaminophen was administered twice on 2/4/23 in the evening, for a total of one inaccurate documentation. On 3/22/23 at 3:31 p.m., the remsident care anager (RCM) stated that qualified medication administration persons (QMAPs) were marking medication off twice due to duplicates in the MAR. The RCM stated that the ALMCD needed to take these duplicates off the MAR.On 3/23/23 at 5:15 p.m., the ALMCD stated that the pharmacy put in Claritin, acetaminophen, senna and latanoprost twice and it should not have been that way in the eMARs and she should have corrected the error. The ALMCD confirmed that Resident #9 did not get her medications multiple times. The ALMCD further stated that all other medications should have been documented and not left blank. On 3/24/23 at 6:42 p.m., the administrator stated that she did not know why the February and March 2023 eMARs had duplicate medication administrations and stated it should not have been. The administrator stated that the blanks were a result of electronic medication record printing errors. 4. Former Resident #24 was admitted to the residence on 6/27/22 with diagnoses including Parkinson's disease, lewy body dementia, insomnia and constipation.a. FlorastorA written practitioner's order, dated 12/15/22, directed the residence to administer Florastor 250 mg twice daily. However, the January through February 2023 eMARs revealed no evidence of the brand of probiotic to administer, how many milligrams to administer for a total of 59 days. b. SinemetWritten practitioner's orders, dated 12/15/22 and 1/23/23, directed the residence to administer Sinemet 25/100 two tablets four times daily. However, the January through February 2023 eMARs revealed no evidence of documentation at 11:00 a.m., on 1/14, at 2:00 p.m.on 1/12, 1/14, at 5:00 p.m., on 1/10, 1/12- 1/14, 1/25, 2/2, 2/17 and 2/25/23 for a total of 11 doses. A written practitioner's order, dated 12/15/22, directed the residence to administer Sinemet 25/100 once daily at bedtime. However, the January 2023 eMAR revealed no evidence of documentation on 1/23 and 1/28/23 for a total of two doses. A written practitioner's order, dated 12/15/22, directed the residence to administer Sinemet 50/200 once daily at bedtime. However, the January 2023 eMAR revealed no evidence of documentation on 1/23 and 1/28/23 for a total of two doses. c. Seroquel A written practitioner's order, dated 12/15/22, directed the residence to administer Seroquel 25 mg half tablet twice daily and noon and 5:00 p.m. However, the January through February 2023 eMARs revealed no evidence of documentation on 1/10 at 5:00 p.m., 1/12, 1/13 at 5:00 p.m., 1/14, 1/25 at 5:00 p.m., 2/2 at 5:00 p.m. and 2/17/23 at 5:00 p.m. for a total of nine doses. A written practitioner's order, dated 12/15/22, directed the residence to administer Seroquel 75 mg once daily at bedtime. However, the January 2023 eMAR revealed no evidence of documentation on 1/23 and 1/28/23 for a total of two doses.d. MentholA written practitioner's order, dated 1/11/23, directed the residence to administer menthol topical analgesic 7.5% on bilateral calves three times a day. However, the January 2023 eMAR revealed no evidence of documentation on 1/12/23 afternoon dose for a total of one dose. On 3/22/23 at 4:22 p.m., the ALMCD stated she reviewed eMARs to discover whether the residence was running low on medications; however, she did not review the eMARs for accurate QMAP documentation. On 3/22/23 at 5:46 p.m., the administrator stated the blank spaces were partly due to the electronic medication administration record system. She stated that staff was not able to sign out of the system without accurate documentation but the printed eMARs did not reflect that . The administrator stated that this deficiency that was previously cited was not corrected because she did not review the eMARs enough to ensure accurate documentation.

Based on record review and interviews the administrator and the qualified medication administration person (QMAP) supervisor failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records. Additionally, the administrator and the QMAP supervisor failed to investigate and resolve any irregularities, affecting nine of nine current sample residents (#1, #2, #4, #5, #7, #22, #26-#27). (Cross-reference Q1430, Q1468, Q1510)This deficiency was cited previously during a complaint investigation completed on 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's medication policy, dated 7/9/20, did not address the requirement to ensure the administrator and QMAP supervisor, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, nor investigate nor solve any irregularities. Documents titled Residential Care Facility Medication Storage Compliance Checklist, dated 1/24/23 and 1/25/23, read that the residence failed to ensure that both the administrator and the QMAP supervisor participated in medication audits. Additionally, no evidence was provided that the administrator and the QMAP supervisor audited the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, nor investigated nor solved any irregularities. On 3/22/23 at 2:56 p.m., the resident care manager stated that the administrator and the assisted living and memory care director (ALMCD) completed a medication audit every three months with a QMAP. She stated she participated in one audit which included shadowing a QMAP to ensure they met infection control standards and checking medication labels to ensure they matched the medication administration records. She stated she did not cross-check the written practitioner's orders during the audit. On 3/22/23 at 4:22 p.m., the ALMCD stated the administrator completed quarterly medication audits. She stated she participated in a recent medication audit, for which she checked to ensure medications were labeled properly, that the medication cart had all of the required supplies, and checked the controlled substances documentation. She stated she was not aware of the requirement to audit irregularities and resolve them by reviewing the MARs, controlled substance list, medication error reports, and medication disposal records. The ALMCD stated the errors found during the onsite investigation could have been corrected and/or prevented if the residence had completed quarterly audits that met all of the regulatory requirements. On 3/22/23 at 5:46 a.m., the administrator stated she and the ALMCD completed quarterly medication audits together. She stated, however, that their audit did not include checking to ensure written practitioner's orders matched the MARs and the medication labels.

Based on observation, interview, and record review, the residence failed to ensure two individuals who were qualified medication administration persons (QMAP), jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred and report any discrepancy in the controlled substance count to the administrator, affecting one of three sample residents with controlled substances (#9). (Cross-reference Q1468). This deficiency was cited previously during a complaint investigation completed on 10/5/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #9 was admitted to the residence on 8/1/21, with diagnoses including type 2 diabetes and hypertension.a. TramadolA written practitioner's order, dated 1/27/23, directed the residence to administer tramadol 50 mg one half tablet twice daily. The controlled substance count for tramadol 50 mg twice daily revealed the following:On 2/8/23 in the a.m., there were nine doses of tramadol left. There were no entries for 2/9-2/11/23. On 2/12/23 in the a.m., there were eight doses left. However, the February 2023 electronic medication administration record (eMAR) read that on 2/8 and 2/10/23 in the morning, Resident #9 refused due to sleeping. On 2/9/23 in the morning there was a blank on the eMAR. Moreover, the February 2023 eMAR read on 2/11/23 tramadol 50 mg was administered in the morning, which conflicted with the controlled substance count.b. PregabalinA written practitioner's order, dated 1/27/23, directed the residence to administer pregabalin 50 mg three times daily. The controlled substance count for pregabalin 50 mg three times daily read on 2/8/23 that the medication was administered at noon. Additionally, the controlled substance count revealed no evidence that the medication was jointly counted and signed off prior to the end of each shift. However, the February 2023 eMAR read that the medication was not administered 2/8/23 in the afternoon due to "iuh." On 3/22/23 at 12:25 p.m., Resident #9 stated that she had never refused her tramadol or any other medication, and needed her tramadol since she was always in pain. On 3/22/23 at 3:31 p.m., the resident care manger (RCM) stated that she did not know why the controlled substance count sheet for Resident #9 was inaccurate for tramadol, because staff still had to dispense the medication and give it to the assisted living and memory card director (ALMCD) to destroy and stated that a staff member may have forgot to dispense Resident #9's dose of tramadol on 2/11/23 and just marked it as given. The RCM stated that Resident #9 never refused her medications and was easy to wake up, so her doses of tramadol should not have been marked as refused and should have been signed off on the count sheet to be destroyed with the ALMCD. The RCM stated that she was working the medication cart when Resident #9 refused her pregabalin, and it was due to "the resident not feeling well," and so she had given the medication to the ALMCD to destroy. The RCM stated that she signed off pregabalin in the narcotic sheet because she dispensed the medication so she thought she still had to sign off on it. When the surveyor asked the RCM what she had done when she had noticed the inaccuracies, the RCM stated that she had not done anything because she had not noticed the narcotic count sheet was inaccurate. On 3/22/23 at 5:15 p.m., the ALMCD stated that she did not know why Resident #9's tramadol narcotic count sheet did not match the February eMAR. She stated she did not know why Resident #9's tramadol was not administered and was not jointly counted and signed with herself or another qualified medication administration person (QMAP). She further stated the controlled substance count should have been jointly counted and signed at the end of each shift. The ALMCD stated that Resident #9's pregabalin should have been marked as refused and not signed off as administered on the controlled substance count in the afternoon of 2/8/23. On 3/22/23 at 6:42 p.m., the administrator stated that she did not know why the controlled substance count sheet for Resident #9 had discrepancies and would have been investigated if she had known about it; however, nothing had ever been reported to her. The administrator acknowledged that she would expect two individuals to jointly count all controlled substances and report to her the discrepancies.

