LODGE AT GREELEY, THE

A complaint revisit was completed on 7/17/24 for all previous deficiencies cited on 4/5/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 1/14/24.

Based on record review and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting two of four sample residents who fell (#20, #23). This deficiency was cited previously during a complaint survey on 4/5/23. 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 #20 was admitted to the residence on 5/1/22 with a diagnosis of transient cerebral ischemic attack. The progress notes for Resident #20 in July 2024 revealed the following:On 7/4/24, Resident #20 was found on the floor of her bathroom with no injuries. Additionally, "Resident had no injuries (from a fall on 7/3) only bruising and skin tear from the night before."There were no additional care plan updates in Resident #20's record after 6/18/24 that included details of the approaches necessary to address fall risks related to deficits after Resident #20 fell on 7/3 and 7/4/24.2. Interviews On 7/17/24 at 12:45 p.m., Staff #24 stated they were unaware of any new care plan updates that detailed the approaches necessary to address fall risks related to deficits after Resident #20 fell on 7/3 and 7/4/24. On 7/17/24 at 2:30 p.m., the generations program director (GPD) stated, based on their policy, the residence was required to update care plans within 24 to 48 hours after falls occur. The GPD stated resident #20 and Resident #23 ' s care plans were not updated after the resident had fallen. On 7/17/24 at 4:25 p.m., the administrator stated she expects care plan ' s to be updated. 3. During the onsite visits on 7/16 and 7/17/24 similar deficient practice was found for Resident #23.

Based on record review and interview the residence failed to develop and implement policies and procedures with all of the required elements for the identification, reports, and investigation of injuries of unknown origin, affecting one of seven sample residents residing in the secure environment. This deficiency was cited previously during a complaint survey on 4/5/23. 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 8/24/20. A progress note in Resident #22's record, dated 6/6/24 read staff found a skin tear on Resident #22's elbow. There was no investigation note in Resident #22's record to show how the skin tear occurred. On 7/17/2024 at approximately 3:45 p.m the administrator stated she was not aware of Resident #22's skin tear on 6/6/24 and she said she expected the residence to have conducted an investigation.

Based on record review and interview the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting four of six sample residents (#18, #20, #21, #23). This deficiency was cited previously during a complaint survey on 4/5/23. 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 #21 was admitted to the residence on 11/2/21 with diagnoses including glaucoma. Brimonidine TimololA written practitioner's order, dated 5/2/24, directed the residence to administer brimonidine timolol one drop in both eyes twice daily. However, the July 2024 medication administration record for Resident #21 read the medication was not in stock and not administered on 7/14 in the evening and 7/15 morning and evening doses, for a total of three missed doses. A progress note in Resident #21's record revealed on 7/15/24 Resident #21 was not administered brimonidine timolol due to medication being in-route to the building. On 7/16/24 at 7:49 a.m., Staff #27 stated that the weekend before the onsite visit on 7/16/24, Resident #21 was not administered her eye drops because they were out of stock. On 7/17/24 at 8:29 a.m., Resident #21 stated the residence had trouble getting one of her eye drop medications in stock recently and as a result, the eye drops were not administered. On 7/17/24 at 3:00 p.m., the resident care director confirmed Resident #21's brimonidine timolol eye drops were not administered on the evening of 7/14 and 7/15 morning and evening doses. On 7/17/24 at approximately 3:45 p.m., the administrator said she expected medications to be administered as ordered and not run out of stock. 2. Evidence obtained during the on-site visits revealed that the residence additionally failed to comply with authorized practitioner orders associated with medication administration for Resident #12, #18 and #20.

Based on interview and record review, the residence failed to comply with an intermediate condition, affecting 51 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for six months. Following the completion of Event D95511 on 9/14/22, a licensure complaint investigation, the department imposed an RN consultant for six months to address the cited deficiencies. The intermediate condition read the consultant was required to complete, during the first month of the contract period:-Review each of the cited deficiencies identified in the deficiency list for Event D95511 and dated 9/14/22, with the administrator and evaluate the residence's current compliance with corresponding regulations as outlined in 6 CCR 1011-1 Chapters 2, 7, and 24, where applicable. The intermediate condition read the consultant was required to complete, during the first two months of the contract period:-Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24 and provide recommendations to the administrator on any additional areas of noncompliance. The RN consultant shall also implement a monitoring program, to be completed at least monthly, to ensure the residence remains in compliance with previously cited deficiencies. The monitoring program shall be incorporated into the residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, section 4. The consultant shall make certain that the QMP is designed to improve resident safety and well-being, and promotes continued quality improvement to enhance service delivery. The intermediate condition read the consultant was required to complete, during the entire six-months of the contract period:-The RN consultant shall make certain that the administrator has a process in place to correct the identified deficiencies, which includes utilizing the above-referenced monitoring program to ensure the deficient practice does not reoccur. The intermediate condition read the consultant was required to complete, during the final two months of the contract period:-The RN consultant shall prepare the administrator to independently manage the facility to ensure compliance with all applicable regulations governing assisted living residences. The intermediate condition letter read the residence was required to:-Submit a letter to the department identifying a proposed consultant on 11/24/22;-Submit a executed contract to the department on 12/2/22;-Submit progress notes on 1/15/23. Department records further read the residence:-Submitted a letter to the department identifying a proposed consultant on 2/6/23;-Submitted a executed contract to the department on 2/24/23Therefore during the onsite investigation the residence was within the second month of the contract. 2. Current Deficient PracticeThe onsite licensure complaint investigation survey on 4/4 through 4/5/23, established there was current deficient practice. Eight deficiencies were cited. (Cross-reference Q540, Q1146, Q1150, Q1180, Q1430, Q1468, Q1510, Q514). 3. InterviewOn 4/5/23 at approximately 3:00 p.m., the administrator said she was aware the residence was required to be in compliance with all regulations surveyed while under an intermediate condition. On 4/5/23, multiple attempts were made to contact the residence's consultant; however, the department was unable to reach the contracted consultant.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 51 current residents. This deficiency was cited previously during a state licensure complaint survey 9/14/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. ReferenceThe COVID-19 Mitigation and Outbreak Guidance in Assisted Living and Group Homes, dated 2//22/22, required residences to:-Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one) and (period two). Multiple reports within the same reporting period will overwrite previous reporting and doesnot meet requirements for future reporting periods. Reporting period one (defined as days 1-14 of each month). Complete all facility questions. Reporting period two (defined as days 15-31 of each month). Complete all facility questions. Update reporting when changes occur: vaccine information (see vaccination clinics section); name and contact information of the staff member in charge of infection prevention and control practices at your facility.-Establish and maintain a COVID-19 mitigation, vaccine, and treatment plan that promotes vaccine confidence and acceptance. 2. EMResourceOn 4/4/23 at 10:01 a.m., the department database revealed the residence had not completed EMResource reporting since 12/12/22. On 4/5/23 at approximately 3:00 p.m., the administrator said she was responsible for updating EMResoruce twice monthly. The administrator acknowledged that she had not updated EMResource, as required. The administrator stated the residence census and staffing numbers had changed since December 2022. 3. COVID-19 Mitigation PlanOn 4/4/23 at approximately 1:00 p.m., the residence was asked to provide the COVID-19 ongoing vaccination and treatment plan. On 4/5/23 at approximately 12:00 p.m., the residence's COVID-19 mitigation plan was reviewed and was not completed, as required. The COVID-19 safety coordinator was not identified. The plan did not include their process for vaccination confidence nor acceptance, as required. On 4/5/23 at approximately 3:00 p.m., the administrator stated she had not created a COVID-19 mitigation plan for the residence. She added the reason the citation was recited was because she did not have the time.

Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated for residents whenever residents' conditions changed from baseline status, affecting three of five sample residents (#4, #18, #19) and two former residents (#8 and #10), who experienced a change in baseline status. (Cross-reference Q1180 and Q1150)Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(D) Communication ability and any specific needs to facilitate effective communication;(G) Individual bathroom routines, sleep and awake patterns;(H) Reactions to the environment and others, including changes that may occur at certain times or in certain circumstances(J) History and circumstances of recent falls and any known approaches to prevent future falls;(K) Safety awareness;(L) Types of physical, mental, and social support required.b. The residence's Resident Assessment and Service Plan policy, dated 12/9/21, read, in part, "In order to evaluate residents's needs, the resident care director (RCD) or generations program director (GPD) will ensure that resident assessments are completed for residents in accordance with the procedures contained in this policy. Assessment and service plans will be updated as frequently as necessary to ensure they reflect resident care needs and preferences ... Residents who resident in assisted living will be re-assessed ... whenever there is significant change in resident condition ... For the purposes of updating a resident's assessment and service plan, a 'change of condition' is defined as a decline or improvement that is not considered to be short term in nature. Some examples include but are not limited to: A resident who has fallen and suffered an injury such as a fracture. A resident who has been admitted to hospice care. A resident who has experienced a general decline in their health and requires on-going increased care needs."2. Resident #18 was admitted to the residence on 9/26/20. An assessment for Resident #18, dated 2/6/23, read that Resident #18 used no assistive devices, was a fall risk, required occasional reminders and cueing, required four to six checks per day. The record for Resident #18 revealed no evidence of any other assessments had been completed. Progress notes for Resident #18, dated March 2023, revealed the following:On 3/3/23, Resident #18 sustained an injury and required stitches. On 3/3/23, Resident #18 sent out to the emergency room. On 3/4/23, Resident #18 tripped over his catheter tubing. On 3/22/23, Resident #18 fell on 3/21/23 with staff present. External hospice notes for Resident #18, dated March 2023 revealed the following:On 3/6/23, Resident #18 was admitted to external hospice. On 3/6/21, Resident #18 was seen by an external hospice representative after his return from the emergency department for major skin tears to his left upper and lower arm. On 3/31/23, Resident #18 fell and had a skin tear to his right forearm. Incident reports for Resident #18, dated March 2023, revealed the following:On 3/2/23, Resident #18 stated he scratched himself and was unable to stop the bleeding. Resident #18 had a one inch long laceration on the calf of his right leg. Resident #18's room was covered in blood. Emergency medical services were notified. On 3/3/23, Resident #18's leg wound was still bleeding from the evening before. Resident #18's family member transported him to urgent care for evaluation. On 3/21/23, Resident #18 fell as he transferred from his bed to his wheelchair. Staff was present. Resident #18 had a skin tear on his left hand and forehead. Resident #18 was sent to the emergency room for evaluation. On 3/31/23, Resident #18 was observed on the floor. Skin tear to his right elbow. On 4/4/23 at 1:11 p.m., the GPD said reassessments should have completed upon a change in a residents condition such as external hospice admission, when residents stopped eating and falls that resulted in injuries. She added, the assessment for Resident #18 should have been updated, as required. On 4/5/23 at approximately 3:00 p.m., the administrator said the assessment for Resident #18 should have been updated after his admission to external hospice and after repeated falls that resulted in injury. On 4/4/23 at 5:40 p.m., a family member of Resident #18 stated there was no reassessment completed for Resident #18 moved from independent living to the non-secure assisted living environment in January 2023. 3. Former Resident #8 was admitted to the residence on 9/28/20. An assessment for Former Resident #8, dated 1/25/23, read that Former Resident #8 was a fall risk, required no assistive devices, had behaviors that required staff intervention and/or redirection, did not require additional status checks and did not require hospice services. External hospice provider notes, dated February and March 2023 for Former Resident #8, revealed the following:On 2/9/23, Former Resident #8 was admitted to external hospice. On 3/23/23, Former Resident #8 was showing signs of decline, difficulty with word finding and unable to form sentences. Progress notes in the record of Former Resident #8 in March 2023 revealed the following:On 3/2/23, Former Resident #8 was confused. On 3/3/23, Former Resident #8 was confused and asked to go home across the street. On 3/4/23, Former Resident #8 was confused this evening, kept asking where she was and was almost in tears. On 3/14/23, Former Resident #8 was confused and refused to use her walker when she walked. On 3/21/23, Former Resident #8 was unstable on her feet and stumbled a little. Staff reminded her to use her walker throughout the day and required cueing when eating. On 3/22/23, Former Resident #8 did not eat her breakfast. On 3/23/23, Former Resident #8 did not eat much dinner. On 4/4/23 at approximately 2:00 p.m., the external hospice representative for Former Resident #8 said that Former Resident #8 had a significant decline since she was admitted in February 2023. She added in March 2023 she only formed a couple of words and struggled to express her feelings. On 4/523 at 3:20 p.m., the administrator stated she expected a comprehensive assessment to have been completed for Former Resident #8 to include her external hospice provider and overall decline. 4. Resident #4 was admitted to the residence on 4/18/21, with a diagnosis of Alzheimer's disease. An assessment for Resident #4, dated 1/25/23, read that Resident #4 required one person assistance with transfers other than staff escort, did not require assistive devices, and required redirection. Moreover, the assessment did not mention Resident #4's communication issues. The record for Resident #4 revealed no evidence that any other assessments had been completed. Progress notes in the record of Resident #4, dated January-March 2023, revealed the following:On 1/10/23, Resident #4 was walking too fast and fell on her face. On 3/20/23, Resident #4 was no longer able to stand on her own and needed two-person assistance to transfer from the bed to the wheelchair. External hospice notes in the residence's record for Resident #4, dated March 2023, revealed the following:On 3/16/23, Resident #4 was no longer able to make her needs known. On 3/30/23, Resident #4 was nonverbal. On 4/4/23 at 7:24 a.m., Staff #9 stated that Resident #4 fell in January 2023 and bruised her face, and since then had been declining, and now required total staff assistance with transfers. Staff #9 stated that the administrator or the GPD updated assessments. On 4/5/23 at 9:38 a.m., Resident #4's external hospice provider stated that Resident #4 was no longer ambulatory, had a wheelchair and was also no longer verbal and able to express her needs. Resident #4's external hospice provider stated that Resident #4's decline started after her fall with injury on 1/10/23. On 4/5/23 at 3:17 p.m., the administrator statedthat Resident #4 should have been reassessed since after her fall on 1/10/23, she has had a significant change, and acknowledged that she now required two person assist with transfers and was no longer ambulatory or able to express her needs. 5. Resident #19 was admitted to the residence on 1/26/23. An for Resident #19, dated 2/2/23, read that Resident #19 may be a fall risk, did not use assistive devices with transfer, had external hospice but did not require staff involvement at this time and had behaviors that may require staff intervention and redirection. Moreover, the assessment did not include the types of mental or social support required for his behaviors. Progress notes for Resident #19, dated March 2023, revealed the following:On 2/2/23 and 2/22/23, Resident #19 exhibited aggressive behaviors and attempted to swing at Staff #15. On 3/24/23, Resident #19 kicked and swung his arms at Staff #9. On 3/31/23, Resident #19 was combative toward staff. A practitioner's communication note, written by the GPD dated 3/6/23, read that staff attempted several times to administer medication to Resident #19 and he was swinging at staff. An incident report for Resident #19, dated 3/27/23, read that Resident #19 had a fall due to sliding out of bed. On 4/4/23 at 2:54 p.m., Resident #19's external hospice provider stated that Resident #19 used a walker and required frequent checks and staff interventions with his behaviors. On 4/4/23 at 3:44 p.m., Staff #14 stated that she had never personally had any problems with Resident #19's behaviors, and stated that he responded well to a calm and slow approach. On 4/4/23 at 4:28 p.m., Staff #13 stated that Resident #19 had shown aggressive behaviors toward staff if approached in an aggressive manner. However, Staff #13 stated that Resident #19 had not shown aggressive behaviors toward her, and had never shown aggressive behaviors toward other residents. Staff #13 acknowledged that not all staff knew how to approach Resident #19 in a way he responds well to. On 4/4/23 at 7:24 a.m., Staff #9 stated that Resident #19 had a fall where he slid out of bed in March 2023. Staff #9 stated that the administrator or the GPD updated assessments. On 4/4/23 at 3:44 p.m., Staff #14 stated that Resident #19 had a walker. On 4/5/23 at 3:17 p.m., the administrator stated that Resident #19 should have been reassessed since after his fall on 3/27/23, and acknowledged that he required staff support with his behavioral expressions. 6. Former Resident #10 was admitted to the residence on 12/31/20, with diagnoses including Alzheimer's disease. An incident report, dated 10/25/22, read that Former Resident #10 had a fall with no signs of pain or injury and was assisted back to bed. A comprehensive assessment, dated 10/25/22, read that Former Resident #10 may be a fall risk and required one person assistance with transfers. However, the assessment did not include any history and circumstances of recent falls, any known approaches to prevent future falls, or the health and functional ability of Former Resident #10. A late-entry progress note, dated 10/26/22 at 6:57 p.m., read that Former Resident #10 had a fall with a large purple bruise on her left hip. A hospital bed with a fall mat was delivered. Former Resident #10 had a low mattress and required four staff to reposition her in bed with the use of a draw sheet. An external hospice note, dated 10/26/22 and located in the record of Former Resident #10, read Former Resident #10 was seen for a daily hospice visit and had a fall the prior evening. Former Resident #10 was two person minimum assist with transfers and had extreme pain and a large bruise to her left hip. A care plan for Former Resident #10, dated 11/1/22 with an effective date of 9/9/22, read that Former Resident #10 was on external hospice and required nighttime safety checks, required standby assistance with transfers, was at risk for falls and required a wheelchair and verbal cues. On 4/4/23 at approximately 11:00 a.m., the residence provided the remaining documentation from Former Resident #10's record. However, there were no progress notes or incident reports of prior falls. On 4/4/23 at 9:35 a.m., Former Resident #10's family member stated that after the former resident fell on 10/25/22, she was bedbound, required more than two staff members to reposition her in bed, had a fall mat and wheelchair. The family member stated that as a result of the fall, Former Resident #10 passed away on 11/4/22. Former Resident #10's family member also acknowledged that Former Resident #10 had fallen prior to 10/25/22, she just could not remember dates. On 4/4/23 at 3:15 p.m., Former Resident #10's external hospice agency stated that Former Resident #10's external hospice nurse no longer worked for the agency and were not able to provide any specific information regarding Former Resident #10 and her fall interventions. On 4/4/23 at 3:44 p.m., Staff #14 stated that Former Resident #10 had a fall mat, required total assistance and was bedbound after her fall on 10/25/22. Staff #14 acknowledged the residence had not provided her with fall management training; therefore, she was not aware on how to respond to Former Resident #10's fall. Staff #14 acknowledged that Former Resident #10 was a high fall risk. On 4/4/23 at 5:16 p.m., the administrator stated that she provided all progress notes and other documentation the residence had regarding Former Resident #10 and her falls. On 4/5/23 at approximately 3:30 p.m., the administrator stated that she was aware the residence's current electronic assessments did not include all the required information. The administrator stated the comprehensive assessment should have included information regarding Former Resident #10's overall health and physical abilities and was updated by the secure environment program director. The administrator acknowledged that Former Resident #10 was bedbound and required more than two staff to reposition her in bed. The administrator stated that the consultant had completed the comprehensive assessment update for Former Resident #10 on 10/25/22, not the residence.

Based on observation, record review and interview, the residence failed to ensure that each care plan detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting two of five sample residents (#4, #19) and one former resident (#10). (Cross-reference Q1180 and Q1146)Findings include:1. Residence Policya. The residence's care plan policy, dated 12/9/21, read in part: "each resident care plan shall be developed with input from the resident and the resident's representative, reflect the most current assessment information, promote resident choice, mobility, independence and safety, detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs, identify all external service providers along with care coordination arrangements, identify formal, planned, and informal spontaneous engagement opportunities that match the resident's personal choices and needs."2. Resident #4 was admitted to the residence on 4/18/21, with a diagnosis of Alzheimer's disease. A care plan, dated 10/27/22, read that Resident #4 did not require additional measures to communicate her needs or be understood and was able to ambulate independently without an assistive device. Resident #4 required cuing due to a cognitive impairment. However, the care plan did not include that Resident #4 was no longer able to voice her needs and was no longer able to stand on her own. A progress note, dated 3/20/23 read that Resident #4 was no longer able to stand on her own and needed two-person assistance to transfer from the bed to the wheelchair. External hospice notes for Resident #4, dated March 2023, revealed the following:On 3/16/23, Resident #4 was no longer able to make her needs known. On 3/30/23, Resident #4 was nonverbal. On 4/4/23 at 9:17 a.m., Staff #16 and #19 both transferred Resident #4 out of bed into her wheelchair with a gait belt, and Resident #4 was unable to stand at all or answer any questions. On 4/5/23 at 9:38 a.m., the external hospice provider for Resident #4 stated that the resident was no longer ambulatory, had a wheelchair and was also no longer verbal and able to express her needs since her fall with injury on 1/10/23. On 4/5/23 at 3:17 p.m., the administrator stated that the care plan for Resident #4 should have been updated after her fall on 1/10/23 to include her needs and staff necessary to meet those needs. The administrator stated that Resident #4 had had a significant change, and acknowledged that she now required two person assist with transfers and was no longer ambulatory or able to express her needs. 3. Resident #19 was admitted to the residence on 1/26/23. A care plan for Resident #19, dated 4/4/23, read that Resident #19 expressed agressive physical and/or verbal behaviors and external hospice and the administrator were to be notified and interventions needed to be documented. However, the care plan did not include staff tasks necessary to meet Resident #19's needs in regard to his behavioral expressions. Progress notes dated February and March 2023 revealed the following:On 2/2/23, Resident #19 threw his walker across the room and attempted to hit Staff #15 with closed fists. On 2/5/23 at 5:15 p.m., Resident #19 threw his pills on the floor and smashed his fists into his plate. On 2/5/23 at 5:18 p.m., Resident #19 was aggressive toward staff. On 2/7/23 at 5:27 a.m., Resident #19 was extremely aggressive and punched a staff member in the head. On 2/11/23, Resident #19 was combative with Staff #9 while assisting with toileting care and refused medications. On 2/17/23, Resident #19 pushed Staff #9 away when she tried to take his blood pressure. On 2/22/23, Resident #19 swung at Staff #15. On 2/28/23, Resident #19 was upset and attempted to hit Staff #15. On 3/31/23, Resident #19 was combative with Staff #9 during medication pass and would not allow Staff #9 to administer medications to him with a spoon and folded his fist and used profane language toward Staff #9. On 4/4/23 at 3:25 p.m., Staff #7 stated that the day shift staff did not know how to handle Resident #19's behavioral expressions. Staff #7 stated that Resident #19 responded well to a calm approach and she had observed Staff #15 be controlling and rude to other residents as well. On 4/4/23 at 3:44 p.m., Staff #14 stated that she had never personally had any problems with Resident #19's behaviors, and stated that he responded well to her calm approach. On 4/4/23 at 3:58 p.m., Resident #19's family member stated that Resident #19 often refused medications and did not respond well to staff trying to make him do things that he did not want to do. Resident #19's family member stated that she was concerned that staff members did not know how to address Resident #19's behaviors; however felt like Staff #14 always took a good approach toward Resident #19. On 4/4/23 at 4:28 p.m., Staff #13 stated that Resident #19 had not shown aggressive behaviors toward her and had never shown aggressive behaviors toward other residents. Staff #13 stated that Staff #15 was very assertive and aggressive when providing resident care and had witnessed her boss residents around and rush carelessly. Staff #13 stated that she thought that staff members such as Staff #15 were approaching Resident #19 inappropriately. On 4/5/23 at 2:42 p.m., Staff #21 stated that she had no training on Resident #19's behavioral expressions or how to approach him; however, he responded well if staff approached him in a calm and respectful demeanor to reassure him that staff were only there to help him. On 4/5/23 at 3:40 p.m., the administrator stated that the care plan for Resident #19 should have been updated to include Resident #19's behavioral expressions and how staff intervene and approach him. 4. Former Resident #10 was admitted to the residence on 12/31/20 with diagnoses including Alzheimer's disease. An incident report, dated 10/25/22, read that Former Resident #10 had a fall with no signs of pain or injury and was assisted back to bed. A late-entry progress note, dated 10/26/22 at 6:57 p.m., read that Former Resident #10 had a fall with a large purple bruise on her left hip. A hospital bed with a fall mat was delivered. Former Resident #10 had a low mattress and required four staff to reposition her in bed with the use of a draw sheet. An external hospice note, dated 10/26/22 and located in the record of Former Resident #10, read Former Resident #10 was seen for a daily hospice visit and had a fall the prior evening. Former Resident #10 was two person minimum assist with transfers and had extreme pain and a large bruise to her left hip. A care plan for Former Resident #10, dated 11/1/22 with an effective date of 9/9/22, read that Former Resident #10 was at risk for skin breakdown in bed due to decreased cognitive and functional mobility and topical cream and antifungals were to be used as directed. The care plan also read that Former Resident #10 was standby transfers. However, the care plan did not include information on how staff were to reposition former Resident #10 in the bed. On 4/4/23 at 3:25 p.m., Staff #7 stated that she did not feel that staff were able to provide cares and transfer Former Resident #10 appropriately after her fall on 10/25/22. Staff #7 was not aware of Former Resident #10's specific care needs. 6. InterviewOn 4/5/23 at approximately 3:30 p.m., the administrator stated that she would expect likes, dislakes, care tasks and assistance provided, engagement opportunities, preferences and how to monitor and report changes to be a part of each resident's care plan. The administrator stated that their electronic medical record system generates an outline of a care plan that needed to be updated manually. The administrator stated that she was not aware that care plans for Resident #4, #19 and former Resident #10 were not updated to include the required elements. The administrator stated that this deficiency was being recited because there was a lack of attention from the GPD who was responsible for updates as well as herself.

Based on record review and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting three of five sample residents (#4, #18, #19) and one former resident (#8). (Cross-reference 1146 and Q1150)This deficiency was cited previously during a state licensure complaint survey 9/14/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, former Resident #10 had a fall with injury on 10/25/22, and her care plan was updated on 11/1/22. Contracted staff #17 and #18, and Staff #14 who was in training at the time, were unsure how to respond appropriately to the fall, and picked up former Resident #10 and got her into bed while in pain, and failed to contact external hospice or former Resident #10's family member. Former Resident #10's external hospice nurse found out about former Resident #10's fall on 10/26/22, and contacted former Resident #10's family member themselves. Staff #14 and other staff members acknowledged that they had never received any fall management training from the residence. Furthermore, the care plan did not include and staff were not aware of the individualized approach necessary to address fall risk. Specifically, Resident #4 had a fall on 11/12/22, then a fall with injury on 1/10/23, and an additional fall on 1/22/23. A care plan, dated 10/27/22, read that Resident #4 required one person assist with transfers and ambulate independently without an assistive device. However the care plan was not updated after Resident #4 fell on 11/12/22, and as a result Resident #4 had a fall with injury on 1/10/23 and a major decline that required full staff assistance with transfers and a wheelchair. Furthermore, the care plan was not updated to include, and staff were not aware of the individualized approach necessary to address fall risk. Findings include:1. Residence Policya. The residence's Resident Assessment and Service Plan policy, dated 12/9/21, read, in part, The community's Fall Reduction Program evaluation includes: The fall risk assessment ... shall be conducted by a licensed or registered nurse or trained designee ... Each resident's identified fall risks shall be addressed with recommended interventions included in the resident's service plan. Each resident's service plan and fall risk assessment will be reviewed and updated whenever a resident has: A first fall ... Repeat falls. A fall with injury requiring medical intervention/treatment. A change in condition."2. Former Resident #10 was admitted to the residence on 12/31/20 with diagnoses including Alzheimer's disease. An incident report, dated 10/25/22, read that Former Resident #10 had a fall with no signs of pain or injury and was assisted back to bed. A comprehensive assessment, dated 10/25/22, read that Former Resident #10 may be a fall risk and required one person assistance with transfers. A late-entry progress note, dated 10/26/22 at 6:57 p.m., read that Former Resident #10 had a fall and sustained a large purple bruise on her left hip. A hospital bed with a fall mat was delivered and Former Resident #10 was provided a low mattress and required four staff to move her in bed with the use of a draw sheet. An external hospice note, dated 10/26/22, read Former Resident #10 had a daily hospice visit, had a fall the prior evening. The former resident had required staff to provide a two person minimum assist with transfer and had extreme pain with a large bruise to her left hip. A previous care plan for Former Resident #10, dated 12/31/20, read that Former Resident #10 was at risk for falls due to balance problems and confusion. A care plan for Former Resident #10, effective 9/9/22 and updated 11/1/22, read that Former Resident #10 was on external hospice for care, required nighttime staff safety checks, required one person standby assistance with transfers, was at-risk for falls, required a wheelchair and staff's verbal cues. However, the care plan for Former Resident #10 was not updated with detailed to include the individualized approaches necessary to address fall risk related to deficits in strength, or balance after her fall with injury on 10/25/22, that included a fall mat, draw sheet, hospital bed, and minimum of four person transfers in bed due to being bed bound. A progress note, dated 11/4/22, read that Former Resident #10 passed away. On 4/4/23 at 9:35 a.m., Former Resident #10's family member stated that after Former Resident #10 fell on 10/25/22 she was not notified by the residence and external hospice ended up notifying her the next day. Former Resident #10's family member stated that she required more than two staff members to move her around in the bed and had a fall mat and wheelchair implemented. Former Resident #10's family member stated that as a result of the fall, Former Resident #10 passed away on 11/4/22. On 4/4/23 at 3:15 p.m., Former Resident #10's external hospice provider representative stated that Former Resident #10's external hospice nurse no longer worked for them, and they were not able to provide me any specific information regarding Former Resident #10 and her fall interventions. On 4/4/23 at 3:44 p.m., Staff #14 stated that she was on shift the day Former Resident #10 fell. Staff #14 stated that Former Resident #10 was moaning and in apparent pain and contracted Staff #17 and contracted Staff #18 got her up anyway and insisted to Staff #14 who was still in training and a new hire, that Former Resident #10 was not in pain. Staff #14 stated that Former Resident #10 had a fall mat and required total assist and was bed bound after her fall on 10/25/22. Staff #14 acknowledged that she had received no training on fall management by the residence and was not aware herself on how to respond to Former Resident #10's fall. On 4/5/23 at 2:36 p.m., Former Resident #10's family member stated that Former Resident #10 was on external hospice for a year prior to Former Resident #10's fall on 10/25/22, and had a hospice bed. Former Resident #10's family member stated that contracted staff had gotten her up on 10/25/22 when Former Resident #10 fell. On 4/5/23 at 3:30 p.m., the administrator stated that she would have expected individualized interventions to be included in Former Resident #10's care plan and to have been updated to address how staff were to accommodate Former Resident #10's transfer requirements post fall on 10/25/22. The administrator acknowledged that Former Resident #10 had a significant decline after she had fallen and broken her hip on 10/25/22, and ultimately passed away on 11/4/22. 3. Resident #4 was admitted to the residence on 4/18/21, with a diagnosis of Alzheimer's disease. A care plan, dated 10/27/22, read that Resident #4 required one person assistance with transfers and ambulates independently without an assistive device. However, the care plan for Resident #4 did not mention she was on external hospice, and was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, after any of her falls on 11/12/22, 1/10/23, or 1/22/23. An incident report, dated 11/12/22, read that Resident #4 had a fall and was laughing with water in her mouth and started to choke. An incident report, dated 1/10/23, read that Resident #4 had a fall in the hallway and was observed with a bump on her forehead and a bloody nose. An incident report, dated 1/22/23, read that Resident #4 had a fall in her bedroom and was unable to verbalize details of the incident. An assessment, dated 1/25/23, read that Resident #4 required one person assistance with transfers other than staff escort, did not require assistive devices, and required redirection. There were no other assessments in Resident #4's record. On 4/4/23 at 9:17 a.m. a wheelchair, fallmat, and hospital bed with extending sides was in Resident #4's bedroom. Staff #16 and #19 both got Resident #4 out of bed into her wheelchair with a gait belt, and Resident #4 was unable to stand at all. On 4/4/23 at 7:24 a.m., Staff #9 stated that Resident #4 fell in January 2023 and bruised her face, and since then had been declining, and now required total staff assistance with transfers. On 4/5/23 at 9:38 a.m., Resident #4's external hospice provider stated that Resident #4 was no longer ambulatory and had a wheelchair. Resident #4's external hospice provider stated that Resident #4's decline started after her fall with injury on 1/10/23. Resident #4's external hospice provider stated that Resident #4 was admitted to external hospice in November 2022, and now had fall mats, a bed with extending sides, a bolster sheet, and a wheelchair. On 4/5/23 at 2:42 p.m., Staff #21 stated that she had no training on Resident #4's fall interventions. On 4/5/23 at 2:50 p.m., Staff #20 stated that Resident #4 had a significant decline after her fall on 1/10/23 and was walking prior and was now in a wheelchair and a bed with protective sides. On 4/5/23 at 3:40 p.m., the administrator stated that Resident #4's care plan should have been updated after her fall on 1/10/23, she had a significant change, and acknowledged that she now required two person assist with transfers and was no longer ambulatory. 4. Resident #18 was admitted to the residence on 9/26/20. An assessment in Resident #18's record, dated 2/6/23 read that Resident #18 used no assistive devices, was a fall risk and required occasional reminders and cueing and required four to six checks per day. Progress notes in Resident #18's record, dated March 2023 revealed the following:On 3/3/23 Resident #18 sustained an injury and required stitches. On 3/4/23 Resident #18 tripped over his catheter tubing. On 3/22/23 Resident #18 fell on 3/21/23 with staff present. External hospice provider notes for Resident #18, dated March 2023 revealed the following:On 3/31/23 Resident #18 fell and had a skin tear to his right forearm. Incident reports in Resident #18's record, dated March 2023, revealed the following:On 3/21/23 Resident #18 fell as he transferred from his bed to his wheelchair. Staff was present. Resident #18 had a skin tear on his left hand and forehead. Resident #18 was sent to the emergency room for evaluation. On 3/31/23 Resident #18 was observed on the floor. Skin tear to his right elbow. There were no other assessments in Resident #18's record. On 4/4/23 at 7:35 a.m., the resident care director (RCD) said Resident #18 fell frequently and the intervention she was taught was that she notified the practitioner's for them to schedule a visit. On 4/4/23 at 2:00 p.m., Staff #16 stated she was not provided education or training on fall interventions for Resident #18. On 4/4/23 at 5:40 p.m., a family member of Resident #18 acknowledged that Resident #18 fell with and without injuries recently. She added one intervention she was provided was to consider an external hospice provider, which Resident #18 was enrolled at the beginning of March 2023. The family member said she was never spoken to by management about how to address Resident #18's falls even after his admission with an external hospice provider in March 2023. On 4/5/223 at approximately 3:00 p.m., the administrator stated the residence's fall management program included re-assessment of a resident when they fell and education and training provided to families and staff about fall interventions. The administrator said she expected staff to reassess a resident who has fallen with or without injury and expected the care plans to be updated, as required. The administrator acknowledged that Resident #18 was not reassessed, as required after multiple falls. The administrator said the reason the citation was recited was, "A matter of education diligence on the part of (the generations program director/GPD) and my supervision of her to make sure she has the diligence of the program." 5. Resident #19 was admitted to the residence on 1/26/23. An incident report, dated 1/30/23, read that Resident #19 had a fall. An assessment in Resident #19's record, dated 2/2/23, read that Resident #19 may be a fall risk, did not use assistive devices with transfer. There were no other assessments in Resident #19's record. A progress note, dated 3/27/23, read that Resident #19 had a fall sliding out of bed. A care plan for Resident #19, dated 4/4/23, read that Resident #19 was a fall risk and was unstable at times. However, the care plan for Resident #19 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength. On 4/4/23 at 8:28 a.m., Staff #9 stated that Resident #19 had a walker for transferring. On 4/4/23 at 2:54 p.m., Resident #19's external hospice provider stated that Resident #19 used a walker, had a fall mat and required frequent checks and staff interventions with his behaviors. On 4/4/23 at 3:58 p.m., Resident #19's family member stated that she was not notified of Resident #19's fall out of bed on 3/31/23. On 4/5/23 at 2:42 p.m., Staff #21 stated that she had no training on Resident #19's fall interventions. On 4/5/23 at 3:40 p.m., the administrator stated that because staff were not aware how to manage Resident #19's falls, she would expect care plans to have been updated with those individualized interventions. 6. InterviewsOn 4/4/23 at 8:36 a.m., Staff #19 stated that she was not trained on fall management by the residence. On 4/4/23 at 8:41 a.m., Staff #16 stated that she was not trained by the residence on fall management by the residence. On 4/5/23 at 3:40 p.m., the administrator said the RCC and GPD were responsible for updating care plans, as required. She added, the reason the deficiency was recited was "A matter of education diligence on the part of (GPD) and my supervision of her to make sure she has the diligence of the program."