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

A licensure complaint, prompted by #CO30818, #CO31076, #CO31211, and #CO31317 was completed on 3/23/23. Deficiencies were cited.

Based on observation and interview, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire, for two of three sample staff (#9, #11) affecting 52 current residents. Findings include:The residence's Background Check Policy, dated 1/16/22, read in part: "In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer.(A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the assisted living residence shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI)."Staff #9's personnel file revealed a hire date of 9/5/22. There was no evidence in the personnel file that a name-based criminal history report was conducted by the CBI. Staff #9 was observed on 3/21/23 providing care and services to residents. Staff #11's personnel file revealed a hire date of 12/15/23. However, the CBI criminal history report was dated 3/21/23, the date of the onsite investigation. There was no evidence in the personnel file that a name-based criminal history report was conducted by the CBI prior to Staff #11's hire date. On 3/22/22 at 4:22 p.m., the assisted living and memory care director stated that the administrator was responsible for ensuring that each personnel file contained the required documentation prior to hiring staff. On 3/22/23 at 5:46 p.m., the administrator stated that Staff #9 had worked at the residence previously, so her CBI criminal history report was located in another file and she therefore was unable to provide it. She acknowledged the date on the CBI criminal history report for Staff #11 was the date of the onsite investigation, and she stated that the report had been run prior to hire but the residence was unable to provide the documentation.

Based on record review and interview, the residence failed to include written documentation regarding a description of the employee duties, orientation and training, and tuberculin (TB) tests in each personnel file, for three of three sample staff (#9, #11, #13) affecting 52 current residents. Findings include:The personnel files for Contracted Staff #13 and Staff #11 contained no description of employee duties, no documentation of orientation, and no TB test result. No electronic copies were offered. The personnel file for Staff #9 contained no documentation of orientation and no TB test result. On 3/22/23 at 5:46 p.m., the administrator stated she was responsible for creating and maintaining personnel files. She stated that Staff #11 did receive orientation but the residence's printer was not working, so they were unable to include documentation in the personnel file. The administrator stated that Staff #13 was contracted staff and therefore did not have a job description in the personnel file. She added that she did not have a reason as to why the TB tests results were not in Staff #9, #11, and #13's personnel files.

Based on interview and record review, the residence failed to retain in employee's and volunteer's personnel files documentation that the individual's names appeared on the department's list of individuals who have successfully completed the medication administration competency evaluation and a signed disclosure that the individual has not had a professional medical, nursing, or pharmacy license revoked in this or any other state for reasons directly related to the administration of medications, for two of two sample staff (#9, #13) who were qualified medication administration persons (QMAPs) affecting 52 current residents. On 3/21/23, during an onsite investigation from approximately 7:00 a.m. to 5:45 p.m., Staff #9 and Contracted Staff #13 were observed providing medication administration services to residents. The personnel file for Staff #9 did not include documentation of the individual's name on the Department's list of individuals who have successfully completed the medication administration competency evaluation. The personnel file for Contracted Staff #13 did not include documentation of the individual's name on the Department's list of individuals who have successfully completed the medication administration competency evaluation nor a signed disclosure that the staff had not had a professional medical, nursing, or pharmacy license revoked in this or any other state for reasons directly related to the administration of medication. On 3/22/23 at 4:22 p.m., the assisted living and memory care director stated she was not aware of the requirement to maintain documentation that QMAPs' names appeared on the department's list of individuals who have successfully completed the medication administration competency evaluation. She stated that it was the administrator's responsibility to ensure all required documentation was maintained in personnel files. On 3/22/23 at 5:46 p.m., the administrator acknowledged the personnel files did not have evidence that Staff #9 and Contracted Staff #13 successfully completed the medication administration competency evaluation. She stated this documentation should have been in their files, and she was unable to state a reason as to why they were not. The administrator stated that a signed disclosure was not included in Contracted Staff #13's personnel file because she was a contracted staff member.

Based on interview and record review, the residence failed to have at least one staff member onsite who has current certification in first aid from a nationally recognized organization, affecting 52 current residents (Cross-reference Q734). Findings include:On 3/21/23, a review of staff first aid certifications revealed that Staff #12 had a first aid certification from an organization that was not nationally recognized, and Staff #3 and #13 had no first aid certifications at all. On 3/21/23, the residence's staff schedule and staff time card documents from 3/7/23 to 3/21/23 revealed the following shifts did not have at least one staff member at all times who was certified in basic first aid from a nationally recognized organization:3/7/23 6:00 p.m. to 6:00 a.m. 3/8/23 6:00 p.m. to 6:00 a.m. 3/9/23 6:00 p.m. to 6:00 a.m. 3/12/23 6:00 p.m. to 6:00 a.m. 3/13/23 6:00 p.m. to 6:00 a.m. 3/14/23 6:00 p.m. to 6:00 a.m. 3/15/23 6:00 p.m. to 6:00 a.m. 3/16/23 6:00 p.m. to 6:00 a.m. 3/17/23 6:00 p.m. to 6:00 a.m. On 3/22/23 at 5:46 p.m., the administrator stated the assisted living and memory care director was responsible for ensuring there was a staff certified in first aid at the residence on each shift. She stated she was not aware that the certifications for Staff #3 nor Staff #13 did not include first aid certification. The administrator stated that she thought that all current staff with CPR certifications also had first aid certifications and that they received first aid certification through a nationally recognized organization.

Based on interview and record review, the residence failed to have at least one staff member onsite who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 52 current residents (Cross-reference Q732). Findings include:The residence's CPR policy, dated 6/26/20, read in part that the residence had personnel with certification in CPR at the residence. Staff CPR certifications revealed that Staff #12 had certification in CPR and obstructed airway technique from an organization that was not nationally recognized. On 3/21/23, the residence's staff schedule and staff time card documents from 3/7/23 to 3/21/23 revealed the following shifts did not have at least one staff member at all times who was certified in CPR and obstructed airway technique from a nationally recognized organization: 3/13/23 6:00 p.m. to 6:00 a.m. 3/14/23 6:00 p.m. to 6:00 a.m. On 3/22/23 at 5:46 p.m., the administrator stated she thought that all current staff with CPR certifications received them through a nationally recognized organization.

Based on observation and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation), so that the information was readily available to staff at all times, affecting 52 current residents. (Cross-reference Q732, Q734)Findings include:On 3/21/23 from 7:00 a.m. to 5:45 p.m. and 3/22/23 from 7:00 a.m. to 7:00 p.m., throughout the onsite investigation, there was no list of all staff who had current certification in first aid or CPR placed in a visible location, so that the information was readily available to all staff at all times. On 3/21/23 at 7:08 a.m., Staff #13 stated she had worked at the residence for approximately three months, and she had not seen a list posted anywhere within this time frame. On 3/21/23 at approximately 7:10 a.m., the resident care coordinator for memory care stated there was no list of staff with current certification in first aid or CPR posted at the residence, adding that there may have been a list at the front desk. On 3/22/23 at 4:22 p.m., the assisted living and memory care director stated she was not aware of the requirement to post a visible list of staff with current certification in CPR and first aid. She stated that when she created the staff schedules, she highlighted those with current CPR and first aid certification in red. On 3/22/23 at 5:46 p.m., the administrator stated that staff checked the schedule every day to see which staff were highlighted in red. She acknowledged that a visible list was not readily available to staff in the secure environment. The administrator stated that she thought that noting which staff had current certifications in CPR and first aid on the staff schedule was adequate.

Based on observations, interviews, and record review, the residence failed to provide personal services for five of 11 sample residents (#2, #11, #22, #26, #27). Findings include: 1. ReferenceChapter 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 including, but not limited to assistance with activities of daily living. 2. Resident #11 was admitted to the residence on 4/1/22.a. ObservationsOn 3/21/23 at 8:12 a.m., Resident #11 was laying in his bed and it was urine stained. Resident #11 was observed with towels around his catheter tubing. Resident #11 asked Staff #9, "can you fix the leaking?" Staff #9 responded, "yes."On 3/22/23 at 10:57 a.m., Resident #11's catheter was still leaking all over his bed. On 3/22/23 at 2:27 p.m., Resident #11 was observed with different bed linens, and the bed linens were found to contain urine stains again.b. InterviewsOn 3/21/23 at 8:12 a.m., Resident #11 stated that his catheter bag was leaking all morning and asked Staff #9 to fix it and he stated that she placed towels on his lap. On 3/21/23 at 8:39 a.m., Staff #9 stated that she did not know what to do about Resident #11's leaking catheter. On 3/22/23 at 6:42 p.m., the administrator stated that Resident #11's catheter was leaking because the bag wasn't closed. The administrator stated that Resident #11's family member came to her around 5:00 p.m. on 3/21/23 and asked where the sheets went. The administrator acknowledged the sheets were changed at the point. The administrator stated she did not know why Staff #9 had not addressed Resident #11's leaking catheter when he had asked at 8:12 a.m., and acknowledged that no resident should have to sit in urine all day. 3. Resident #2 was admitted to the residence on 2/27/22. A written practitioner's order, dated 4/21/22, directed the residence to weigh Resident #2 twice weekly: on Mondays and Fridays. Additionally, the written practitioner's order directed the residence to report when the resident gained three pounds within 24 hours or five pounds within one week. The March 2023 electronic medication administration record (eMAR) read in part that the residence was to weigh Resident #2 on Monday and Friday. No weight measurements were recorded on the eMAR.A document of the resident's vital signs, dated 3/15/22 to 3/15/23 read that the residence last recorded a weight measurement for Resident #2 on 7/15/22 of 196.3 pounds. No other weight measurements were recorded on this document. 4. Resident #22 was admitted to the residence on 2/5/21. A written practitioner's order, dated 2/19/23, directed the residence to monitor and log Resident #22's blood pressure and pulse twice daily from 2/18 to 3/1/23. The February 2023 eMAR revealed that the residence failed to record the resident's pulse and blood pressure twice daily on 2/20, 2/27, and 2/28/23. A written practitioner's order, dated 2/28/23, directed the residence to weigh Resident #22 daily and to check the resident's blood pressure while sitting and standing for seven days. Additionally, the written practitioner's order directed the residence to report when the resident gained three pounds within 24 hours or five pounds within one week; they were also to report when the resident's systolic blood pressure was greater than 170 or lower than 90. The March 2023 eMAR revealed the residence failed to record weight measurements 3/1/23 to 3/6/23 as ordered. Additionally, the March 2023 eMAR revealed that the residence only recorded Resident #22's blood pressure while standing; there was no evidence that the residence measured or recorded Resident #22's blood pressure while sitting. 5. Resident #26 was admitted to the residence on 10/23/21. A written practitioner's order, dated 1/19/23, directed the residence to weight Resident #26 weekly. The February and March 2023 eMARs revealed the residence failed to measure and record Resident #26's weight weekly, with weight measurements only being recorded twice: on 2/24/23 and 3/17/23. 6. Resident #27 was admitted to the residence on 6/24/22. A written practitioner's order, dated 1/12/23, directed the residence to weigh the resident daily and to report when the resident gained three pounds within 24 hours or five pounds within one week. A weight log for Resident #27 revealed that the residence failed to weigh the resident as ordered on the following dates: 1/16, 1/17, 1/19-1/27/23, and 1/29-3/21/23.7. InterviewsOn 3/22/23 at 2:56 p.m., the resident care manager stated the qualified medication administration person (QMAP) was required to measure weights and blood pressures as ordered by the residents' practitioner as well as to document these measurements in each residents' eMARs. On 3/22/23 at 4:22 p.m., the assisted living and memory care director stated that the QMAPs were responsible for complying with practitioner's orders for measuring weights and blood pressures for Residents #2, #22, and #26-#27. She stated these measurements were required to be documented in each residents' eMAR, but she was unable to answer as to why they were not. On 3/22/23 at 5:46 p.m., the administrator stated that the QMAPs and care staff were responsible for measuring blood pressures and weights for Residents #2, #22 and #26-#27. She stated these measurements were required to be documented in the eMAR. The administrator stated that there was approximately one week when the seated scale did not work properly; she added, however, that the residence could have had an alternative solution for that time period but did not.