Based on record review and interview, the residence failed to prepare or administer only medication that had been ordered by an authorized practitioner, affecting one sample resident (#11). This deficiency was cited previously during a state licensure survey on 9/14/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's medication policy, dated 6/23/20, read that residents (would) receive assistance with administration of medication in accordance with state regulations ...based on written orders and resident's needs and preferences."2. Resident #11On 4/4/23 at approximately 9:26 a.m., the full resident record and March and April medication administration records (eMARs) with corresponding orders were requested for Resident #11. However, the resident record provided did not include orders for Resident #11's gabapentin or diltiazem dated prior to 3/6/23. On 4/5/23 at 8:11 a.m., Resident #11's diltiazem and gabapentin orders dated prior to 3/6/23, were requested and not provided. The GPD gave back the same orders that the surveyor already had with the date of 3/6/23 on them.a. DiltiazemThe March 2023 eMAR read in part, a practitioner's order dated 3/6/23 directed the residence to administer 120 mg of diltiazem once daily. Resident #11 was administered diltiazem 3/1-3/6/23, for a total of six doses. However, the residence was unable to provide a written practitioner's order dated prior to 3/6/23.b. Gabapentin The March 2023 eMAR read in part, a practitioner's order dated 3/6/23 directed the residence to administer two 800 mg of gabapentin at midnight. Resident #11 was administered gabapentin at midnight 3/1-3/6/23, for a total of six doses. However, the residence was unable to provide a written practitioner's order dated prior to 3/6/23.3. InterviewOn 4/5/23 at approximately 3:50 p.m., the administrator stated that she would expect there to be signed practitioner's orders for all medications being administered and was not aware why the 3/6/23 orders for the gabapentin and diltiazem were provided back to the surveyor again after specifically requesting the orders dated prior to 3/6/23. The administrator stated that she did not know why this deficiency was not corrected.

Based on interview, and record review, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting six of seven sample residents whose medication were reviewed (#4, #7, #11-#12, #18-#19) and one former resident (#10). This deficiency was cited previously during a state licensure survey on 9/14/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #11 was prescribed two 800 mg tablets of gabapentin at midnight for nerve pain. On 3/31/23, Resident #11 went without her two 800 mg tablets of midnight gabapentin and was up all night with severe nerve pain as a result. Findings include:1. Reference and Residence Policiesa. According to New Choices Treatment Centers, gabapentin withdrawal side effects can begin to occur within 12 hours after stopping the medication, and include muscle pain, tremors, and restlessness. Retrieved from: https://newchoicestc.com/blog/gabapentin-withdrawal-symptoms-nc/b. The residence's Medication Administration Policy, dated 6/23/20, read that residents (would) receive assistance with administration of medication in accordance with state regulations ...based on written orders and resident's needs and preferences."c. The residence's Medication Services policy, dated 12/9/21, read, in part, "The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration ..."d. The residence's Med Room Workflow policy, dated 12/9/21, read, in part, "It is the responsibility of every staff member involved with medications to ensure the medications are ordered appropriately. Medications are ordered at least 7 days before running out (more days may be needed when needed due to difficult or mail order pharmacies, upcoming holidays/weekends, and controlled substances) ..."2. Resident #11 was admitted to the residence on 7/13/21, with a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery. A practitioner's after visit summary, dated 3/6/23, read that Resident #11 had further diagnosis of idiopathic peripheral neuropathy, hyperlipidemia, osteoarthritis, and chronic respiratory failure with hypoxia. a. GabapentinA written practitioner's order, dated 3/6/23, directed the residence to administer two tablets of 800 mg gabapentin three times daily and once at midnight. However, the March 2023 electronic medication administration record (eMAR) read that the residence failed to administer gabapentin at midnight on 3/31/23, for a total of one missed dose. On 4/5/23 at approximately 9:45 a.m., Resident #11 stated that when she missed her midnight dose of gabapentin on 3/31/23 she kept waking up with severe nerve pain, and could not sleep through the night. Resident #11 stated that her nerve pain was in her face. On 4/5/23 at 12:11 p.m., a nurse at Resident #11's practitioner's office stated that since Resident #11 was on such a high dose of gabapentin, even her having missed one dose can cause the nerve pain that Resident #11 described. On 4/5/23 at 12:30 p.m., the GPD stated that she was not aware of Resident #11's symptoms and would expect staff to report to her when medication was not available. On 4/5/23 at 3:54 p.m., the administrator stated that she was not aware of the pain Resident #11 experienced due to missing her gabapentin and would expect staff to notify her.b. BenzonatateA written practitioner's order, dated 2/10/23, directed the residence to administer one 100 mg tablet of benzonatate three times daily and discontinue on 3/2/23. However, the March 2023 eMAR read that the residence failed to administer benzonatate in the evening on 3/1/23, due to waiting on the pharmacy to deliver, for a total of one missed dose. c. CelecoxibA written practitioner's order, dated 2/10/23, directed the residence to administer one 100 mg tablet of celecoxib three times daily. However, the March 2023 eMAR read that the residence failed to administer celecoxib in the morning on 3/31/23 due to the waiting on the pharmacy for delivery, for a total of one missed dose. d. Sulfamethoxazole-TrimethoprimA written practitioner's order, dated 3/9/23, directed the residence to administer one 800-160 mg tablet of sulfamethoxazole-trimethoprim every 12 hours for seven days. However, the March 2023 eMAR read that the residence failed to administer sulfamethoxazole-trimethoprim in the morning on 3/9/23 in the evening due to the waiting on the pharmacy for delivery, for a total of one missed dose. 3. Former Resident #10 was admitted to the residence on 12/31/20, with a diagnosis of early onset Alzheimers.a. MorphineA written practitioner's order, dated 10/29/22, directed the residence to discontinue the order for morphine sulfate 20 mg/ml 0.5 ml every 6 hours daily for pain, and increase the dose to 20 mg/ml 0.5 ml every 4 hours for pain. However, the October and November 2022 eMAR read that the new dose of 20 mg/ml 0.5 ml every 4 hours for pain was not on either MAR until the order changed to every two hours on 11/3/23, for a total of twenty-four missed doses.b. HaloperidolA written practitioner's order, dated 9/21/22, directed the residence to administer 2 mg/ml of haloperidol lactate every 6 hours. However, the October 2022 eMAR read that the residence failed to administer haloperidol in the afternoon and evening on 10/29/22 due to waiting on pharmacy for delivery, for a total of two missed doses. On 4/4/23 at 9:35 a.m. former Resident #10's family member stated that she did not think the residence was administering former Resident #10's morphine as directed by Resident #10's practitioner. 4. Resident #7 was admitted to the residence on 3/24/22, with diagnoses including Alzhiemer's disease and seizures.a. Divalproex SodiumA written practitioner's order, dated 8/10/22, directed the residence to administer 500 mg tablets of divalproex sodium daily at bedtime. However, the March 2023 eMAR read that the residence failed to administer divalproex sodium 3/12-3/13/23 and 3/15/23, for a total of three missed doses, due to waiting on the pharmacy to deliver.b. AcetaminophenA written practitioner's order, dated 8/10/22, directed the residence to administer 325 mgs of acetaminophen three times daily. However, the March 2023 eMAR read that the residence failed to administer acetaminophen on 3/5/23 in the evening, for a total of one missed dose. 5. Resident #19 was admitted to the residence on 1/26/23, with no diagnoses listed.a. QuetiapineA written practitioner's order, dated 3/9/23, directed the residence to administer 25 mgs of quetiapine once daily. However, the March and April 2023 eMARs read that the residence failed to administer quetiapine 3/28-3/30/23, and 4/2-4/3/23, for a total of five missed doses. 6. Resident #4 was admitted to the residence on 4/18/21, with a diagnosis of Alzheimer's disease. a. AcetaminophenA written practitioner's order, dated 1/12/23, directed the residence to administer two 325 mg tablets of acetaminophen three times daily. However, the March 2023 eMAR read that acetaminophen was not administered on 3/22/23 in the evening, and 3/23/23 all three doses due to waiting on the pharmacy for delivery, for a total of four missed doses. 7. Resident #12 was admitted to the residence on 6/30/22. A written practitioner's order, dated 3/19/23, directed the residence to administer amoxicillin 875-125 mg twice daily. However, the March 2023 eMAR for Resident #12 read the medication was not available and not administered on 3/26-3/28/23, for a total of six missed doses. On 4/5/23 at 1:20 p.m., the GPD said the medication was not available and not administered to Resident #12.8. Resident #18 was admitted to the residence on 9/26/20. A written practitioner's order, dated 1/23/23, directed the residence to administer clonidine twice daily. However, the medication was not available and not administered on 3/2/23, for a total of two missed doses. On 4/5/23 at 1:10 p.m., the GPD said the medication was not administered to Resident #18 because the pharmacy had not delivered the medication or staff were unable to find the medication in the cart. 9. InterviewsOn 4/5/23 at 1:15 p.m., the GPD stated that staff needed to follow up with the pharmacy before a medication ran out of stock and check on medications in the overstock before marking a medication as missed. The GPD stated that she expected staff to inform her if they could not find a medication before making it off as missed. The GPD stated that she would expect that staff order medications at least a week prior to them running out, and that the residence comply with practitioner's orders. On 4/5/23 at approximately 3:54 p.m., the administrator stated that she would expect that all residents received their medications as ordered and not run out of stock. The administrator stated that the GPD and Resident Care Coordinator (RCC) were in charge of medication management, however, the RCC was on vacation. The administrator stated that this deficiency was not corrected because the residence had struggled with filling medications with the pharmacy to ensure they were always in stock.