Based on record review and interview the residence failed to develop a fall management program that included, fall management education and materials to residents and family members, detail in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or the effects of medication, routinely inspect and maintain a safe environment, and provide staff training related to fall prevention, affecting three of three sample residents (#7, #22 and #27) who had sustained recent falls. Specifically, Resident #27 sustained a fall in November 2022, which resulted in a fractured hip. The resident sustained at least three subsequent falls following readmission after her surgery to repair her hip. The residence failed to provide fall management education and materials to the resident's family member, detail in the care plan the individualized approach necessary to address fall risk, and provide all staff with training related to fall prevention. The resident sustained a fall on 3/17/23 which resulted in a hospitalization due to several broken ribs and a requirement for an external services provider. Specifically, Resident #7 sustained falls on 1/9/23, 2/13/23, and 3/12/23. Staff reminded the resident to use a call pendant for assistance, but the resident did not comply. A private sitter was with the resident seven days per week from 2:00 p.m. to 10:00 p.m. However, Resident #7 still sustained a fall while a private sitter was on duty. The residence failed to update the resident's care plan with new individual approaches necessary to address fall risk after each fall on the above dates, and on the morning of 3/21/23, and the resident again was found on the floor with a skin tear on his elbow. Findings include:1. Residence Policya. The residence's fall management policy, dated 6/26/20, read in part that the residence observed the resident's living area for hazards and potential problems and inspected the environment for trip hazards, clutter, proper lighting, and any other items that placed residents at risk for falls. The residence created a care plan to help prevent falls utilizing a fall risk assessment form which included interventions that addressed specific identified deficits and specific activities to help maintain the resident's strength and balance. Further, the residence provided staff training related to fall prevention within 30 days of hire and provided family members and residents with education on fall prevention.b. The residence's undated care plan policy read in part that the program director and the resident care director completed a care plan on admission to address fall prevention. The care plan addressed resident goals, actual and potential problems, needs, and strengths. 2. Resident #27 was admitted to the residence on 6/24/22 with diagnoses including vascular dementia.a. Record ReviewA care plan, dated 7/1/22, read in part that the resident maintained her ability to ambulate and transfer independently without devices. A fall risk assessment, dated 11/25/22, read in part that the resident sustained one or two falls in one month/quarter, and had a fall-related fracture to her right hip. A hospital discharge document, dated 11/26/22, read in part that Resident #27 was admitted to the hospital from 11/22-11/28/22. Resident #27 presented from the residence with a fall and was found to have a right femoral neck fracture. She underwent right hip hemiarthroplasty on 11/23/23. A progress note, dated 2/2/29, read in part that staff observed Resident #27 exit her room, When the staff member approached her, the resident's head was down and she was leaning against the railing, Resident #27 stated she felt dizzy and weak. Two staff members assisted the resident to bed and noticed she had difficulty when walking. A progress note, dated 2/16/23, read in part that Resident #27 was very tired and weak. An incident report, dated 2/24/23, read in part that staff found Resident #27 on the floor. Resident #27 stated she fell and hit her head; the resident later stated she did not hit her head. A hospital discharge document, dated 2/25/23, read in part that the resident was seen because she fell and was experiencing arm and back pain. An incident report, dated 3/5/23, read in part that Resident #27 sustained an unwitnessed fall in her room. An incident report, dated 3/18/23, read in part that Resident #27 sustained an unwitnessed fall in another resident's room. The resident stated she lost her balance and fell. Resident #27's head was against the wall by the chair. There was no evidence that the care plan was updated with any fall interventions following the resident's falls on approximately 11/22/23, 2/24/23, or 3/5/23. The care plan did not address the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or the effects of medication.b. InterviewsOn 3/21/23, a family member for Resident #27 stated that the resident sustained a fall at the residence for the first time in November 2022. She stated this fall resulted in a hip injury that required a partial hip replacement, adding that the resident had fallen four times since then. The family member stated that Resident #27 had been admitted to the hospital since the night of 2/17/23 due to a fall that resulted in five broken ribs. She stated that the residence failed to provide fall management education and materials to her at any time. The family member stated the residence informed her that Resident #27 was on the maximum level of care that the residence provided so there was nothing more they could do for fall prevention. On 3/21/23 at 4:05 p.m., the administrator stated that Resident #27 was not currently at the residence because she recently fell and broke three ribs. On 3/22/23 at 9:40 a.m., Staff #13 stated Resident #27 often forgot to use her walker when ambulating. She stated staff reminded her to use it several times per day but the resident would become distracted, forget to use it, and walk without it. Staff #13 stated Resident #27 did not fall when she used the walker. Staff #13 stated the residence did not provide her any training for fall mitigation; she added the resident's room was not evaluated or changed in any way after any falls since she had worked at the residence (approximately three months). Staff #13 stated she needed one on one care for fall prevention but she did not have it. On 3/22/23 at 10:05 a.m., Staff #8 stated that Resident #27 fell because she would trip herself up or would not sit properly on her bed and slid down to the floor. She stated the resident had a walker but regularly did not use it. Staff #8 stated Resident #27 would exit seek, and she did not know what to do except provide reminders and redirection. She added that the residence did not provide any other training to prevent Resident #27 from falling. Staff #8 stated the resident's family member rearranged the furniture in the room approximately two months prior to the on site visit, and she acknowledged this did not prevent the resident from falling. 3. Resident #7 was admitted to the residence on 11/1/20 with diagnoses including mild cognitive impairment and unsteadiness on his feet.a. Record ReviewA care plan, dated 9/8/22, read in part that staff encouraged the resident to call for assistance when rising from his chair and to use his walker when walking to the restroom. Resident #7 required staff assistance with transferring as well as a safety check every two hours. A care plan, update 11/4/23, read in in part that Resident #7 was admitted to an external services provider. When the resident fell, staff were to notify the external services provider. An incident report, dated 1/19/23, read in part that upon entering Resident #7's room staff found Resident #7 lying on his back in front of his dresser between the dresser and the recliner. He sustained two skin tears on his left elbow: one was dime-sized and one was about two inches in length. The resident stated he rose from his chair and did not have slippers on, lost his footing, and he fell. An incident report, dated 2/13/23, read in part that staff found Resident #7 lying on his back on the floor in front of his dresser which was in front of his bed. A private sitter stated that the resident had been seated in his recliner, and she went to use the bathroom. Upon her return to the room, the private sitter found the resident on the floor. The resident stated he had a little back pain. A progress note, dated 3/12/23, read in part that Resident #7 had a fall. He stated his back was sore. The resident did not use his call pendant to request assistance for toileting prior to falling. Instead, he used it to call for assistance when he fell. Staff provided a reminder to Resident #7 to use the call pendant when he needed help to prevent him from falling. A progress note, dated 3/13/23, read in part that Resident #7 was not using his call pendant to request assistance despite staff reminders. Resident #7 complained of quite a bit of back pain. A progress note, dated 3/15/23 read in part that Resident #7 stated that he was in tremendous pain in his back from a previous fall that was reported. He expressed pain when moving in his bed, walking, and sitting up in his bed. He stated several times that something was broken. There was no evidence that the care plan was updated with any fall interventions following the resident's falls on 1/19/23, 2/13/23, and 3/12/23. The care plan did not address the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or the effects of medication.b. InterviewsOn 3/21/23 at 9:04 a.m., an external agency nurse (EAN) stated that emergency responders had just left that morning of the on site visit on 3/21/23 because Resident #7 tried to get out of bed, fell, and sustained a skin tear to his right arm. On 3/22/23 at 9:40 a.m., Staff #13 stated that Resident #7 had a private sitter with him at all times from 2:00 p.m. to 10:00 p.m., seven days per week, because that was the timeframe when the likelihood for a fall was higher. She stated Resident #7 sustained a fall on the morning of 3/21/23. Staff #13 stated she did not know how he fell because she administered his medications in his room and approximately ten minutes later, Staff #8 found him on the floor. She added that without staff being able to keep an eye on him at all times, the residence was unable to prevent him from falling. On 3/22/23 at 9:46 a.m., the resident care coordinator for memory care (RCCMC) stated that Resident #7 did not request assistance when he needed it. She stated a private sitter that stayed with him from 2:00 p.m. to 10:00 p.m., and she acknowledged that having the private sitter in place for that time frame did not prevent Resident #7 from falling the morning of 3/21/23. The RCCMC stated the care plan did not reflect Resident #7's fall risk nor any individualized approaches to mitigate falls, adding that the care plan should have been updated. On 3/22/23 at 10:05 a.m., Staff #8 stated Resident #7 pushed his call pendant when he wanted food, drink, or someone to find his remote control. However, she added, he did not push the call pendant for assistance to walk, including to go to the bathroom. She stated he did this because he did not think he required assistance with walking, adding the resident knew he was going to stand up but did not tell staff. Staff #8 stated Resident #7 fell the morning of 3/21/23, adding that Staff #13 administered his medications to him in his room. She stated a few minutes later, she walked past his room and observed the resident on the floor, he had reopened a skin tear on his right elbow that was a result of a prior fall approximately one and one-half months prior to the on site visit. On 3/22/23 at 4:22 p.m., the assisted living and memory care director (ALMCD) stated Resident #7 had a private sitter with him at all times from 2:00 p.m. to 10:00 p.m. She acknowledged that the resident fell the morning of 3/21/23, adding that nothing was implemented to prevent him from sustaining another fall in the mornings before the private sitter's arrival. 4. Resident #22 was admitted to the residence on 2/5/21 with diagnoses including syncope and collapse.a. Record ReviewA care plan, dated 9/30/22, read in part that staff encouraged the resident to exercise, keep up mobility, and decrease falls by attending activities. A fall risk assessment, dated 11/7/23, read in part that Resident #22 had a fall related injury which required brain surgery. It further read that a score above eight points meant that the resident was at a high risk for falls. The resident's score was 10 points. A hospital discharge document, dated 1/11/23, read that Resident #22 was seen in the neuro-critical care department by a surgeon in relation to a subdural hematoma. A progress note, dated 2/7/23, read in part that the resident was readmitted to the residence after an inpatient stay at a rehabilitation facility. The administrator had a discussion with the resident's family member regarding a private sitter to eliminate future concerns. An Assessment, dated 2/10/23, read in part that the resident had a change in condition which included a fall that resulted in being transported to the emergency department, a hospitalization, and an inpatient stay at a rehabilitation center. A fall risk assessment, dated 3/2/23 read the resident had a history of falling one to two times per month/quarter. It further read that a score above eight points meant that the resident was at a high risk for falls. The resident's score was 12 points. There was no evidence that the care plan was updated with any fall interventions following the resident's readmission to the residence on 2/7/23 after rehabilitation necessary as a result of a fall. b. InterviewsOn 3/22/23 at 2:56 p.m., the resident care manager (RCM) stated that when a resident fell, staff completed an incident report and would brainstorm interventions to keep the residents from falling again. She acknowledged, however, that interventions were not included in the incident reports and resident care plans were not updated with individual approaches necessary to address falls. The RCM stated it was the residence's management team's responsibility to follow up with fall interventions and discuss fall prevention with family members. On 3/22/23 at 4:22 p.m., the ALMCD stated when a resident fell, she was responsible for updating the care plans. She stated when staff completed safety checks every one to two hours, residents still fell. On 3/22/23 at 5:46 p.m., the administrator stated the residence's fall policy included ensuring spaces were free from clutter and fall hazards, obtaining a referral for physical and occupational therapies, and providing additional strength training. The administrator stated she expected the care plan to reflect the fall risk and the individual approaches necessary to address fall risks. She stated that a former memory care director did not update the care plans for Residents #7 and #27 as required.