Based on record review and interview, the residence failed to ensure that each qualified medication administration person (QMAP), nurse, or practitioner accurately documented each medication administration or monitoring event at the time the event is completed for each resident, including any medication omissions or refusals, affecting three of seven sample residents (#7, #12, #19) and one former resident (#10) whose medications were reviewed. (Cross-reference Q1514)This deficiency was cited previously during a state licensure complaint survey 9/14/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's Med Room Workflow policy, dated 12/9/21, read, in part, "The MARs (medication administration records) are intitled at the time the medication is placed in the cup. Each qualified medication administration, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident."2. Former Resident #10 was admitted to the residence on 12/31/20, with diagnoses including Alzheimer's disease. On 4/5/23, a paper MAR dated October 2022 from 10/1-10/14/22 was found in former Resident #10's file.a. MorphineA written practitioner's order, dated 9/21/22, directed the residence to administer 20 mg/ml of morphine every 6 hours. However, the October 2022 paper MAR contained blanks 10/1-10/13/22 at 2:00 a.m., on 10/8/22 at 8:00 a.m. and 2:00 p.m., and 10/1-10/5 and 10/7-10/13/22 at 8:00 p.m. with no reason provided in the documentation.b. LorazepamA written practitioner's order, dated 9/21/22, directed the residence to administer 2 mg/ml of lorazepam every 6 hours. However, the October 2022 paper MAR contained blanks 10/1-10/13/22 at 2:00 a.m., on 10/8/22 at 8:00 a.m. and 2:00 p.m., and 10/1-10/5 and 10/7-10/13/22 at 8:00 p.m. Additionally, the October 2022 eMAR for former Resident #10 had a blank space on 10/23/23 at night and on 10/27/23 in the evening.c. HaloperidolA written practitioner's order, dated 9/21/22, directed the residence to administer 1 mg of haloperidol every 6 hours. However, the October 2022 paper MAR contained blanks 10/1-10/13/22 at 2:00 a.m., on 10/8/22 at 8:00 a.m. and 2:00 p.m., and 10/1-10/5 and 10/7-10/13/22 at 8:00 p.m. with no reason documented.d. Baza ProtectA written practitioner's order, dated 9/21/22, directed the residence to apply baza protect twice daily. However, the October 2022 paper MAR contained a circle with no documentation attached as to why the medication was circled, on 10/1, 10/4, and 10/11/2 in the morning, and 10/6/22 in the evening. Additionally, the eMAR contained blanks on 10/8/22 in the morning, and 10/1-10/5 and 10/7-10/11/22 in the evening.e. NystatinA written practitioner's order, dated 9/21/22 directed the residence to administer 100000 unit/gm nystatin ointment twice daily. However, the October 2022 paper MAR contained a circle with no documentation attached as to why the medication was circled, on 10/1, 10/4, and 10/11/22 in the morning. Additionally, there were blanks in the paper MAR on 10/8/22 in the morning, 10/1-10/5 and 10/7-10/13/22 in the evening.f. MiralaxA written practitioner's order, dated 9/21/22, directed the residence to administer 17 gram miralax once daily. However, the October 2022 paper MAR contained a circle with no documentation attached as to why the medication was circled, on 10/4 and 10/11/22. Additionally, the eMAR contained a blank on 10/8/22. On 4/4/23 at 9:35 a.m., former Resident #10's family member stated that she was concerned that former Resident #10's nystatin was not applied to her perineal area as prescribed because she was red and itchy. Former Resident #10's family member also stated that she was concerned that Resident #10's morphine was not being administered as prescribed either. On 4/4/23 at 1:06 p.m., the administrator stated the residence switched to electronic eMARs from paper on 10/14/22, which was why there were "X's in former Resident #10's eMAR prior to 10/14/22. On 4/5/23 at 3:59 p.m., the administrator stated that she would expect all medications to have been documented, and would have expected staff to have given a reason for all of the circled medications on former Resident #10's paper MAR. 3. Resident #19 was admitted to the residence on 1/26/23.a. QuetiapineA written practitioner's order, dated 3/9/23, directed the residence to administer 25 mgs of quetiapine once daily. However, the March and April 2023 eMAR read that Resident #19's quetiapine was administered 3/31-4/1/23. However, the March and April 2023 eMAR read that the residence failed to administer quetiapine 3/28-3/30/23, and 4/2-4/3/23 due to waiting on the pharmacy. On 4/5/23 at 3:55 p.m., the administrator acknowledged that there was no way Resident #19s medication could have been administered on 3/14/23 if it was out of stock the other days due to waiting on the pharmacy. The administrator stated this would be a documentation error. 4. Resident #7 was admitted to the residence on 3/24/22, with diagnoses including Alzhiemer's disease and seizures.a. Divalproex SodiumA written practitioner's order, dated 8/10/22, directed the residence to administer 500 mg tablets of divalproex sodium daily at bedtime. However, the March 2023 eMAR read that the residence administered divalproex sodium on 3/14/23. However on 3/12-3/13/23 and 3/15/23 divalproex sodium was not administered due to waiting on the pharmacy to deliver. On 4/5/23 at 3:55 p.m., the administrator acknowledged that there was no way Resident #7s medication could have been administered on 3/14/23 if it was out of stock the other days due to waiting on the pharmacy. The administrator stated this would be a documentation error. 5. Resident #12 was admitted to the residence on 6/30/22 with diagnoses that included hypocalcemia. AcetaminophenA written practitioner's order, dated 3/19/23, directed the residence to administer acetaminophen 325 mg three times daily. However, the April 2023 eMAR for Resident #12 had a blank space on 4/3/23 in the afternoon.b. Calcium Antacid A written practitioner's order, dated 3/19/23, directed the residence to administer calcium antacid 100 mg three times daily. However, the April 2023 eMAR for Resident #12 had a blank space on 4/3/23 in the afternoon. 6. InterviewOn 4/5/23 at approximately 3:00 p.m., the administrator said a blank space on the eMAR for residents was considered medications that were not documented by the QMAPs, as required. She added the reason the citation was not corrected was because of the residence's failure to follow through on procedures that were put into place.

Based on record review and interview, the residence failed to ensure the administrator and the QMAP supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records, affecting six of seven sample residents whose medications were reviewed (#4, #7, #11, #12, #18, #19) and one former resident (#10). (Cross-reference Q1468, Q1510)This deficiency was cited previously during a state licensure complaint survey 9/14/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 4/4/23 at approximately 9:30 a.m., the residence's quarterly audits of medication administration records', controlled substance lists, medication error reports, and medication disposal records were requested. On 4/4/23 at approximately 10:30 a.m., the administrator provided a binder that included a medication count that included residents who received medications from the residence's preferred pharmacy and family members. The contents included a specific medication cart audit. The binder did not include an audit of the accuracy and completeness of the MARs, controlled substance lists, medication error reports or medication disposal records. On 4/5/23 at approximately 3:00 p.m., the administrator said the residence completed a couple of different audits that included cart organization, expired medications, over the counter medication labeling a count of the remaining medication supply for residents who were enrolled with hospice and for residents whose family members provided mediation. The administrator said she reviewed the audits completed and had not participated in an audit of the accuracy and completeness of the medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records. The administrator said the reason the citation was not corrected was because she misunderstood the regulation requirement and reviewed the documentation and had not completed an actual audit with the QMAP supervisor, as required.

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 #CO30281, #CO31474 and #CO31576 was completed on 4/5/23. Deficiencies were cited.

Based on interview and record review, the residence failed to comply with an intermediate condition, affecting 51 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for six months. Following the completion of Event D95511 on 9/14/22, a licensure complaint investigation, the department imposed an RN consultant for six months to address the cited deficiencies. The intermediate condition read the consultant was required to complete, during the first month of the contract period:-Review each of the cited deficiencies identified in the deficiency list for Event D95511 and dated 9/14/22, with the administrator and evaluate the residence's current compliance with corresponding regulations as outlined in 6 CCR 1011-1 Chapters 2, 7, and 24, where applicable. The intermediate condition read the consultant was required to complete, during the first two months of the contract period:-Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24 and provide recommendations to the administrator on any additional areas of noncompliance. The RN consultant shall also implement a monitoring program, to be completed at least monthly, to ensure the residence remains in compliance with previously cited deficiencies. The monitoring program shall be incorporated into the residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, section 4. The consultant shall make certain that the QMP is designed to improve resident safety and well-being, and promotes continued quality improvement to enhance service delivery. The intermediate condition read the consultant was required to complete, during the entire six-months of the contract period:-The RN consultant shall make certain that the administrator has a process in place to correct the identified deficiencies, which includes utilizing the above-referenced monitoring program to ensure the deficient practice does not reoccur. The intermediate condition read the consultant was required to complete, during the final two months of the contract period:-The RN consultant shall prepare the administrator to independently manage the facility to ensure compliance with all applicable regulations governing assisted living residences. The intermediate condition letter read the residence was required to:-Submit a letter to the department identifying a proposed consultant on 11/24/22;-Submit a executed contract to the department on 12/2/22;-Submit progress notes on 1/15/23. Department records further read the residence:-Submitted a letter to the department identifying a proposed consultant on 2/6/23;-Submitted a executed contract to the department on 2/24/23Therefore during the onsite investigation the residence was within the second month of the contract. 2. Current Deficient PracticeThe onsite licensure complaint investigation survey on 4/4 through 4/5/23, established there was current deficient practice. Sixteen deficiencies were cited. (Cross-reference Q523, Q740, Q934, Q1142, Q1146, Q1150, Q1160, Q1180, Q1362, Q1430, Q1468, Q1510, Q1514, Q2114, Q2130, Q2132). 3. InterviewOn 4/5/23 at approximately 3:00 p.m., the administrator said she was aware the residence was required to be in compliance with all regulations surveyed while under an intermediate condition. The administrator stated that the consultant the residence was contracted with, recently had quit and the residence was in the process of obtaining a new consultant. On 4/5/23, multiple attempts were made to contact the residence's consultant; however, the department was unable to reach the contracted consultant.

Based on record review and interview, the residence failed to have an administrator who had taken the training program that met all assisted living requirements including at least 40 actual hours of curriculum training, affecting 51 current residents. Findings include:Chapter VII regulations governing assisted living residences version 14, adopted- 4/18/18, part 6.5, read effective January 1, 2019, an administrator training program shall meet all of the following requirements:(A) The program or program components are conducted by an accredited college, university, or vocational school; or an organization, association, corporation, group or agency with specific expertise in the provision of residential care and services, and(B) The curriculum includes at least 40 actual hours, 20 of which shall focus on applicable state regulations. The remaining 20 hours shall provide an overview of the following topics:(1) Business operations including, but not limited to,(a) Budgeting,(b) Business plan/service model,(c) Insurance,(d) Labor laws,(e) Marketing, messaging and liability consequences, and(f) Resident agreement. On 4/4/23 at approximately 12:00 p.m., the administrator provided proof she completed a 30 hour administrator training program on 10/19/16. On 4/4/23, review of the department's database revealed the administrator was first an administrator of record on 2/17/19 (one month and 17 days after the regulation was effective). On 4/5/23 at approximately 3:00 p.m., the administrator stated she was the administrator of another residence in 2018. She added the owner of the residence had not paid the change of administrator fee so she was not reflected in the database until February 2019. The administrator was not aware she did not meet the requirements.

Based on observation, interview and record review, the residence failed to require all staff certified in cardiopulmonary resuscitation (CPR) to provide CPR services in accordance with their training, affecting 51 current residents. (Cross-reference Q934)Specifically, Former Resident #8 was admitted to the residence on on 9/28/20 with diagnoses including vascular dementia and Alzheimer's disease and was admitted to external hospice on 2/9/23. The record for Former Resident #8 had a Medical Orders for Scope of Treatment (MOST) form, dated 4/22/18, that read she did not want CPR. On 3/26/23, a staff member found Former Resident #8 lying face down on the floor in the hallway in the secure environment. Although the former resident was breathing with difficulty and had a pulse, Staff #5 started chest compressions on Former Resident #8. While Staff #5 completed chest compressions on the former resident, Staff #2 located the former resident's MOST form in her room and immediately informed Staff #5 of Former Resident #8's MOST form that documented her request for Do Not Resuscitate (DNR). Staff #5 stopped chest compressions. Former Resident #8 was transported to the hospital. The hospital discharge summary revealed the former resident sustained multiple rib fractures, a sternum fracture and a bruised lung consistent with chest compressions. On 4/1/23, Former Resident #8 passed away. On 4/4/23, Staff #5 stated he was aware of where to locate an advance directive for a resident who resided in the secure environment; however, he stated he was not aware where to locate an advance directive for a resident who resided in the non-secure environment. On 4/4/23, the administrator stated she believed state statute required staff to first initiate and perform CPR on a resident and then confirm the resident's advance directive. This failure created an immediate jeopardy risk of failure to follow residents' advance directives with injury or death to all 51 current residents. On 4/4/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Residence Policya. According to Irving, "A MOST form is a doctor's order that helps you keep control over medical care at the end of life ... the form tells emergency medical personnel and other health care providers whether or not to administer cardiopulmonary resuscitation (CPR) in the event of a medical emergency." Irving, S., (2022) Nolo Legal Encyclopedia, Colorado's Medical Orders for Scope of Treatment (MOST) Form, retrieved from: https://www.nolo.com/legal-encyclopedia/colorados-medical-orders-scope-treatment-most-form.htmlb. The residence's First Aid, Emergency Training, and CPR policy, dated 12/9/21, read, in part, "Whenever one or more residents are present in the assisted living residence, there shall be at least one staff member present who is certified in CPR and obstructed airway techniques and is capable of responding to an emergency ... Each assisted living residence shall require that all staff who are certified in CPR promptly provide those services in accordance with their training, unless the affected resident has a do not resuscitate order ... If a resident is experiencing respiratory or cardiac arrest, EMS (emergency medical services) 911 or the hospice agency will be called ... If the resident has a valid Do Not Resuscitate (DNR) order readily available, the community staff member shall honor the DNR order if done in good faith. "c. The residence's Working with Advance Directives policy, dated 12/9/21, read, in part, "If a resident has a MOST order, the MOST order will be recognized and honored."2. Former Resident #8 was admitted to the residence on 9/28/20 with diagnoses including vascular dementia and Alzheimer's disease. Former Resident #8 was admitted to external hospice on 2/9/23. The record for Former Resident #8 contained a MOST form, dated 4/22/18, which read she did not want CPR. An incident report for Former Resident #8, dated 3/26/23 at 12:48 p.m., read Staff #5 performed three sets of (chest) compressions on Former Resident #8. At the time of the incident, the former resident had a blood pressure reading of 193/77. Staff documented pulse and respiration readings; however, the numbers were crossed out. An internal investigation dated, 3/26/23, revealed the following:Staff #2's written statement read around 12:40 p.m., on 3/26/23 she exited another resident's room and saw someone lying on the floor in the hallway face down. Staff #2 identified Staff #22 and #5 in the area and Former Resident #8 as the resident on the floor. Staff #2 saw/heard Staff #5 stated Former Resident #8 was seizing and started conducting CPR. The statement further read Staff #2 ran to Former Resident #8's room to find her MOST form and subsequently advised Staff #5 that Former Resident #8 was a DNR. Staff #5's written statement read on 3/26/23 he heard screaming and observed Former Resident #8 on the floor face down. He turned the former resident over and "started tapping on her" she was not responding. Staff #5 checked the former resident's breathing and noticed she gasping for air. Staff #5 subsequently started chest compressions and completed almost three sets of compressions. Staff #7's written statement read on 3/26/23 at 12:30 p.m., she was in the break room and was alerted that assistance was needed in the secure environment. She observed a staff member (Staff #5) performing chest compressions. The QMAP (qualified medication administration person) yelled Former Resident #8 was a DNR. Staff #7 sat next to the former resident, who was responsive on the floor, and talked to her until the ambulance arrived. The investigation revealed no evidence that Staff #22 was interviewed. A hospital admission note, dated 3/26/23, in Former Resident #8's record read, in part, "Found apparently unresponsive, no initial vitals provided. Pt (Former Resident #8) did receive 3 rounds CPR/chest compressions. Awake, alert when EMS (emergency medical services) arrived. Normal vitals. (complained) chest/upper abdominal pain." Former Resident #8 had a bruised lung, five right rib fractures, three left rib fractures and a sternum fracture. "Pateint requires hospital admission and hospital monitoring due to need for aggressive pain control in setting of multiple acute fractures." A hospital discharge summary, dated 3/29/23, read Former Resident #8's diagnoses included multiple rib fractures, a sternum fracture and a contusion of her right upper lobe. On 3/26/23, a chest computed tomography (CT) (x-ray) was performed and revealed, "Multiple acute predominantly non-displaced rib fractures likely related to chest compressions. Non-displaced sternum fracture ... probable contusion versus laceration with the anteromedial right upper lobe (bruised lung). This could be explained by the chest compressions ..."On 4/4/23 from approximately 7:15 a.m. to 2:30 p.m., Staff #5 was observed providing care and service to residents in the non-secure environment of the residence. On 4/4/23 at 7:25 a.m., Staff #5 stated he knew where to locate residents' advance directives who lived in the secure environment; however, he stated he did not know where advanced directives were located in the non-secure environment of the residence. On 4/4/23 at 8:10 a.m., the generations program director (GPD) said she was not working on 3/26/23 when staff found Former Resident #8 face down on the floor. She stated she was informed that the former resident had been gasping for air. She stated Staff #5 completed two sets of 30 chest compressions on the former resident. The GPD added, staff were trained to look for a resident's advance directive on the back of their bedroom doors or on their personal refrigerators. On 4/4/23 at 1:45 p.m., Staff #5 said on 3/26/23 he heard a yell come from the hallway and went to look. The staff stated he saw Former Resident #8 on the floor face down, Staff #2 subsequently dialed emergency medical services. Staff #5 stated Former Resident #5 had a pulse and gasped for air, but was unresponsive, so he started CPR. He stated that he was not able to find a CPR barrier mask to breathe for her and therefore he completed two sets of 30 compressions, then 20 compressions and was stopped when Staff #2 informed him that Former Resident #8 was a DNR. He added, "I forgot. I was in the moment (that Former Resident #8 was a DNR). I knew she was on hospice ... It went right past me that she was a DNR." Staff #5 further stated he was never trained on where to locate a resident's advanced directive prior to the incident on 3/26/23 (contrary to training documentation in his personnel record) and stated even after the incident he was not trained. On 4/4/23 at 3:40 p.m., the administrator stated the internal investigation revealed that Staff #22 found Former Resident #8 on the floor face down. The administrator stated when Staff #5 and Staff #22 turned her over, Former Resident #8 was not breathing and was unconscious (which conflicted to Staff #5's interview and written statement, Staff #22's interview and the secure environment's program director's interview). The administrator stated that Staff #5 subsequently started CPR and completed two compression cycles. The administrator stated Staff #2 informed Staff #5 that Former Resident #5 had a DNR, so Staff #5 stopped compressions. The administrator stated Staff #5 had just received his CPR recertification days prior to the incident on 3/26/23. She added since Staff #5 did not know Former Resident #8's code status he performed CPR. The administrator stated she has not provided additional training for Staff #5 on where to locate a resident's advance directive after the incident on 3/26/23. The administrator said the state statute was that staff were required to perform CPR until the resident's code status was confirmed. She added it would be impossible for staff to know code status on each resident that resided at the residence. On 4/5/23 at 10:16 a.m., Staff #22 stated on 3/26/23 she saw someone on the floor crying. She added Staff #5 came out of another resident's room, turned over Former Resident #8 and noticed her breathing. She added Staff #5 began CPR compressions and stated Former Resident #8 was having a seizure. Staff #22 stated Staff #5 did not check to see if Former Resident #8 had a pulse, did chest compressions only and did not perform any breaths for her. She added she received no training from the residence regarding advanced directives or CPR after the incident with Former Resident #8. 3. Staff #'s Personnel FileThe personnel file for Staff #5 revealed he was hired and trained on where to locate advance directives on 4/16/22. Staff #5 was subsequently CPR-certified on 3/21/23 (five days prior to the incident). The file revealed no further training on advanced directives or CPR had been conducted since the incident. 4. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 51 current residents at immediate jeopardy risk for harm, injury or death. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 4/4/23 at 5:00 p.m., the administrator submitted written evidence that read in pertinent part: "Dated 4/16/22 (Staff #5) completed a new hire checklist when management transitioned, acknowledging training in multiple areas to include CPR directive and where to locate resident information ... On 4/4/23 (Staff #5) re-educated on the procedure for emergency response. On 4/4/23 (Staff #5) re-educated on locating emergency information including the DNR list in the narcotic book on the (medication) cart, the DNR list posted in the care areas, and the MOST form on the (resident's) door ... "However, the written evidence did not indicate the risk had been removed because it did not include how the residence would train all staff member's to ensure they understood the requirement of the regulation for those staff to provide CPR promptly residents only when the resident's advance directive instructed staff to do so. Additionally, the written evidence did not include how the residence would ensure staff did not perform CPR on a resident who had a valid DNR, was breathing and had a pulse. On 4/4/23 at 6:09 p.m., the administrator submitted written evidence that read in pertinent part, "Globally, two staff members in addition to (Staff #5) will be selected to identify the location of emergency information and procedures of response in case of an emergency weekly for four weeks then monthly thereafter. These random knowledge audits will be maintained by the supervisor. Emergency procedures including basic emergency response (identifying need for CPR) and where to locate advanced directive information will be trained at hire, re-visited with routine computer-based compliance training, and reviewed with monthly clinical meetings. Documentation of attendance will be maintained."

Based on observation and interview, the residence failed to ensure each first aid kit contained all the required items, affecting 18 residents who resided in the secure environment. (Cross-reference Q740)Findings include:On 4/5/23 at approximately 9:42 a.m., Staff #2 provided the secure environment residence's first aid kit. The kit did not contain the following items: latex free disposable gloves, triangular bandages with safety pins, a CPR (cardiopulmonary resuscitation) device or mask and soap or waterless hand sanitizer. On 4/5/23 at approximately 3:00 p.m., the administrator said she was not aware the residence's first aid kit for the secure environment did not contain the required items. She added the residence did have a complete first aid kit but was not sure where it was placed.

Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated for residents whenever residents' conditions changed from baseline status, affecting three of five sample residents (#4, #18, #19) and two former residents (#8 and #10), who experienced a change in baseline status. (Cross-reference Q1180, Q1150 and Q2130)Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(D) Communication ability and any specific needs to facilitate effective communication;(G) Individual bathroom routines, sleep and awake patterns;(H) Reactions to the environment and others, including changes that may occur at certain times or in certain circumstances(J) History and circumstances of recent falls and any known approaches to prevent future falls;(K) Safety awareness;(L) Types of physical, mental, and social support required.b. The residence's Resident Assessment and Service Plan policy, dated 12/9/21, read, in part, "In order to evaluate residents's needs, the resident care director (RCD) or generations program director (GPD) will ensure that resident assessments are completed for residents in accordance with the procedures contained in this policy. Assessment and service plans will be updated as frequently as necessary to ensure they reflect resident care needs and preferences ... Residents who resident in assisted living will be re-assessed ... whenever there is significant change in resident condition ... For the purposes of updating a resident's assessment and service plan, a 'change of condition' is defined as a decline or improvement that is not considered to be short term in nature. Some examples include but are not limited to: A resident who has fallen and suffered an injury such as a fracture. A resident who has been admitted to hospice care. A resident who has experienced a general decline in their health and requires on-going increased care needs."2. Resident #18 was admitted to the residence on 9/26/20. An assessment for Resident #18, dated 2/6/23, read that Resident #18 used no assistive devices, was a fall risk, required occasional reminders and cueing, required four to six checks per day. The record for Resident #18 revealed no evidence of any other assessments had been completed. Progress notes for Resident #18, dated March 2023, revealed the following:On 3/3/23, Resident #18 sustained an injury and required stitches. On 3/3/23, Resident #18 sent out to the emergency room. On 3/4/23, Resident #18 tripped over his catheter tubing. On 3/22/23, Resident #18 fell on 3/21/23 with staff present. External hospice notes for Resident #18, dated March 2023 revealed the following:On 3/6/23, Resident #18 was admitted to external hospice. On 3/6/21, Resident #18 was seen by an external hospice representative after his return from the emergency department for major skin tears to his left upper and lower arm. On 3/31/23, Resident #18 fell and had a skin tear to his right forearm. Incident reports for Resident #18, dated March 2023, revealed the following:On 3/2/23, Resident #18 stated he scratched himself and was unable to stop the bleeding. Resident #18 had a one inch long laceration on the calf of his right leg. Resident #18's room was covered in blood. Emergency medical services were notified. On 3/3/23, Resident #18's leg wound was still bleeding from the evening before. Resident #18's family member transported him to urgent care for evaluation. On 3/21/23, Resident #18 fell as he transferred from his bed to his wheelchair. Staff was present. Resident #18 had a skin tear on his left hand and forehead. Resident #18 was sent to the emergency room for evaluation. On 3/31/23, Resident #18 was observed on the floor. Skin tear to his right elbow. On 4/4/23 at 1:11 p.m., the GPD said reassessments should have completed upon a change in a residents condition suchas external hospice admission, when residents stopped eating and falls that resulted in injuries. She added, the assessment for Resident #18 should have been updated, as required. On 4/5/23 at approximately 3:00 p.m., the administrator said the assessment for Resident #18 should have been updated after his admission to external hospice and after repeated falls that resulted in injury. On 4/4/23 at 5:40 p.m., a family member of Resident #18 stated there was no reassessment completed for Resident #18 moved from independent living to the non-secure assisted living environment in January 2023. 3. Former Resident #8 was admitted to the residence on 9/28/20. An assessment for Former Resident #8, dated 1/25/23, read that Former Resident #8 was a fall risk, required no assistive devices, had behaviors that required staff intervention and/or redirection, did not require additional status checks and did not require hospice services. External hospice provider notes, dated February and March 2023 for Former Resident #8, revealed the following:On 2/9/23, Former Resident #8 was admitted to external hospice. On 3/23/23, Former Resident #8 was showing signs of decline, difficulty with word finding and unable to form sentences. Progress notes in the record of Former Resident #8 in March 2023 revealed the following:On 3/2/23, Former Resident #8 was confused. On 3/3/23, Former Resident #8 was confused and asked to go home across the street. On 3/4/23, Former Resident #8 was confused this evening, kept asking where she was and was almost in tears. On 3/14/23, Former Resident #8 was confused and refused to use her walker when she walked. On 3/21/23, Former Resident #8 was unstable on her feet and stumbled a little. Staff reminded her to use her walker throughout the day and required cueing when eating. On 3/22/23, Former Resident #8 did not eat her breakfast. On 3/23/23, Former Resident #8 did not eat much dinner. On 4/4/23 at approximately 2:00 p.m., the external hospice representative for Former Resident #8 said that Former Resident #8 had a significant decline since she was admitted in February 2023. She added in March 2023 she only formed a couple of words and struggled to express her feelings. On 4/523 at 3:20 p.m., the administrator stated she expected a comprehensive assessment to have been completed for Former Resident #8 to include her external hospice provider and overall decline. 4. Resident #4 was admitted to the residence on 4/18/21, with a diagnosis of Alzheimer's disease. An assessment for Resident #4, dated 1/25/23, read that Resident #4 required one person assistance with transfers other than staff escort, did not require assistive devices, and required redirection. Moreover, the assessment did not mention Resident #4's communication issues. The record for Resident #4 revealed no evidence that any other assessments had been completed. Progress notes in the record of Resident #4, dated January-March 2023, revealed the following:On 1/10/23, Resident #4 was walking too fast and fell on her face. On 3/20/23, Resident #4 was no longer able to stand on her own and needed two-person assistance to transfer from the bed to the wheelchair. External hospice notes in the residence's record for Resident #4, dated March 2023, revealed the following:On 3/16/23, Resident #4 was no longer able to make her needs known. On 3/30/23, Resident #4 was nonverbal. On 4/4/23 at 7:24 a.m., Staff #9 stated that Resident #4 fell in January 2023 and bruised her face, and since then had been declining, and now required total staff assistance with transfers. Staff #9 stated that the administrator or the GPD updated assessments. On 4/5/23 at 9:38 a.m., Resident #4's external hospice provider stated that Resident #4 was no longer ambulatory, had a wheelchair and was also no longer verbal and able to express her needs. Resident #4's external hospice provider stated that Resident #4's decline started after her fall with injury on 1/10/23. On 4/5/23 at 3:17 p.m., the administrator stated that Resident #4 should have been reassessed since after her fall on 1/10/23, she has had a significant change, and acknowledged that she now required two person assist with transfers and was no longer ambulatory or able to express her needs. 5. Resident #19 was admitted to the residence on 1/26/23. An for Resident #19, dated 2/2/23, read that Resident #19 may be a fall risk, did not use assistive devices with transfer, had external hospice but did not require staff involvement at this time and had behaviors that may require staff intervention and redirection. Moreover, the assessment did not include the types of mental or social support required for his behaviors. Progress notes for Resident #19, dated March 2023, revealed the following:On 2/2/23 and 2/22/23, Resident #19 exhibited aggressive behaviors and attempted to swing at Staff #15. On 3/24/23, Resident #19 kicked and swung his arms at Staff #9. On 3/31/23, Resident #19 was combative toward staff. A practitioner's communication note, written by the GPD dated 3/6/23, read that staff attempted several times to administer medication to Resident #19 and he was swinging at staff. An incident report for Resident #19, dated 3/27/23, read that Resident #19 had a fall due to sliding out of bed. On 4/4/23 at 2:54 p.m., Resident #19's external hospice provider stated that Resident #19 used a walker and required frequent checks and staff interventions with his behaviors. On 4/4/23 at 3:44 p.m., Staff #14 stated that she had never personally had any problems with Resident #19's behaviors, and stated that he responded well to a calm and slow approach. On 4/4/23 at 4:28 p.m., Staff #13 stated that Resident #19 had shown aggressive behaviors toward staff if approached in an aggressive manner. However, Staff #13 stated that Resident #19 had not shown aggressive behaviors toward her, and had never shown aggressive behaviors toward other residents. Staff #13 acknowledged that not all staff knew how to approach Resident #19 in a way he responds well to. On 4/4/23 at 7:24 a.m., Staff #9 stated that Resident #19 had a fall where he slid out of bed in March 2023. Staff #9 stated that the administrator or the GPD updated assessments. On 4/4/23 at 3:44 p.m., Staff #14 stated that Resident #19 had a walker. On 4/5/23 at 3:17 p.m., the administrator stated that Resident #19 should have been reassessed since after his fall on 3/27/23, and acknowledged that he required staff support with his behavioral expressions. 6. Former Resident #10 was admitted to the residence on 12/31/20, with diagnoses including Alzheimer's disease. An incident report, dated 10/25/22, read that Former Resident #10 had a fall with no signs of pain or injury and was assisted back to bed. A comprehensive assessment, dated 10/25/22, read that Former Resident #10 may be a fall risk and required one person assistance with transfers. However, the assessment did not include any history and circumstances of recent falls, any known approaches to prevent future falls, or the health and functional ability of Former Resident #10. A late-entry progress note, dated 10/26/22 at 6:57 p.m., read that Former Resident #10 had a fall with a large purple bruise on her left hip. A hospital bed with a fall mat was delivered. Former Resident #10 had a low mattress and required four staff to reposition her in bed with the use of a draw sheet. An external hospice note, dated 10/26/22 and located in the record of Former Resident #10, read Former Resident #10 was seen for a daily hospice visit and had a fall the prior evening. Former Resident #10 was two person minimum assist with transfers and had extreme pain and a large bruise to her left hip. A care plan for Former Resident #10, dated 11/1/22 with an effective date of 9/9/22, read that Former Resident #10 was on external hospice and required nighttime safety checks, required standby assistance with transfers, was at risk for falls and required a wheelchair and verbal cues. On 4/4/23 at approximately 11:00 a.m., the residence provided the remaining documentation from Former Resident #10's record. However, there were no progress notes or incident reports of prior falls. On 4/4/23 at 9:35 a.m., Former Resident #10's family member stated that after the former resident fell on 10/25/22, she was bedbound, required more than two staff members to reposition her in bed, had a fall mat and wheelchair. The family member stated that as a result of the fall, Former Resident #10 passed away on 11/4/22. Former Resident #10's family member also acknowledged that Former Resident #10 had fallen prior to 10/25/22, she just could not remember dates. On 4/4/23 at 3:15 p.m., Former Resident #10's external hospice agency stated that Former Resident #10's external hospice nurse no longer worked for the agency and were not able to provide any specific information regarding Former Resident #10 and her fall interventions. On 4/4/23 at 3:44 p.m., Staff #14 stated that Former Resident #10 had a fall mat, required total assistance and was bedbound after her fall on 10/25/22. Staff #14 acknowledged the residence had not provided her with fall management training; therefore, she was not aware on how to respond to Former Resident #10's fall. Staff #14 acknowledged that Former Resident #10 was a high fall risk. On 4/4/23 at 5:16 p.m., the administrator stated that she provided all progress notes and other documentation the residence had regarding Former Resident #10 and her falls. On 4/5/23 at approximately 3:30 p.m., the administrator stated that she was aware the residence's current electronic assessments did not include all the required information. The administrator stated the comprehensive assessment should have included information regarding Former Resident #10's overall health and physical abilities and was updated by the secure environment program director. The administrator acknowledged that Former Resident #10 was bedbound and required more than two staff to reposition her in bed. The administrator stated that the consultant had completed the comprehensive assessment update for Former Resident #10 on 10/25/22, not the residence.