Based on observation and interview the residence failed to ensure that residents had the right to civil and religious liberties including the right to be treated with dignity and respect, affecting two of 11 current residents (#9, #23) and one former resident (#24). Findings include:1. Residence PolicyThe residence's resident rights policy, dated 6/26/20, read in part that pursuant to state law, residents had the right to civil and religious liberties, including the right to be treated with dignity and respect. 2. Resident #9On 3/22/23 at 9:00 a.m., Resident #9 was observed laying in her bed without breakfast while all other residents were in the dining area eating breakfast. At 12:35 p.m., Resident #9 was observed laying in her bed without lunch while all the other residents were in the dining area eating lunch. On 3/22/23 at 12:25 p.m., Resident #9 stated that she did not want to get up for breakfast or lunch and wanted food and drink brought to her room, however, the resident care manager (RCM) told her that she would have to get up to eat and had been trying to get her out of bed all morning even though Resident #9 refused. Resident #9 stated that the RCM did not respect her wishes and tried to verbally force her out of bed, the resident stated since refused to get up, the RCM would not provide her with meals in her bed. On 3/22/23 at 5:56 p.m., the administrator stated that residents should be treated with respect and their wishes should be respected as well. 3. Resident #23 and Former Resident #24On 3/21/23 at approximately 8:00 a.m., a staff who wished to remain anonymous stated Staff #9 did not treat residents with respect and dignity, instead she spoke to some residents in a mean tone. On 3/21/23 at 2:17 p.m., Resident #23 stated she was moving out of the residence. She stated one of the contributing factors for her decision was that staff "acted like they were doing her a favor." Resident #23 stated a staff member (she could not recall the staff's name) came into her room and assisted her with getting dressed. She stated another staff member came in and offered to assist her with a shower because it had been one week since she last received shower assistance. Resident #23 stated she heard the original staff member, who assisted her with getting dressed, stated that the resident wasted the staff's time assisting her with getting dressed when the resident was then undressing for a shower. On 3/22/23 at approximately 10:00 a.m., another staff who wished to remain anonymous stated Former Resident #24 required a higher level of care. S/he stated the resident was very heavy and that his body had a tendency to stiffen due to Parkinson's Disease. The anonymous staff stated Staff #9 and the RCM avoided assisting Former Resident #24 when he requested it. The anonymous staff stated the resident used his call pendant often, and Staff #9 and the RCM would assist all other residents before they would go to assist him. The anonymous staff stated they both spoke to Former Resident #24 in a disrespectful tone, saying, "You have to get up...Now." S/he added Former Resident #24's facial reaction was that he was upset but did not know what to do. The anonymous staff stated that they used a tone that sounded like they were yelling, adding that some staff reported it to the residence's management team. S/he stated s/he was unaware as to whether the residence implemented steps to mitigate these interactions. On 3/22/23 at 2:56 p.m., the RCM stated residents reported to the assisted living and memory care director (ALMCD) and/or the administrator when they were not treated with respect and dignity. She stated when staff spoke with residents disrespectfully, it was grounds for termination. The RCM stated she had not witnessed any staff interact with residents in a disrespectful or undignified manner. On 3/22/23 at 4:22 p.m., the ALMCD stated staff and residents reported incidents of residents not being treated with respect and dignity to the administrator, who should have initiated an investigation. On 3/22/23 at 5:46 p.m., the administrator stated that residents reported disrespectful and undignified interactions with staff to the administrator. She added, however, she had no such reports as of late. She stated that residents had the right to be treated with respect and dignity, adding that residents rights were posted. The administrator stated she wanted to know when residents were not treated with respect and dignity so that she could interview staff and residents and proceed with disciplinary action when applicable.

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Based on observation, interview and record review the residence failed to have an accurate electronic medication administration record (eMAR) affecting two of ten sample residents (#1, #9) and one former resident (#24). Findings include:1. References and Residence Policy:a. The residence's medication administration policy, dated 7/9/20, read in part: For residents whose medications are monitored or administered by residence staff, a current record shall be maintained of the resident's medications including name of drug, dosage, route of administration and directions for administration of medication. The administration of medication should be documented at the time of administration. 2. Resident #1 was admitted to the residence on 6/22/22, with a diagnosis of type 1 diabetes.a. LantusA written practitioner's order, dated 1/16/23, directed the residence to administer 14 units of 100 unit/ml solution of lantus twice daily. However, the March 2023 eMAR contained "x's" on 3/9/23 in the evening, and 3/10/23 in the morning. On 3/22/23 at 5:15 p.m., the assisted living and memory care director (ALMCD) stated that did not know what blanks or "x's" in the eMAR meant; however, it should have been documented why the medication was not given. On 3/22/23 at 6:42 p.m., the administrator stated that she did not know what "x's" in the eMAR meant and stated that it should have been documented. 3. Resident #9 was admitted to the residence on 8/1/21, with diagnoses including type 2 diabetes and hypertension.a. LatanoprostA written practitioner's order, dated 1/27/23, directed the residence to instill one drop of latanoprost ophthalmic solution 4% in each eye at bedtime. However, the February 2023 eMAR read that latanoprost was administered three times on 2/4 once during the p.m. and twice at bedtime, once in the the p.m. and once at bedtime 2/1-2/3/23, and twice at bedtime on 2/5-2/25/23, for a total of twenty-four inaccurate documentations. b. ClaritinA written practitioner's order, dated 1/27/23, directed the residence to administer Claritin 10 mg once daily. However, the February 2023 eMAR read that Claritin was administered twice on 2/2, 2/8-2/10, 2/12, 2/13, 2/15, 2/17, 2/18, and 2/23-2/26/23 for a total of twelve inaccurate documentations. c. TramadolA written practitioner's order, dated 1/27/23, directed the residence to administer tramadol 50 mg one half tablet twice daily. However, the February 2023 eMAR revealed no evidence of documentation on 2/9/23 in the morning.d. OmeprazoleA written practitioner's order, dated 1/27/23, directed the residence to administer omeprazole 20 mg once daily. However, the February 2023 eMAR revealed no evidence of documentation on 2/6/23.e. SennaA written practitioner's order, dated 1/27/23, directed the residence to administer one 8.6 mg tablet of senna once daily. However, the February 2023 eMAR read that senna was administered twice on 2/4/23, for a total of one inaccurate documentation. f. AcetaminophenA written practitioner's order, dated 1/27/23, directed the residence to administer acetaminophen 1000 mg three times daily. However, the February 2023 eMAR read that acetaminophen was administered twice on 2/4/23 in the evening, for a total of one inaccurate documentation. On 3/22/23 at 3:31 p.m., the remsident care anager (RCM) stated that qualified medication administration persons (QMAPs) were marking medication off twice due to duplicates in the MAR. The RCM stated that the ALMCD needed to take these duplicates off the MAR.On 3/23/23 at 5:15 p.m., the ALMCD stated that the pharmacy put in Claritin, acetaminophen, senna and latanoprost twice and it should not have been that way in the eMARs and she should have corrected the error. The ALMCD confirmed that Resident #9 did not get her medications multiple times. The ALMCD further stated that all other medications should have been documented and not left blank. On 3/24/23 at 6:42 p.m., the administrator stated that she did not know why the February and March 2023 eMARs had duplicate medication administrations and stated it should not have been. The administrator stated that the blanks were a result of electronic medication record printing errors. 4. Former Resident #24 was admitted to the residence on 6/27/22 with diagnoses including Parkinson's disease, lewy body dementia, insomnia and constipation.a. FlorastorA written practitioner's order, dated 12/15/22, directed the residence to administer Florastor 250 mg twice daily. However, the January through February 2023 eMARs revealed no evidence of the brand of probiotic to administer, how many milligrams to administer for a total of 59 days. b. SinemetWritten practitioner's orders, dated 12/15/22 and 1/23/23, directed the residence to administer Sinemet 25/100 two tablets four times daily. However, the January through February 2023 eMARs revealed no evidence of documentation at 11:00 a.m., on 1/14, at 2:00 p.m.on 1/12, 1/14, at 5:00 p.m., on 1/10, 1/12- 1/14, 1/25, 2/2, 2/17 and 2/25/23 for a total of 11 doses. A written practitioner's order, dated 12/15/22, directed the residence to administer Sinemet 25/100 once daily at bedtime. However, the January 2023 eMAR revealed no evidence of documentation on 1/23 and 1/28/23 for a total of two doses. A written practitioner's order, dated 12/15/22, directed the residence to administer Sinemet 50/200 once daily at bedtime. However, the January 2023 eMAR revealed no evidence of documentation on 1/23 and 1/28/23 for a total of two doses. c. Seroquel A written practitioner's order, dated 12/15/22, directed the residence to administer Seroquel 25 mg half tablet twice daily and noon and 5:00 p.m. However, the January through February 2023 eMARs revealed no evidence of documentation on 1/10 at 5:00 p.m., 1/12, 1/13 at 5:00 p.m., 1/14, 1/25 at 5:00 p.m., 2/2 at 5:00 p.m. and 2/17/23 at 5:00 p.m. for a total of nine doses. A written practitioner's order, dated 12/15/22, directed the residence to administer Seroquel 75 mg once daily at bedtime. However, the January 2023 eMAR revealed no evidence of documentation on 1/23 and 1/28/23 for a total of two doses.d. MentholA written practitioner's order, dated 1/11/23, directed the residence to administer menthol topical analgesic 7.5% on bilateral calves three times a day. However, the January 2023 eMAR revealed no evidence of documentation on 1/12/23 afternoon dose for a total of one dose. On 3/22/23 at 4:22 p.m., the ALMCD stated she reviewed eMARs to discover whether the residence was running low on medications; however, she did not review the eMARs for accurate QMAP documentation. On 3/22/23 at 5:46 p.m., the administrator stated the blank spaces were partly due to the electronic medication administration record system. She stated that staff was not able to sign out of the system without accurate documentation but the printed eMARs did not reflect that . The administrator stated that this deficiency that was previously cited was not corrected because she did not review the eMARs enough to ensure accurate documentation.