Based on observation, record review and interview, the residence failed to ensure that each care plan detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting two of five sample residents (#4, #19) and one former resident (#10). (Cross-reference Q1146, Q1362 and Q2130)Findings include:1. Residence Policya. The residence's care plan policy, dated 12/9/21, read in part: "each resident care plan shall be developed with input from the resident and the resident's representative, reflect the most current assessment information, promote resident choice, mobility, independence and safety, detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs, identify all external service providers along with care coordination arrangements, identify formal, planned, and informal spontaneous engagement opportunities that match the resident's personal choices and needs."2. Resident #4 was admitted to the residence on 4/18/21, with a diagnosis of Alzheimer's disease. A care plan, dated 10/27/22, read that Resident #4 did not require additional measures to communicate her needs or being understood and was able to ambulate independently without an assistive device. Resident #4 required cuing due to a cognitive impairment. However, the care plan did not include that Resident #4 was no longer able to voice her needs and was no longer able to stand on her own. A progress note, dated 3/20/23 read that Resident #4 was no longer able to stand on her own and needed two-person assistance to transfer from the bed to the wheelchair. External hospice notes for Resident #4, dated March 2023, revealed the following:On 3/16/23, Resident #4 was no longer able to make her needs known. On 3/30/23, Resident #4 was nonverbal. On 4/4/23 at 9:17 a.m., Staff #16 and #19 both transferred Resident #4 out of bed into her wheelchair with a gait belt, and Resident #4 was unable to stand at all or answer any questions. On 4/5/23 at 9:38 a.m., the external hospice provider for Resident #4 stated that the resident was no longer ambulatory, had a wheelchair and was also no longer verbal and able to express her needs since her fall with injury on 1/10/23. On 4/5/23 at 3:17 p.m., the administrator stated that the care plan for Resident #4 should have been updated after her fall on 1/10/23 to include her needs and staff necessary to meet those needs. The administrator stated that Resident #4 had had a significant change, and acknowledged that she now required two person assist with transfers and was no longer ambulatory or able to express her needs. 3. Resident #19 was admitted to the residence on 1/26/23. A care plan for Resident #19, dated 4/4/23, read that Resident #19 expressed agressive physical and/or verbal behaviors and external hospice and the administrator were to be notified and interventions needed to be documented. However, the care plan did not include staff tasks necessary to meet Resident #19's needs in regard to his behavioral expressions. Progress notes dated February and March 2023 revealed the following:On 2/2/23, Resident #19 threw his walker across the room and attempted to hit Staff #15 with closed fists. On 2/5/23 at 5:15 p.m., Resident #19 threw his pills on the floor and smashed his fists into his plate. On 2/5/23 at 5:18 p.m., Resident #19 was aggressive toward staff. On 2/7/23 at 5:27 a.m., Resident #19 was extremely aggressive and punched a staff member in the head. On 2/11/23, Resident #19 was combative with Staff #9 while assisting with toileting care and refused medications. On 2/17/23, Resident #19 pushed Staff #9 away when she tried to take his blood pressure. On 2/22/23, Resident #19 swung at Staff #15. On 2/28/23, Resident #19 was upset and attempted to hit Staff #15. On 3/31/23, Resident #19 was combative with Staff #9 during medication pass and would not allow Staff #9 to administer medications to him with a spoon and folded his fist and used profane language toward Staff #9. On 4/4/23 at 3:25 p.m., Staff #7 stated that the day shift staff did not know how to handle Resident #19's behavioral expressions. Staff #7 stated that Resident #19 responded well to a calm approach and she had observed Staff #15 be controlling and rude to other residents as well. On 4/4/23 at 3:44 p.m., Staff #14 stated that she had never personally had any problems with Resident #19's behaviors, and stated that he responded well to her calm approach. On 4/4/23 at 3:58 p.m., Resident #19's family member stated that Resident #19 often refused medications and did not respond well to staff trying to make him do things that he did not want to do. Resident #19's family member stated that she was concerned that staff members did not know how to address Resident #19's behaviors; however, she stated she felt like Staff #14 always took a good approach toward Resident #19. On 4/4/23 at 4:28 p.m., Staff #13 stated that Resident #19 had not shown aggressive behaviors toward her and had never shown aggressive behaviors toward other residents. Staff #13 stated that Staff #15 was very assertive and aggressive when providing resident care and had witnessed her boss residents around and rush carelessly. Staff #13 stated that she thought that staff members such as Staff #15 were approaching Resident #19 inappropriately. On 4/5/23 at 2:42 p.m., Staff #21 stated that she had no training on Resident #19's behavioral expressions or how to approach him; however, he responded well if staff approached him in a calm and respectful demeanor to reassure him that staff were only there to help him. On 4/5/23 at 3:40 p.m., the administrator stated that the care plan for Resident #19 should have been updated to include Resident #19's behavioral expressions and how staff intervene and approach him. 4. Former Resident #10 was admitted to the residence on 12/31/20 with diagnoses including Alzheimer's disease. An incident report, dated 10/25/22, read that Former Resident #10 had a fall with no signs of pain or injury and was assisted back to bed. A late-entry progress note, dated 10/26/22 at 6:57 p.m., read that Former Resident #10 had a fall with a large purple bruise on her left hip. A hospital bed with a fall mat was delivered. Former Resident #10 had a low mattress and required four staff to reposition her in bed with the use of a draw sheet. An external hospice note, dated 10/26/22 and located in the record of Former Resident #10, read Former Resident #10 was seen for a daily hospice visit and had a fall the prior evening. Former Resident #10 was two person minimum assist with transfers and had extreme pain and a large bruise to her left hip. A care plan for Former Resident #10, dated 11/1/22 with an effective date of 9/9/22, read that Former Resident #10 was at risk for skin breakdown in bed due to decreased cognitive and functional mobility and topical cream and antifungals were to be used as directed. The care plan also read that Former Resident #10 was standby transfers. However, the care plan did not include information on how staff were to reposition former Resident #10 in the bed. On 4/4/23 at 3:25 p.m., Staff #7 stated that she did not feel that staff were able to provide cares and transfer Former Resident #10 appropriately after her fall on 10/25/22. Staff #7 was not aware of Former Resident #10's specific care needs. On 4/5/23 at approximately 3:30 p.m., the administrator stated that she expected residents' likes, dislikes, care tasks level of staff assistance, engagement opportunities, preferences, and how staff were to monitor and report changes were in each resident's care plan. The administrator stated that their electronic medical record system generated an outline of a care plan that needed to be updated manually. The administrator stated that she was not aware that care plans for Resident #4, #19 and former Resident #10 were not updated to include the required elements.

Based on interview and record review the residence failed to coordinate care with known external service providers, affecting one of five sample residents (#18) and two former residents (#8, #10). (Cross-reference Q740)Specifically, on 3/21/23 Resident #18 fell and sustained major skin tears to his left upper and lower arm and was treated at the emergency room. The resident returned the same day to the residence and an external hospice provider re-bandaged the skin tears. On 3/22/23, the day shift staff notified the external hospice provider for Resident #18 that the bandage had fallen off. Contrary to the external hospice provider triage nurse's instructions, unlicensed Staff #15 did not wait for the external hospice provider to arrive to re-bandage the dressing. The unlicensed staff wrapped the new bandage too tightly and, as a result, Resident #18's circulation was compromised which caused purple discoloration and swelling in the resident's left elbow and left hand. Findings include:1. Reference and Residence Policiesa. Chapter VII regulations governing assisted living residence, part 2.21, defines "External services" as personal services and protective oversight services provided to a resident by family members or healthcare professionals who are not employees, contractors, or volunteers of the facility. External service providers include, but are not limited to, home health, hospice, private pay caregivers and family members.b. The residence's First Aid, Emergency Training, and Cardiopulmonary Resuscitation (CPR) policy, dated 12/9/21, read, in part, "Specifically for terminally ill resident that is receiving hospice services who has completed an advance directive ... and is experiencing a life-threatening emergency as displayed by symptoms of impending death that is directly related to the expected course of the resident's terminal illness, the community may immediately notify the resident's hospice agency in lieu of calling emergency response (911)."c. The residence's Working with Advance Directives policy, dated 12/9/21, read, in part, "If the resident is receiving hospice service and has a do-not-resuscitate order, the hospice nurse may be summoned, in lieu of calling 911 in the event the resident has stopped breathing and the heart has stopped beating (or other life-threatening emergency) that is directly related to the expected course of the resident's terminal illness."d. The residence's Home Health and Other Outside Agencies policy, dated 12/9/21, read, in part, "The assisted living residence shall be responsible for the coordination of resident care services with known external service providers."e. The residence's Hospice policy, dated 12/9/21, read, in part, "Specifically for a terminally ill resident that is receiving hospice services who has completed an advance directive ... and is experiencing a life-threatening emergency as displayed by symptoms of impending death that is directly related to the expected course of the resident's terminal illness, the community may immediately notify the resident's hospice agency in lieu of calling emergency response (911)."2. Resident #18 was admitted to the residence on 9/26/20. External hospice provider (EHP) notes for Resident #18's revealed the following:On 3/21/23 Resident #18 returned from the emergency room after he suffered a fall that resulted in major skin tears to his upper and lower left arm. An EHP re-bandaged the skin tear dressings. On 3/22/23 "Follow up nsg (nursing) visit made after call from facility to triage nurse that dsg (dressing) needs to be (re-bandaged). Upon arrival, (Staff #16) reports that night shift removed the dsgs (dressings) that (EHP) placed yesterday and that she re-wrapped it this morning. Wrap is so tight that it is cutting off the circulation and causing swelling in left elbow and left hand as well as purple discoloration. Dsgs (dressings) removed entirely. New bandages applied with light/gentle wrap externally for reinforcement. 'Donot remove' written on all dsgs (dressings). Educated several staff members to leave dsgs (dressings) in place and only reinforce with gauze and tape externally if needed." The department or regulatory agencies database was reviewed and revealed Staff #15 held no professional license. The staff schedule for the week of 3/19-3/25/23 read unlicensed Staff #15 worked the overnight shift on 3/21/23 from 10:00 p.m. to 6:00 a.m. and Staff #16 worked on 3/22/23 from 6:00 a.m. to 2:00 p.m. On 4/4/23 at 1:45 p.m., Staff #5 stated that unlicensed Staff #15 re-bandaged Resident #18's skin tear bandage so tight that Resident #18's arm was discolored. On 4/4/23 at approximately 2:00 p.m., an EHP stated staff removed and re-bandaged the skin tear dressing from fall on 3/21/23. She added, she was surprised and upset when she saw how Resident #18's arm looked. The EHP said Resident #18's left arm was blue and his hand was swollen and further stated unlicensed staff were not supposed to re-bandaged dressings. On 4/5/23 at approximately 3:00 p.m., the administrator stated she expected staff to coordinate care with EHPs. She added she was not aware unlicensed Staff #15 re-bandaged Resident #18's skin tears that caused swelling and discoloration. 3. Former Resident #8 was admitted to the residence on 9/28/20 and admitted to external hospice on 2/9/23Internal investigation notes from 3/26/23 revealed the following:An incident report for Former Resident #18, dated 3/26/23, authored by Staff #5 read Former Resident #8 was found face down on the floor, unresponsive to physical touch, gasping for air, emergency medical services were notified at 12:45 p.m. and arrived to the residence at 1:00 p.m. Staff #2's written statement read at 12:40 p.m. she observed Former Resident #8 lying face down in the hallway. She added she notified the EHP and emergency medical services. Staff #7's written statement read on 3/26/23 at 12:30 p.m., staff requested assistance in the secure environment via walkie talkies. When Staff #7 arrived, she observed Former Resident #8 on the floor. Former Resident #8 was responsive when emergency medical services arrived. On 4/4/23 at 1:45 p.m., Staff #5 stated during the incident that involved Former Resident #8 on 3/26/23, Staff #2 notified emergency medical services and not external hospice. On 4/5/23 at 9:30 a.m., Staff #2 stated during the incident that involved Former Resident #8, she notified emergency medical services and not external hospice. On 4/5/23 at approximately 3:00 p.m., the administrator stated the residence policy read that when a resident emergency occurred in which a resident was unconscious, staff were directed to notify emergency medical services because staff were unable to treat an unconscious resident. The administrator did not address the requirement to coordinate care with external hospice providers. 4. Former Resident #10 was admitted to the residence on 12/31/20 with diagnoses including Alzheimer's disease and admitted to external hospice on an unknown date. An external hospice note, dated 10/26/22, read Former Resident #10 had a daily hospice visit, had a fall the prior evening and that the residence did not notify the EHP about the fall. Former Resident #10 required a two person minimum assist with transfers and had extreme pain and a large bruise to her left hip. The EHP notified Former Resident #10's family member of the fall but the family member told the EHP that the residence had not notified her of the fall. A late-entry progress note, dated 10/26/22 at 6:57 p.m., read that Former Resident #10 had a fall and sustained a large purple bruise on her left hip. On 4/4/23 at 9:35 a.m., Former Resident #10's family member stated the only way she knew of Former Resident #10's fall, was from the EHP who had only found out the day after the fall when doing an onsite visit, and was upset that the residence did not notify them. On 4/4/23 at 3:44 p.m., Staff #14 stated that she was on shift the day Former Resident#10 fell. Staff #14 stated that Former Resident #10 was moaning and in apparent pain and Staff #17 and #18 assisted the former resident to an upright position. Staff #14 stated she had just been hired and was still in training at the time. Staff #14 stated that Staff #17 and #18 told her while they provided the two-person transfer of the former resident that the former resident was not in pain. Staff #14 acknowledged that she herself and #17 and #18 did not know how to coordinate services with external providers. On 4/5/23 at 3:35 p.m., the administrator stated that she would have expected Former Resident #10's external hospice provider to have been notified of Former Resident #10's fall.