Based on record review and interviews the administrator and the qualified medication administration person (QMAP) supervisor failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Additionally, the administrator and the QMAP supervisor failed to investigate and resolve any irregularities, affecting nine of nine current sample residents (#1, #2, #4, #5, #7, #22, #23 and #26-#27). (Cross-reference Q1430, Q1468, Q1510)Findings include:The residence's medication policy, dated 7/9/20, did not address the requirement to ensure the administrator and QMAP supervisor, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, nor investigate nor solve any irregularities. Documents titled Residential Care Facility Medication Storage Compliance Checklist, dated 1/24/23 and 1/25/23, read that the residence failed to ensure that both the administrator and the QMAP supervisor participated in medication audits. Additionally, no evidence was provided that the administrator and the QMAP supervisor audited the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, nor investigated nor solved any irregularities. On 3/22/23 at 2:56 p.m., the resident care manager stated that the administrator and the assisted living and memory care director (ALMCD) completed a medication audit every three months with a QMAP. She stated she participated in one audit which included shadowing a QMAP to ensure they met infection control standards and checking medication labels to ensure they matched the medication administration records. She stated she did not cross-check the written practitioner's orders during the audit. On 3/22/23 at 4:22 p.m., the ALMCD stated the administrator completed quarterly medication audits. She stated she participated in a recent medication audit, for which she checked to ensure medications were labeled properly, that the medication cart had all of the required supplies, and checked the controlled substances documentation. She stated she was not aware of the requirement to audit irregularities and resolve them by reviewing the MARs, controlled substance list, medication error reports, and medication disposal records. The ALMCD stated the errors found during the onsite investigation could have been corrected and/or prevented if the residence had completed quarterly audits that met all of the regulatory requirements. On 3/22/23 at 5:46 a.m., the administrator stated she and the ALMCD completed quarterly medication audits together. She stated, however, that their audit did not include checking to ensure written practitioner's orders matched the MARs and the medication labels.

Based on observation, interview, and record review, the residence failed to ensure two individuals who were qualified medication administration persons (QMAP), jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred and report any discrepancy in the controlled substance count to the administrator, affecting one of three sample residents with controlled substances (#9). (Cross-reference Q1468). Findings include:Resident #9 was admitted to the residence on 8/1/21, with diagnoses including type 2 diabetes and hypertension.a. TramadolA written practitioner's order, dated 1/27/23, directed the residence to administer tramadol 50 mg one half tablet twice daily. The controlled substance count for tramadol 50 mg twice daily revealed the following:On 2/8/23 in the a.m., there were nine doses of tramadol left. There were no entries for 2/9-2/11/23. On 2/12/23 in the a.m., there were eight doses left. However, the February 2023 electronic medication administration record (eMAR) read that on 2/8 and 2/10/23 in the morning, Resident #9 refused due to sleeping. On 2/9/23 in the morning there was a blank on the eMAR. Moreover, the February 2023 eMAR read on 2/11/23 tramadol 50 mg was administered in the morning, which conflicted with the controlled substance count.b. PregabalinA written practitioner's order, dated 1/27/23, directed the residence to administer pregabalin 50 mg three times daily. The controlled substance count for pregabalin 50 mg three times daily read on 2/8/23 that the medication was administered at noon. Additionally, the controlled substance count revealed no evidence that the medication was jointly counted and signed off prior to the end of each shift. However, the February 2023 eMAR read that the medication was not administered 2/8/23 in the afternoon due to "iuh." On 3/22/23 at 12:25 p.m., Resident #9 stated that she had never refused her tramadol or any other medication, and needed her tramadol since she was always in pain. On 3/22/23 at 3:31 p.m., the resident care manger (RCM) stated that she did not know why the controlled substance count sheet for Resident #9 was inaccurate for tramadol, because staff still had to dispense the medication and give it to the assisted living and memory card director (ALMCD) to destroy and stated that a staff member may have forgot to dispense Resident #9's dose of tramadol on 2/11/23 and just marked it as given. The RCM stated that Resident #9 never refused her medications and was easy to wake up, so her doses of tramadol should not have been marked as refused and should have been signed off on the count sheet to be destroyed with the ALMCD. The RCM stated that she was working the medication cart when Resident #9 refused her pregabalin, and it was due to "the resident not feeling well," and so she had given the medication to the ALMCD to destroy. The RCM stated that she signed off pregabalin in the narcotic sheet because she dispensed the medication so she thought she still had to sign off on it. When the surveyor asked the RCM what she had done when she had noticed the inaccuracies, the RCM stated that she had not done anything because she had not noticed the narcotic count sheet was inaccurate. On 3/22/23 at 5:15 p.m., the ALMCD stated that she did not know why Resident #9's tramadol narcotic count sheet did not match the February eMAR. She stated she did not know why Resident #9's tramadol was not administered and was not jointly counted and signed with herself or another qualified medication administration person (QMAP). She further stated the controlled substance count should have been jointly counted and signed at the end of each shift. The ALMCD stated that Resident #9's pregabalin should have been marked as refused and not signed off as administered on the controlled substance count in the afternoon of 2/8/23. On 3/22/23 at 6:42 p.m., the administrator stated that she did not know why the controlled substance count sheet for Resident #9 had discrepancies and would have been investigated if she had known about it; however, nothing had ever been reported to her. The administrator acknowledged that she would expect two individuals to jointly count all controlled substances and report to her the discrepancies.

Based on interview and record review, the residence failed to document out of the ordinary events along with the action taken by staff to address the resident's changing needs. Additionally, the residence's resident records failed to include documentation of on-going services provided by external service providers, affecting two of two sample residents (#22, #27) and one former resident (#24) that had out of the ordinary events. (Cross-reference Q1180)Findings include:1. Resident #27 was admitted to the residence on 6/24/22 with diagnoses including vascular dementia. A progress note, dated 2/25/23, read in part that Resident #27 was having a good day and was not having any issues. Resident #27 was transported to the emergency department (ED) per her family member's request. The progress notes revealed no other documentation regarding the reason for or follow up from the ED visit. An incident report, dated 3/18/23 read the resident was found on the floor of another resident's room. Staff "notified everyone who needed to be notified." There was no evidence in the progress notes that Resident #27 was admitted to the hospital due to broken ribs from this incident and had not returned to the residence as of 3/22/23. On 3/21/23 at 4:05 p.m., the administrator stated that Resident #27 was not currently at the residence but was at the hospital due to a fall she sustained at the residence which resulted in broken ribs. 2. Resident #22 was admitted to the residence on 2/5/21 with diagnoses including syncope and collapse. A hospital discharge document, dated 1/11/23, read that Resident #22 was seen in the neuro-critical care department by a surgeon in relation to a subdural hematoma. A progress note, dated 2/7/23, read in part that the resident was readmitted to the residence after an inpatient stay at a rehabilitation facility. The administrator had a discussion with the resident's family member regarding a private sitter to eliminate future concerns. An Assessment, dated 2/10/23, read in part that the resident had a change in condition which included a fall that resulted in being transported to the emergency department, a hospitalization, and an inpatient stay at a rehabilitation center. The resident record included no documentation in a progress note regarding his inpatient stay at a rehabilitation center. On 3/22/23 at 5:46 p.m., the administrator stated that all qualified medication administration persons (QMAPs), care staff, the resident care coordinators, the assisted living memory care director (ALMCD), and she were responsible for completing progress notes to document any changes in resident's baseline status, including things that required follow-up. She stated all staff were required to read progress notes. The administrator stated a progress note should be completed whenever a resident was transported to the emergency department and returned from a hospital or rehabilitation center. She acknowledged the resident records for Resident #22 and Former Resident #23 did not include discharge documentation, stating the residence had attempted to request records but did not get a response. 3. Resident #9 was admitted to the residence on 8/1/21, with diagnoses including type 2 diabetes and hypertension. A progress note, dated 2/27/23 for a late entry from 2/26/23, read that Resident #9 was admitted to the hospital. The progress note revealed no other documentation that provided the reason for the hospital visit. A progress note dated 3/3/23, read that Resident #9 was admitted to a rehabilitation facility for pneumonia. A progress note, dated 3/15/23 read that Resident #9 should have been back on Friday from the rehabilitation facility. A progress note, dated 3/18/23, read that Resident #9 was doing well today. However, the progress notes did not reveal the actions taken by staff to address Resident #9's changing needs when she came back to the residence from the hospital. On 3/22/23 at 2:01 p.m. the administrator stated that Resident #9's family member had taken her to the hospital on 2/26/23 to get her heart checked, and then went straight from the hospital to a rehabilitation facility on 3/3/23. The administrator stated she did not know why this was not included in the progress notes. On 3/22/23 at 2:56 p.m., the resident care manager (RCM) stated qualified medication administration persons and care staff were required to enter a progress note whenever a resident had a change in baseline status or an incident. She stated staff did not document when a resident returned from the hospital in a progress note, adding that staff informed the next shift verbally when a resident was readmitted to the residence. Additionally, the RCM stated that staff verbally relayed any changes in resident care needs upon readmission. She stated that hospital and rehabilitation notes were required to be in the resident record, and acknowledged that they were not. 4. Former Resident #24 was admitted to the residence on 6/27/22 with diagnoses including Parkinson's disease, lewy body dementia, insomnia and constipation. An ED discharge summary, dated 2/22/23, read in part: Former Resident #24 arrived via ambulance secondary to seizures noted by the assisted living residence. "Does not appear patient was actively seizing as he was responding to the environment however he did have severe uncontrollable shakes. Patient has a history of Parkinson although usually he is bradycardic and has not had actual shaking." The discharge summary further read, the former resident was shaking his upper extremities in a fast pattern; however, he did not respond towards his head to sound when asked questions with yes or no. Former Resident #24 had a "pretty severe tremor but no active seizing." The former resident was administered cogentin and Ativan and went back to baseline status. The former resident was subsequently discharged. However, the record for Former Resident #23 revealed no evidence of the resident being sent to the ED for a possible seizure or tremors that were out of the ordinary and therefore revealed no evidence of the actions taken by staff to address his changing needs. An incident report dated 3/1/23 at 10:40 a.m., read Former Resident #24 was administered Sinemet 50/200 two tablets instead of Sinemet 25/100 two tablets. The incident report revealed no further information regarding follow-up or notifications. A progress note, dated 3/1/23, read Former Resident #23 was having a hard time getting up in the morning and around lunch time the resident "perked and ... was his usual self." The progress note revealed no evidence regarding any out of the ordinary event regarding staff administering too much Sinemet, along with the action taken by staff to address that resident's changing needs. On 3/22/23 at 4:22 p.m., the ALMCD stated QMAPs, care staff, and she were required to enter progress notes into the resident record whenever there was a change in the resident's baseline status, including anything important. She stated she expected detailed progress notes about residents because verbal communication among staff was not enough to ensure pertinent information was passed along. The ALMCD stated she was aware of the requirement to include hospital and rehabilitation discharge documentation in the resident records, and she acknowledged that the records for Resident #22 and Former Resident #24 did not have them.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.6.8 The administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (K) Appointing and supervising a qualified designee who is capable of satisfactorily fulfilling the administrator's duties when the administrator is unavailable. (1) The name and contact information for the administrator or qualified designee on duty shall always be readily available to the residents and public. (2) The administrator or qualified designee shall always, whether on or off site, be readily accessible to staff. 12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status. 12.17 The assisted living residence shall ensure that it has trained staff available to evaluate residents who have fallen or are otherwise unable to independently get up off the floor and provide lift assistance when determined appropriate instead of relying on emergency medical responders. 14.9 No medication shall be administered by a qualified medication administration person on a pro re nata (PRN) or "as needed" basis except:(A) In a residential treatment facility that is licensed to provide services for the mentally ill; (B) Where the resident understands the purpose of the medication, is capable of voluntarily requesting the medication, and the assisted living residence has documentation from an authorized practitioner that the use of such medication in this manner is appropriate; or(C) Where specifically allowed by statute. 14.27 No stock medications shall be stored or administered by qualified medication administration persons. A) All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident's full name.

A licensure revisit was completed on 3/23/23 for all previous deficiencies cited on 6/7/22. Deficiencies were cited.

Based on observation and interview, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire, affecting two of three sample staff (#29, #31). This deficiency was cited previously during a licensure revisit on 6/7/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's Background Check Policy, dated 1/16/22, read in part: "In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer.(A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the assisted living residence shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI)."Staff #29's personnel file revealed a hire date of 9/5/22. There was no evidence in the personnel file that a name-based criminal history report was conducted by the CBI. Staff #29 was observed on 3/21/23 providing care and services to residents. Staff #31's personnel file revealed a hire date of 12/15/23. However, the CBI criminal history report was dated 3/21/23, the date of the onsite visit. There was no evidence in the personnel file that a name-based criminal history report was conducted by the CBI prior to Staff #31's hire date. On 3/22/22 at 4:22 p.m., the assisted living and memory care director stated that the administrator was responsible for ensuring that each personnel file contained the required documentation prior to hiring staff. On 3/22/23 at 5:46 p.m., the administrator stated that Staff #29 had worked at the residence previously, so her CBI criminal history report was located in another file. She acknowledged the date on the CBI criminal history report for Staff #31 was the date of the on site visit, and she stated that the report had been run prior to hire but the residence was unable to provide the documentation. The administrator stated she could not answer as to why this deficiency that was previously cited was not corrected.

Based on record review and interview, the residence failed to include written documentation regarding a description of the employee duties, orientation and training, and tuberculin (TB) tests in each personnel file, affecting three of three sample staff (#29-#31). This deficiency was cited previously during a licensure revisit on 6/7/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The personnel files for Contracted Staff #30 and #31 contained no description of employee duties, no documentation of orientation, and no TB test result. The personnel file for Staff #29 contained no documentation of orientation and no TB test result. On 3/22/23 at 5:46 p.m., the administrator stated she was responsible for creating and maintaining personnel files. She stated that Staff #31 did receive orientation but the residence's printer was not working, so they were unable to include documentation in the personnel file. The administrator stated that Staff #30 was contracted staff and therefore did not have a job description in the personnel file. She added that she did not have a reason as to why the TB tests results were not in Staff #29-#31's personnel files.

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

A licensure revisit was completed on 3/23/23 for the previous deficiency cited on 6/7/22. A deficiency was cited.