Based on record review and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks and provide staff training related to fall prevention, affecting three of five sample residents (#4, #18, #19) and one former resident (#10). (Cross-reference Q1146, Q1150 and Q2130). Specifically, Former Resident #10 fell on 10/25/22, and sustained a fractured left hip with pain. The residence updated the care plan for the former resident on 11/1/22. Staff #17 and #18, and Staff #14 who were in training at the time, were unsure how to respond appropriately to the fall due to a lack of fall management training, and all three staff assisted Former Resident #10 from the floor into her bed, despite her moaning and apparent pain during the transfer into bed. Furthermore, the care plan did not include and staff were not aware of the individualized approach necessary to address fall risk. Specifically, Resident #4 had a fall on 11/12/22, then a fall with injury on 1/10/23, and an additional fall on 1/22/23. A care plan, dated 10/27/22, read that Resident #4 required one person assist with transfers and ambulate independently without an assistive device. However the care plan was not updated after Resident #4 fell on 11/12/22, and as a result Resident #4 had a fall with injury on 1/10/23 and a major decline that required full staff assistance with transfers and a wheelchair. Furthermore, the care plan was not updated to include, and staff were not aware of the individualized approach necessary to address fall risk. Findings include:1. Residence Policya. The residence's Resident Assessment and Service Plan policy, dated 12/9/21, read, in part, The community's Fall Reduction Program evaluation includes: The fall risk assessment ... shall be conducted by a licensed or registered nurse or trained designee ... Each resident's identified fall risks shall be addressed with recommended interventions included in the resident's service plan. Each resident's service plan and fall risk assessment will be reviewed and updated whenever a resident has: A first fall ... Repeat falls. A fall with injury requiring medical intervention/treatment. A change in condition."2. Former Resident #10 was admitted to the residence on 12/31/20 with diagnoses including Alzheimer's disease. An incident report, dated 10/25/22, read that Former Resident #10 had a fall with no signs of pain or injury and was assisted back to bed. A comprehensive assessment, dated 10/25/22, read that Former Resident #10 was a fall risk and required one person assistance with transfers. A late-entry progress note, dated 10/26/22 at 6:57 p.m., read that Former Resident #10 had a fall and sustained a large purple bruise on her left hip. A hospital bed with a fall mat was delivered and Former Resident #10 was provided a low mattress and required four staff to move her in bed with the use of a draw sheet. An external hospice note, dated 10/26/22, read Former Resident #10 had a daily hospice visit, had a fall the prior evening. The former resident had required staff to provide a two person minimum assist with transfer and had extreme pain with a large bruise to her left hip. A previous care plan for Former Resident #10, dated 12/31/20, read that Former Resident #10 was at risk for falls due to balance problems and confusion. A care plan for Former Resident #10, effective 9/9/22 and updated 11/1/22, read that Former Resident #10 was on external hospice for care, required nighttime staff safety checks, required one person standby assistance with transfers, was at-risk for falls, required a wheelchair and staff's verbal cues. However, the care plan for Former Resident #10 was not updated with detailed to include the individualized approaches necessary to address fall risk related to deficits in strength, or balance after her fall with injury on 10/25/22, that included a fall mat, draw sheet, hospital bed, and minimum of four person transfers in bed due to being bed bound. A progress note, dated 11/4/22, read that Former Resident #10 passed away. On 4/4/23 at 9:35 a.m., Former Resident #10's family member stated that after Former Resident #10 fell on 10/25/22 she required more than two staff members to move her around in the bed and had a fall mat and wheelchair implemented. Former Resident #10's family member stated that as a result of the fall, Former Resident #10 passed away on 11/4/22. On 4/4/23 at 3:15 p.m., Former Resident #10's external hospice provider representative stated that Former Resident #10's external hospice nurse no longer worked for them, and they were not able to provide me any specific information regarding Former Resident #10 and her fall interventions. On 4/4/23 at 3:44 p.m., Staff #14 stated that she was on shift the day Former Resident #10 fell. Staff #14 stated that Former Resident #10 was moaning and in apparent pain and Contracted Staff #17 and Contracted Staff #18 lifted her up anyway and insisted to Staff #14, who was still in training and a new hire, that Former Resident #10 was not in pain. Staff #14 stated that Former Resident #10 had a fall mat and required total assist and was bed bound after her fall on 10/25/22. Staff #14 acknowledged that she had received no training on fall management by the residence and was not aware herself on how to respond to Former Resident #10's fall. On 4/5/23 at 2:36 p.m., the family member for Former Resident #10 stated the former resident was on external hospice for a year prior to her fall on 10/25/22, and had a hospice bed. Former Resident #10's family member stated that contracted staff had lifted her up on 10/25/22 when Former Resident #10 fell and had sustained previous falls at the residence. On 4/5/23 at 3:30 p.m., the administrator stated that she would have expected individualized interventions to be included in the care plan for Former Resident #10's and to have been updated to address how staff were to accommodate Former Resident #10's transfer requirements post fall on 10/25/22. The administrator acknowledged that Former Resident #10 had a significant decline after she had fallen and broken her hip on 10/25/22, and ultimately passed away on 11/4/22. 3. Resident #4 was admitted to the residence on 4/18/21 with a diagnosis of Alzheimer's disease. A care plan, dated 10/27/22, read that Resident #4 required one person assistance with transfers and ambulated independently without an assistive device. However, the care plan for Resident #4 did not include she was on external hospice, and was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, after any of her falls on 11/12/22, 1/10/23, or 1/22/23. An incident report, dated 11/12/22, read Resident #4 had a fall and was laughing with water in her mouth and started to choke. An incident report, dated 1/10/23, read Resident #4 had a fall in the hallway and was observed with a bump on her forehead and a bloody nose. An incident report, dated 1/22/23, read Resident #4 had a fall in her bedroom and was unable to verbalize details of the incident. An assessment, dated 1/25/23, read that Resident #4 required one person assistance with transfers other than staff escort, did not require assistive devices, and required redirection. There were no other assessments in Resident #4's record. On 4/4/23 at 9:17 a.m. a wheelchair, fall mat, and hospital bed with extending sides was in Resident #4's bedroom. Staff #16 and #19 both transferred Resident #4 out of bed into her wheelchair with a gait belt and Resident #4 was unable to stand at all. On 4/4/23 at 7:24 a.m., Staff #9 stated that Resident #4 fell in January 2023 and bruised her face, and since then had been declining, and now required total staff assistance with transfers. On 4/5/23 at 9:38 a.m., Resident #4's external hospice provider stated that Resident #4 was no longer ambulatory and had a wheelchair. Resident #4's external hospice provider stated that Resident #4's decline started after her fall with injury on 1/10/23. Resident #4's external hospice provider stated that Resident #4 was admitted to external hospice in November 2022. On 4/5/23 at 2:42 p.m., Staff #21 stated that she had no training on Resident #4's fall interventions. On 4/5/23 at 2:50 p.m., Staff #20 stated that Resident #4 had a significant decline after her fall on 1/10/23 and was walking prior and was now in a wheelchair and a bed with protective sides. On 4/5/23 at 3:40 p.m., the administrator stated the care plan for Resident #4 should have been updated after her fall on 1/10/23 when she had a significant change and acknowledged that she now required two person assistance with transfers and was no longer ambulatory. 4. Resident #18 was admitted to the residence on 9/26/20. An assessment for Resident #18, dated 2/6/23, read that Resident #18 used no assistive devices, was a fall risk and required occasional reminders and cueing and required four to six checks per day. There were no other assessments in Resident #18's record. Progress notes for Resident #18, dated March 2023, revealed the following:On 3/3/23 Resident #18 sustained an injury and required stitches. On 3/4/23 Resident #18 tripped over his catheter tubing. On 3/22/23 Resident #18 fell on 3/21/23 with staff present. External hospice provider notes for Resident #18, dated 3/31/23 Resident #18 fell and had a skin tear to his right forearm. Incident reports for Resident #18, dated March 2023, revealed the following:On 3/21/23 Resident #18 fell as he transferred from his bed to his wheelchair. Staff was present. Resident #18 had a skin tear on his left hand and forehead. Resident #18 was sent to the emergency room for evaluation. On 3/31/23 Resident #18 was observed on the floor. Skin tear to his right elbow. On 4/4/23 at 7:35 a.m., the resident care director (RCD) stated Resident #18 fell frequently and the only intervention she was taught was to notify the practitioner's for them to schedule a visit. On 4/4/23 at 2:00 p.m., Staff #16 stated she was not provided education or training on fall interventions for Resident #18. On 4/4/23 at 5:40 p.m., a family member for Resident #18 acknowledged that Resident #18 fell with injuries recently. She added one intervention she was provided was to consider an external hospice provider, which Resident #18 was admitted to in the beginning of March 2023. The family member said she was never spoken to by management about how to address Resident #18's falls even after his admission with an external hospice provider in March 2023. On 4/5/23 at approximately 3:00 p.m., the administrator stated the residence's fall management program included re-assessment of a resident when they fell and education and training provided to families and staff about fall interventions. The administrator said she expected staff to reassess a resident who has fallen with or without injury and expected the care plans to be updated, as required. The administrator acknowledged that Resident #18 was not reassessed, as required after multiple falls. The administrator said the reason the citation was cited was, "A matter of education diligence on the part of (the generations program director/GPD) and my supervision of her to make sure she has the diligence of the program." 5. Resident #19 was admitted to the residence on 1/26/23. An incident report, dated 1/30/23, read that Resident #19 had a fall. An assessment in Resident #19's record, dated 2/2/23, read that Resident #19 may be a fall risk, did not use assistive devices with transfer. There were no other assessments in Resident #19's record. A progress note, dated 3/27/23, read that Resident #19 had a fall sliding out of bed. A care plan for Resident #19, dated 4/4/23, read that Resident #19 was a fall risk and was unstable at times. However, the care plan for Resident #19 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength. On 4/4/23 at 8:28 a.m., Staff #9 stated that Resident #19 had a walker for transferring. On 4/4/23 at 2:54 p.m., Resident #19's external hospice provider stated that Resident #19 used a walker, had a fall mat and required frequent checks and staff interventions with his behaviors. On 4/4/23 at 3:58 p.m., Resident #19's family member stated that she was not notified of Resident #19's fall out of bed on 3/31/23. On 4/5/23 at 2:42 p.m., Staff #21 stated that she had no training on Resident #19's fall interventions. On 4/5/23 at 3:40 p.m., the administrator stated that because staff were not aware how to manage Resident #19's falls, she would expect care plans to have been updated with those individualized interventions. On 4/4/23 at 8:36 a.m., Staff #19 stated that she was not trained on fall management by the residence. On 4/4/23 at 8:41 a.m., Staff #16 stated that she was not trained by the residence on fall management by the residence. On 4/5/23 at 3:40 p.m., the administrator said the resident care coordinator and GPD were responsible for updating care plan, as required.

Based on observation, record review and interview, the residence failed to implement policies and procedures for the identification, reporting and investigation of injuries of unknown origin, affecting 18 current residents in the secure environment. (Cross-reference Q1150)Specifically, a document titled skin integrity monitoring form, dated 4/2/23, revealed Resident #19 sustained a bruise on his right arm between the shoulder and elbow; a second bruise on his left forearm between his elbow and wrist; a third bruise on the top of his right foot; a fourth bruise on the left leg between the ankle and knee and four additional bruises were located on the inside of the his left leg. Interviews revealed staff at the residence reported the injures of unknown origin on 4/2/23 by placing the skin integrity form in the office of the administrator and the generations program director (GPD). The GPD reported seeing the form on 4/3/23 and the administrator on 4/4/23. Although the residence became aware of the multiple injuries on 4/3/23, the residence failed to initiate an investigation of injuries of unknown origin. Interviews further revealed that resident abuse was suspected; however, nothing was done to protect the resident from further injuries. This failure created an immediate jeopardy risk of continued serious harm or injury. On 4/4/23 the department directed the residence to provide the department with written evidence that the immediate risk had been removed. 1. Reference and Resident Policya. Chapter VII regulations governing assisted living residences, requires in part 13.12, that the assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements:- the residence must identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either the resident cannot explain how the injury occurred, or the resident can explain the source of the injury, but the source could be addressed to prevent future injuries.- the residence is required to document the following: The investigation and identification of any injury identified above. The implementation and outcome of the following for injuries for which the investigation determines the source/origin.- when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; the residence is required to take steps to prevent or mitigate future injuries of like nature. Such steps were to include, but not limited to: Staff or volunteer corrective action and/or additional training. Modification of the residence's policies, procedures or physical environment. - if the source of the injuries is undetermined, the residence is required to take steps to monitor the resident in an effort to prevent similar injuries. - all documentation of the investigation, outcomes and steps taken are to be retained by the residence to include, but not limited to, details of any interviews and/or records used in the investigation. - the documentation has to be made available for review at the Department ' s request. - the documentation may be maintained separately and not in the resident's record, but the summary of the investigation must be in the resident's care plan and progress notes- the residence is required to notify the resident's representative of the outcome of the investigation and steps taken.b. The residence's Investigation of Injuries of Unknown Origin policy, dated 12/9/21, read in part: "1. The assisted living residence shall identify and document resident injures for which the origin of the injury was not observed by or otherwise known by staff, and eithera) The resident cannot explain how the injury occurred; or b) The resident can explain the source of the injury, but the source could be addressed to prevent future falls. 2. The assisted living residence shall document the following: a) The investigation and identification of any injury identified in (Paragraph 1), above.b) The implementation and outcome of the following for injuries for which the investigation determines the source/origin:i) Compliance with (this investigation of Elder Abuse, Neglect, and Exploitation policy), when the source/origin of the injury is suspected to be abuse ... orii) The steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury is not suspected abuse ... Such steps may include, but not be limited to:(1) Staff or volunteer corrective action and/or additional training; or(2) Modification of assisted living residence's polices, procedures or physical environment.c) (sic) When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort (to) identify and prevent similar injuries. 3. All documentation of the investigation, outcomes, and steps taken may be maintained separately from the resident record, in which case a summary of the investigation and steps taken shall be included in the resident's care plan and progress notes. 4. The assisted living residence shall notify the resident's representative of the outcome of the investigation and steps taken."c. The residence's investigation of abuse policy, dated 12/9/21, read in part: "Upon the notice of reported, observed, suspected or at imminent risk of any form of abuse ... Immediate steps will be taken to ensure the resident is protected from potential future abuse and neglect while the investigation is conducted ... Law enforcement will be notified as required by State regulations ... A report will be made to Social Services and Adult Protective Service."2. Resident #19 was admitted to the residence's secure environment on 1/26/23 with a diagnosis of late Alzheimer's disease with behavioral disturbance. On 4/4/23 at approximately 3:44 p.m., observations of Resident #19's left leg revealed four bruises that were approximately one inch in diameter and approximately three inches long. On 4/4/23 at 3:25 p.m., Staff #7 stated that the day shift did not know how to handle Resident #19's behavioral expressions and was concerned because the resident had what appeared to have been a hand-shaped bruise on his left leg. Staff #7 stated that Staff #13 reported the injury during the evening shift on 4/2/23. Staff #7 further stated she had concerns that the bruising on Resident #19 may have been caused by Staff #15. She stated Staff #15 was rough with Resident #19 when he showed aggressive behavioral expressions. Additionally, the staff stated that Resident #19 responded well to a calm approach and she had observed Staff #15 be controlling and rude to other residents in addition to Resident #19. On 4/4/23 at 3:44 p.m., Staff #14 stated that she was notified by Staff #7 on 4/4/23 of Resident #19's bruise. Staff #14 stated that she had never personally had any problems with Resident #19's behaviors, and stated that he responded well to her calm approach. On 4/4/23 at 3:58 p.m., during a routine visit to the residence, Resident #19's family member stated that she was not aware of Resident #19's bruise. The family member stated while looking at the bruise, it had the appearance of a hand print and subsequently expressed her concerns. On 4/4/23 at 4:28 p.m., Staff #13 stated that she had filled out a skin integrity form and slid it under the door after her night shift for the GPD and the administrator after observing a hand print bruise on the lower left leg, a bruise between the shoulder and elbow, a bruise on top of the foot and elbow and another bruise between the wrist and elbow of Resident #19. Staff #13 stated that Resident #19 had a history of aggressive behaviors toward staff, if he was approached in an aggressive manner. However, Staff #13 stated that Resident #19 had not shown aggressive behaviorstoward her and had never shown aggressive behaviors toward other residents. Staff #13 stated that Staff #15 was assertive and aggressive towards other residents. Staff #13 further stated that she had witnessed staff members such as Staff #15 had approach Resident #19 inappropriately, and stated that she thought Resident #19 was being abused after observing the hand print shaped bruise on his body. On 4/4/23 at 5:05 p.m., the GPD stated that she had received the skin integrity form for Resident #19 regarding bruises of unknown origin the morning of 4/3/23. The GPD stated that she was not aware what the policy was for injuries of unknown origin. She stated that Resident #19 could be resistant to care and had gotten aggressive toward other staff members; however, the GPD stated he was never aggressive to other residents. The GPD stated that no investigation was done since they had just received the skin integrity report on 4/3/23 one day prior. On 4/4/23 at 5:06 p.m., the administrator stated that she had not received the skin integrity report until the morning of 4/4/23. The administrator stated that she had not taken any steps into the investigation since she had been attending to the surveyors all day. On 4/5/23 at 3:48 p.m., during a second interview the administrator stated that she expected staff to document bruises and any injury of unknown origin. The administrator stated that the GPD should have notified her right when she received the skin integrity report on 4/3/23 and it should have been investigated by herself and the GPD right away on 4/3/23. An assessment for Resident #19, dated 2/2/23, read the resident exhibited aggressive behavior. Progress notes, dated 2/2/23 and 2/22/23, read that Resident #19 exhibited aggressive behaviors and attempted to swing at Staff #15. A progress note, dated 3/24/23, Resident #19 kicked and swung his arms at Staff #9. However, there were no progress notes documented from 3/31 through 4/2/23. A handwritten skin integrity form written by Staff #13, dated 4/2/23, read in part: "bruise on arm between shoulder and elbow on right arm, bruise on forearm of left arm between elbow and wrist, bruise on the top of right foot, and bruise on left leg between ankle and knee and four bruises on inside of left leg."A care plan for Resident #19, dated 4/4/23 (the day of the onsite investigation), read in part: Staff were to monitor and report changes in Resident #19's behavior and document resident specific interventions, and notify the family, external hospice and practitioner. Staff to observe for redness or discoloration of Resident #19's skin and document and promptly notify the supervisor on shift, hospice and the practitioner. The residence per their policy failed to:Initiate and document the following: -The investigation and identification of any injury identified in (Paragraph 1), above.-The implementation and outcome of the following for injuries for which the investigation determines the source/origin:-Compliance with (this investigation of Elder Abuse, Neglect, and Exploitation policy), when the source/origin of the injury is suspected to be abuse ... or-The steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury is not suspected abuse ... Such steps may include, but not be limited to:-Staff or volunteer corrective action and/or additional training; or-Modification of assisted living residence's polices, procedures or physical environment.c) (sic) When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort (to) identify and prevent similar injuries.-All documentation of the investigation, outcomes, and steps taken may be maintained separately from the resident record, in which case a summary of the investigation and steps taken shall be included in the resident's care plan and progress notes. -The assisted living residence shall notify the resident's representative of the outcome of the investigation and steps taken."5. Immediate Jeopardy - Written evidence, immediate correctionThe survey established that the findings above placed the one resident at immediate jeopardy risk for failure to investigate injuries of unknown origin. The residence was directed to provide the department with written evidence that the risk had been removed. Part 13.12 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 4/4/23 at 6:52 p.m., the administrator submitted written evidence that read in pertinent part, "On 4/4/23 the administrator was made aware of a skin concern on a resident in the memory care neighborhood of the community. On 4/4/23 an investigation was initiated to determine the cause of bruises, and found and documented on the resident. Initial interview show resident #19) ha(d) been combative during care. This included an initial report to the (department) reporting system and interviews of the resident, family member, hospice team, and staff who ha(d) been assigned to resident (#19) in the previous five days. Review of the documentation show(ed) that resident (#19) (was) often out of the community with (his family member), who w(ould) be interviewed including a demonstration of how she assist(ed) him getting in/out of the vehicle. All staff were inserviced on resident rights on 11/29/22, and attendance was documented. On 4/4/23 the GPD was educated using GP 12- Resident Abuse, Neglect, and Exploitation and GP 10-Personal Rights. All new hires (were) educated on these policies during orientation, and staff sign(ed) a check-off form. Computer-based compliance training include(d) identifying and reporting Abuse and Neglect, and this module (was) assigned to all staff in this month of April 2023. 100% compliance with this training (would) be enforced and documented. Resident rights and recognizing/reporting abuse (would) be reviewed at every all-staff meeting, held monthly. Attendance (would) be recorded. The (administrator) or designee (would) review skin integrity sheets weekly on Thursdays for irregularities, and conduct interviews to determine if abuse is suspected or cause is unknown. Abuse investigations (would) be reported in the (department) system with 24 hours of notification. All occurrences (would be) reviewed with the clinical consultant group, and reviewed during QA activities no less than monthly."However, the written evidence did not indicate the risk had been removed because it did not include how the residence was going to protect and prevent the resident from further harm while the investigation was occurring, notification of law enforcement or APS of suspected abuse, how to prevent a lapse of time to ensure investigations occur within 24 hours of an incident occurring and more frequent skin integrity sheet review in relation. On 4/4/23 at 7:12 p.m., the administrator submitted written evidence that read in pertinent part, "Staff (had) been directed- that two people must be present during (Resident #19's) care activities at all times, in order to prevent further injury during the investigation ...In accordance with this reporting, law enforcement, APS, and the ombudsman (would) be notified ...the (administrator) or designee (would) review skin integrity sheets daily for irregularities ... Abuse investigations (would) be reported in the (department) system with 24 hours of notification and reported to AFCG. In the absence of the administrator, the consulting group (would be) granted access to provide for timely reporting."However, the written evidence did not indicate the risk had been removed because it did not include that APS and Law enforcement be notified in accordance with the regulation, opposed to in accordance with the investigation. On 4/4/23 at 7:33 p.m., the administrator submitted a third and final attempt with written evidence that read in pertinent part, "In accordance with 6 CR 1011 Chapter 2 Section 13.12, law enforcement, APS, and the ombudsman (would be) notified."