Based on record review and interview the residence failed to develop a fall management program that included, fall management education and materials to residents and family members, detail in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or the effects of medication, routinely inspect and maintain a safe environment, and provide staff training related to fall prevention, affecting three of three sample residents (#1, #10, #11) who had sustained recent falls. This deficiency was cited previously during a state licensure revisit on 6/7/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Specifically, Resident #11 sustained a fall in November 2022, which resulted in a fractured hip. The resident sustained at least three subsequent falls following readmission after her surgery to repair her hip. The residence failed to provide fall management education and materials to the resident's family member, detail in the care plan the individualized approach necessary to address fall risk, and provide all staff with training related to fall prevention. The resident sustained a fall on 3/17/23 which resulted in a hospitalization due to several broken ribs and a requirement for an external services provider. Specifically, Resident #10 sustained falls on 1/9/23, 2/13/23, and 3/12/23. Staff reminded the resident to use a call pendant for assistance, but the resident did not comply. A private sitter was with the resident seven days per week from 2:00 p.m. to 10:00 p.m. However, Resident #10 still sustained a fall while a private sitter was on duty. The residence failed to update the resident's care plan with new individual approaches necessary to address fall risk after each fall on the above dates, and on the morning of 3/21/23, and the resident again was found on the floor with a skin tear on his elbow. Findings include:1. Residence Policya. The residence's fall management policy, dated 6/26/20, read in part that the residence observed the resident's living area for hazards and potential problems and inspected the environment for trip hazards, clutter, proper lighting, and any other items that placed residents at risk for falls. The residence created a care plan to help prevent falls utilizing a fall risk assessment form which included interventions that addressed specific identified deficits and specific activities to help maintain the resident's strength and balance. Further, the residence provided staff training related to fall prevention within 30 days of hire and provided family members and residents with education on fall prevention.b. The residence's undated care plan policy read in part that the program director and the resident care director completed a care plan on admission to address fall prevention. The care plan addressed resident goals, actual and potential problems, needs, and strengths. 2. Resident #11 was admitted to the residence on 6/24/22 with diagnoses including vascular dementia.a. Record ReviewA care plan, dated 7/1/22, read in part that the resident maintained her ability to ambulate and transfer independently without devices. A fall risk assessment, dated 11/25/22, read in part that the resident sustained one or two falls in one month/quarter, and had a fall-related fracture to her right hip. A hospital discharge document, dated 11/26/22, read in part that Resident #11 was admitted to the hospital from 11/22-11/28/22. Resident #11 presented from the residence with a fall and was found to have a right femoral neck fracture. She underwent right hip hemiarthroplasty on 11/23/23. A progress note, dated 2/2/29, read in part that staff observed Resident #11 exit her room, when the staff member approached her, the resident's head was down and she was leaning against the railing, Resident #11 stated she felt dizzy and weak. Two staff members assisted the resident to bed and noticed she had difficulty when walking. A progress note, dated 2/16/23, read in part that Resident #11 was very tired and weak. An incident report, dated 2/24/23, read in part that staff found Resident #11 on the floor. Resident #11 stated she fell and hit her head; the resident later stated she did not hit her head. A hospital discharge document, dated 2/25/23, read in part that the resident was seen because she fell and was experiencing arm and back pain. An incident report, dated 3/5/23, read in part that Resident #11 sustained an unwitnessed fall in her room. An incident report, dated 3/18/23, read in part that Resident #11 sustained an unwitnessed fall in another resident's room. The resident stated she lost her balance and fell. Resident #11's head was against the wall by the chair. There was no evidence that the care plan was updated with any fall interventions following the resident's falls on approximately 11/22/23, 2/24/23, or 3/5/23. The care plan did not address the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or the effects of medication.b. InterviewsOn 3/21/23, a family member for Resident #11 stated that the resident sustained a fall at the residence for the first time in November 2022. She stated this fall resulted in a hip injury that required a partial hip replacement, adding that the resident had fallen four times since then. The family member stated that Resident #11 had been admitted to the hospital since the night of 2/17/23 due to a fall that resulted in five broken ribs. She stated that the residence failed to provide fall management education and materials to her at any time. The family member stated the residence informed her that Resident #11 was on the maximum level of care that the residence provided so there was nothing more they could do for fall prevention. On 3/21/23 at 4:05 p.m., the administrator stated that Resident #11 was not currently at the residence because she recently fell and broke three ribs. On 3/22/23 at 9:40 a.m., Staff #30 stated Resident #11 often forgot to use her walker when ambulating. She stated staff reminded her to use it several times per day but the resident would become distracted, forget to use it, and walk without it. Staff #30 stated Resident #11 did not fall when she used the walker. Staff #30 stated the residence did not provide her any training for fall mitigation; she added the resident's room was not evaluated or changed in any way after any falls since she had worked at the residence (approximately three months). Staff #30 stated she needed one on one care for fall prevention but she did not have it. On 3/22/23 at 10:05 a.m., Staff #29 stated that Resident #11 fell because she would trip herself up or would not sit properly on her bed and slid down to the floor. She stated the resident had a walker but regularly did not use it. Staff #29 stated Resident #11 would exit seek, and she did not know what to do except provide reminders and redirection. She added that the residence did not provide any other training to prevent Resident #11 from falling. Staff #29 stated the resident's family member rearranged the furniture in the room approximately two months prior to the on site visit, and she acknowledged this did not prevent the resident from falling. 3. Resident #10 was admitted to the residence on 11/1/20 with diagnoses including mild cognitive impairment and unsteadiness on his feet.a. Record ReviewA care plan, dated 9/8/22, read in part that staff encouraged the resident to call for assistance when rising from his chair and to use his walker when walking to the restroom. Resident #10 required staff assistance with transferring as well as a safety check every two hours..A care plan, update 11/4/23, read in in part that Resident #10 was admitted to an external services provider. When the resident fell, staff were to notify the external services provider. An incident report, dated 1/19/23, read in part that upon entering Resident #10's room staff found Resident #10 lying on his back in front of his dresser between the dresser and the recliner. He sustained two skin tears on his left elbow: one was dime-sized and one was about two inches in length. The resident stated he rose from his chair and did not have slippers on, lost his footing, and he fell. An incident report, dated 2/13/23, read in part that staff found Resident #10 lying on his back on the floor in front of his dresser which was in front of his bed. A private sitter stated that the resident had been seated in his recliner, and she went to use the bathroom. Upon her return to the room, the private sitter found the resident on the floor. The resident stated he had a little back pain..A progress note, dated 3/12/23, read in part that Resident #10 had a fall. He stated his back was sore. The resident did not use his call pendant to request assistance for toileting prior to falling. Instead, he used it to call for assistance when he fell. Staff provided a reminder to Resident #10 to use the call pendant when he needed help to prevent him from falling. A progress note, dated 3/13/23, read in part that Resident #10 was not using his call pendant to request assistance despite staff reminders. Resident #10 complained of quite a bit of back pain. A progress note, dated 3/15/23 read in part that Resident #10 stated that he was in tremendous pain in his back from a previous fall that was reported. He expressed pain when moving in his bed, walking, and sitting up in his bed. He stated several times that something was broken. There was no evidence that the care plan was updated with any fall interventions following the resident's falls on 1/19/23, 2/13/23, and 3/12/23. The care plan did not address the individualized approach necessary to address fall risk related to deficits in strength, balance, eyesight, or the effects of medication.b. InterviewsOn 3/21/23 at 9:04 a.m., an external agency nurse (EAN) stated that emergency responders had just left that morning of the on site visit on 3/21/23 because Resident #10 tried to get out of bed, fell, and sustained a skin tear to his right arm. On 3/22/23 at 9:40 a.m., Staff #30 stated that Resident #10 had a private sitter with him at all times from 2:00 p.m. to 10:00 p.m., seven days per week, because that was the timeframe when the likelihood for a fall was higher. She stated Resident #10 sustained a fall on the morning of 3/21/23. Staff #30 stated she did not know how he fell because she administered his medications in his room and approximately ten minutes later, Staff #29 found him on the floor. She added that without staff being able to keep an eye on him at all times, the residence was unable to prevent him from falling. On 3/22/23 at 9:46 a.m., the resident care coordinator for memory care (RCCMC) stated that Resident #10 did not request assistance when he needed it. She stated a private sitter that stayed with him from 2:00 p.m. to 10:00 p.m., and she acknowledged that having the private sitter in place for that time frame did not prevent Resident #10 from falling the morning of 3/21/23. The RCCMC stated the care plan did not reflect Resident #10's fall risk nor any individualized approaches to mitigate falls, adding that the care plan should have been updated. On 3/22/23 at 10:05 a.m., Staff #29 stated Resident #10 pushed his call pendant when he wanted food, drink, or someone to find his remote control. However, she added, he did not push the call pendant for assistance to walk, including to go to the bathroom. She stated he did this because he did not think he required assistance with walking, adding the resident knew he was going to stand up but did not tell staff. Staff #29 stated Resident #10 fell the morning of 3/21/23, adding that Staff #30 administered his medications to him in his room. She stated a few minutes later, she walked past his room and observed the resident on the floor, hehad reopened a snake tear on his right elbow that was a result of a prior fall approximately one and one-half months prior to the on site visit. On 3/22/23 at 4:22 p.m., the assisted living and memory care director (ALMCD) stated Resident #10 had a private sitter with him at all times from 2:00 p.m. to 10:00 p.m. She acknowledged that the resident fell the morning of 3/21/23, adding that nothing was implemented to prevent him from sustaining another fall in the mornings before the private sitter's arrival. 4. Resident #1 was admitted to the residence on 2/5/21 with diagnoses including syncope and collapse. .A care plan, dated 9/30/22, read in part that staff encouraged the resident to exercise, keep up mobility, and decrease falls by attending activities. A fall risk assessment, dated 11/7/23, read in part that Resident #1 had a fall related injury which required brain surgery. It further read that a score above eight points meant that the resident was at a high risk for falls. The resident's score was 10 points. A hospital discharge document, dated 1/11/23, read that Resident #1 was seen in the neuro-critical care department by a surgeon in relation to a subdural hematoma. A progress note, dated 2/7/23, read in part that the resident was readmitted to the residence after an inpatient stay at a rehabilitation facility. The administrator had a discussion with the resident's family member regarding a private sitter to eliminate future concerns. An Assessment, dated 2/10/23, read in part that the resident had a change in condition which included a fall that resulted in being transported to the emergency department, a hospitalization, and an inpatient stay at a rehabilitation center. A fall risk assessment, dated 3/2/23 read the resident had a history of falling one to two times per month/quarter. It further read that a score above eight points meant that the resident was at a high risk for falls. The resident's score was 12 points. There was no evidence that the care plan was updated with any fall interventions following the resident's readmission to the residence on 2/7/23 after rehabilitation necessary as a result of a fall. b. InterviewsOn 3/22/23 at 2:56 p.m., the resident care manager (RCM) stated that when a resident fell, staff completed an incident report and would brainstorm interventions to keep the residents from falling again. She acknowledged, however, that interventions were not included in the incident reports and resident care plans were not updated with individual approaches necessary to address falls. The RCM stated it was the residence's management team's responsibility to follow up with fall interventions and discuss fall prevention with family members. On 3/22/23 at 4:22 p.m., the ALMCD stated when a resident fell, she was responsible for updating the care plans. She stated when staff completed safety checks every one to two hours, residents still fell. On 3/22/23 at 5:46 p.m., the administrator stated the residence's fall policy included ensuring spaces were free from clutter and fall hazards, obtaining a referral for physical and occupational therapies, and providing additional strength training. The administrator stated she expected the care plan to reflect the fall risk and the individual approaches necessary to address fall risks. She stated that this deficiency that was previously cited was not corrected because a former memory care director did not update the care plans for Residents #10 and #11 as required. Additionally, the administrator acknowledged that she needed assistance with fall management because she thought the residence had improved.

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