Based on record review and interview, the residence failed to prepare or administer only medication that had been ordered by an authorized practitioner, affecting one sample resident (#11). Findings include:1. Residence PolicyThe residence's medication policy, dated 6/23/20, read that residents (would) receive assistance with administration of medication in accordance with state regulations ...based on written orders and resident's needs and preferences."2. Resident #11On 4/4/23 at approximately 9:26 a.m., the full resident record and March and April medication administration records (eMARs) with corresponding orders were requested for Resident #11. However, the resident record provided did not include orders for Resident #11's gabapentin or diltiazem dated prior to 3/6/23. On 4/5/23 at 8:11 a.m., Resident #11's diltiazem and gabapentin orders dated prior to 3/6/23, were requested and not provided. a. DiltiazemThe March 2023 electronic medication administration record (eMAR) read Resident #11 was administered diltiazem 120 mg once daily from 3/1-3/6/23, for a total of six doses in which there was no evidence of a written practitioner's order.a. Gabapentin The March 2023 eMAR read in part, a practitioner's order dated 3/6/23 directed the residence to administer gabapentin 800 mg two tabs from 3/1-3/6/23, for a total of six doses in which there was no evidence of a written practitioner's order. On 4/5/23 at approximately 3:50 p.m., the administrator stated that she would expected written practitioner's orders for all medications being administered and was not aware why orders prior to 3/6/23 orders were not provided.

Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting six of seven sample residents (#4, #7, #11, #12, #18,#19) and one former resident (#10). (Cross-reference Q1514)Specifically, Resident #11 was prescribed gabapentin 800 mg two tablets at midnight for nerve pain. However, on 3/31/23, Resident #11 went without her gabapentin at midnight and was up all night with severe nerve pain as a result. Findings include:1. Reference and Residence Policiesa. According to New Choices Treatment Centers, gabapentin withdrawal side effects can begin to occur within 12 hours after stopping the medication, and include muscle pain, tremors, and restlessness. Retrieved from: https://newchoicestc.com/blog/gabapentin-withdrawal-symptoms-nc/b. The residence's Medication Administration Policy, dated 6/23/20, read that residents (would) receive assistance with administration of medication in accordance with state regulations ...based on written orders and resident's needs and preferences."c. The residence's Medication Services policy, dated 12/9/21, read, in part, "The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration ..."d. The residence's Med Room Workflow policy, dated 12/9/21, read, in part, "It is the responsibility of every staff member involved with medications to ensure the medications are ordered appropriately. Medications are ordered at least 7 days before running out (more days may be needed when needed due to difficult or mail order pharmacies, upcoming holidays/weekends, and controlled substances) ..."2. Resident #11 was admitted to the residence on 7/13/21, with a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, idiopathic peripheral neuropathy, hyperlipidemia, osteoarthritis, and chronic respiratory failure with hypoxia. a. GabapentinA written practitioner's order, dated 3/6/23, directed the residence to administer gabapentin 800 mg two tablets three times daily and once at midnight. However, the March 2023 electronic medication administration record (eMAR) read the residence failed to administer gabapentin at midnight on 3/31/23, for a total of one missed dose. On 4/5/23 at approximately 9:45 a.m., Resident #11 stated that when she missed her midnight dose of gabapentin on 3/31/23 she kept waking up with severe nerve pain and could not sleep through the night. Resident #11 stated that her nerve pain was in her face. On 4/5/23 at 12:11 p.m., a nurse at the practitioner's office for Resident #11 stated that since the resident was on such a high dose of gabapentin, her missing one dose of the medication would have caused the nerve pain that Resident #11 described. On 4/5/23 at 12:30 p.m., the generations program director (GPD) stated that she was not aware of Resident #11's symptoms and would have expected staff to report to her when medication was not available. On 4/5/23 at 3:54 p.m., the administrator stated that she was not aware of the pain Resident #11 experienced due to missing her gabapentin and would have expected staff to notify her.b. BenzonatateA written practitioner's order, dated 2/10/23, directed the residence to administer benzonatate 100 mg three times daily and discontinue on 3/2/23. However, the March 2023 eMAR read that the residence failed to administer benzonatate in the evening on 3/1/23, due to waiting on the pharmacy to deliver, for a total of one missed dose. c. CelecoxibA written practitioner's order, dated 2/10/23, directed the residence to administer celecoxib 100 mg three times daily. However, the March 2023 eMAR read the residence failed to administer celecoxib in the morning on 3/31/23 due to the waiting on the pharmacy for delivery, for a total of one missed dose. 3. Former Resident #10was admitted to the residence on 12/31/20, with a diagnosis of early onset Alzheimer's.a. MorphineA written practitioner's order, dated 10/29/22, directed the residence to discontinue the order for morphine sulfate 20 mg/ml 0.5 ml every six hours daily for pain, and increase the dose to 20 mg/ml 0.5 ml every four hours for pain. However, the October and November 2022 eMARs read that the new dose of 20 mg/ml 0.5 ml every four hours for pain was not transcribed on eMAR until the order changed to every two hours on 11/3/23, for a total of twenty-four missed doses.b. HaloperidolA written practitioner's order, dated 9/21/22, directed the residence to administer haloperidol lactate 2 mg/ml every six hours. However, the October 2022 eMAR read the residence failed to administer haloperidol in the afternoon and evening on 10/29/22 due to waiting on pharmacy for delivery, for a total of two missed doses. On 4/4/23 at 9:35 a.m., a family member for Former Resident #10 stated that she did not think the residence was administering Former Resident #10's morphine as directed by Resident #10's practitioner. 4. Resident #7 was admitted to the residence on 3/24/22, with diagnoses including Alzheimer's disease and seizures.a. Divalproex SodiumA written practitioner's order, dated 8/10/22, directed the residence to administer divalproex sodium 500 mg once daily at bedtime. However, the March 2023 eMAR read the residence failed to administer divalproex sodium on 3/12, 3/13 and 3/15/23, for a total of three missed doses, due to waiting on the pharmacy to deliver.b. AcetaminophenA written practitioner's order, dated 8/10/22, directed the residence to administer acetaminophen 325 mg three times daily. However, the March 2023 eMAR read the residence failed to administer acetaminophen on 3/5/23 in the evening, for a total of one missed dose. 5. Resident #19 was admitted to the residence on 1/26/23, with a diagnosis of late Alzheimer's disease with behavioral disturbance.a. QuetiapineA written practitioner's order, dated 3/9/23, directed the residence to administer quetiapine 25 mg once daily. However, the March and April 2023 eMARs read the residence failed to administer quetiapine 3/28-3/30/23 and 4/2-4/3/23, for a total of five missed doses. 6. Resident #4 was admitted to the residence on 4/18/21, with a diagnosis of Alzheimer's disease. a. AcetaminophenA written practitioner's order, dated 1/12/23, directed the residence to administer two 325 mg tablets of acetaminophen three times daily. However, the March 2023 eMAR read that acetaminophen was not administered on 3/22/23 in the evening, and 3/23/23 all three doses due to waiting on the pharmacy for delivery, for a total of four missed doses. 7. Resident #12 was admitted to the residence on 6/30/22. A written practitioner's order, dated 3/19/23, directed the residence to administer Amoxicillin 875-125 mg twice daily. However, the March 2023 eMAR for Resident #12 read the medication was not available and not administered on 3/26-3/28/23, for a total of six missed doses. On 4/5/23 at 1:20 p.m., the GPD said the medication was not available and not administered to Resident #12.8. Resident #18 was admitted to the residence on 9/26/20. A written practitioner's order, dated 1/26/23, directed the residence to administer clonidine 0.1 mg two tablets in the morning and one tablet in the afternoon and bedtime. However, the medication was not available and not administered on 3/2/23 for the afternoon, for a total of one missed dose. On 4/5/23 at 1:10 p.m., the GPD said the medication was not administered to Resident #18 because the pharmacy had not delivered the medication or staff were unable to find the medication in the cart. On 4/5/23 at 1:15 p.m., the GPD stated that staff needed to follow up with the pharmacy before a medication ran out of stock and check on medications in the overstock before marking a medication as missed. The GPD stated that she expected staff to inform her if they could not find a medication before making it off as missed. The GPD stated that she would expect that staff order medications at least a week prior to them running out, and that the residence comply with practitioner's orders. On 4/5/23 at approximately 3:54 p.m., the administrator stated that she would expect that all residents received their medications as ordered and not run out of stock. The administrator stated that the GPD and Resident Care Coordinator (RCC) were in charge of medication management, however, the RCC was on vacation.

Based on record review and interview, the residence failed to ensure that each qualified medication administration person (QMAP), nurse, or practitioner accurately documented each medication administration or monitoring event at the time the event is completed for each resident, including any medication omissions or refusals, affecting three of seven sample residents (#7, #12, #19) and one former resident (#10). (Cross-reference Q1514)Findings include:1. Residence PolicyThe residence's Med Room Workflow policy, dated 12/9/21, read, in part, "The MARs (medication administration records) are initialed at the time the medication is placed in the cup. Each qualified medication administration, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident."2. Former Resident #10 was admitted to the residence on 12/31/20, with diagnoses including Alzheimer's disease.a. MorphineA written practitioner's order, dated 9/21/22, directed the residence to administer morphine 20 mg/ml every six hours. However, the October 2022 medication administration record (MAR ) revealed no evidence of administration on 10/1-10/13 at 2:00 a.m., on 10/8 at 8:00 a.m. and 2:00 p.m., 10/1-10/5 and 10/7-10/13/22 at 8:00 p.m. b. LorazepamA written practitioner's order, dated 9/21/22, directed the residence to administer lorazepam 2 mg/ml every six hours. However, the October 2022 MAR revealed no evidence of administration on 10/1-10/13 at 2:00 a.m., on 10/8 at 8:00 a.m. and 2:00 p.m., 10/1-10/5 and 10/7-10/13/22 at 8:00 p.m. Additionally, the October 2022 eMAR for former Resident #10 had no evidence of administration on 10/23 at night and on 10/27/23 in the evening.c. HaloperidolA written practitioner's order, dated 9/21/22, directed the residence to administer haloperidol 1 mg every six hours. However, the October 2022 MAR revealed no evidence of administration on 10/1-10/13 at 2:00 a.m., on 10/8 at 8:00 a.m. and 2:00 p.m., on 10/1-10/5 and 10/7-10/13/22 at 8:00 p.m. d. NystatinA written practitioner's order, dated 9/21/22 directed the residence to administer nystatin 100000 unit/gm twice daily. However, the October 2022 MAR contained a circle with no documentation attached as to why the medication was circled, on 10/1, 10/4, and 10/11/22 in the morning. Additionally, there was not evidence of administration on 10/8/22 in the morning, 10/1-10/5 and 10/7-10/13/22 in the evening.f. MiralaxA written practitioner's order, dated 9/21/22, directed the residence to administer miralax 17 gram once daily. However, the October 2022 MAR contained a circle with no documentation attached as to why the medication was circled, on 10/4 and 10/11/22. Additionally, the eMAR revealed no evidence of documentation on 10/8/22. On 4/4/23 at 9:35 a.m., the family member for Former Resident #10 stated that she was concerned that Former Resident #10's nystatin was not applied to her perineal area as prescribed because she was red and itchy. Former Resident #10's family member also stated that she was concerned that Resident #10's morphine was not being administered as prescribed either. On 4/4/23 at 1:06 p.m., the administrator stated the residence switched to electronic MAR's from paper on 10/14/22, which was why there were "X's in former Resident #10's eMAR prior to 10/14/22. On 4/5/23 at 3:59 p.m., the administrator stated that she expected all medications to have been documented, and would have expected staff to have given a reason for all of the circled medications on Former Resident #10's MAR. 3. Resident #19 was admitted to the residence on 1/26/23, with a diagnosis of late Alzheimer's disease with behavioral disturbance.a. QuetiapineA written practitioner's order, dated 3/9/23, directed the residence to administer quetiapine 25 mg once daily. However, the March and April 2023 MARs read that Resident #19's quetiapine was administered 3/31-4/1/23. However, the March and April 2023 MAR readthat the residence failed to administer quetiapine 3/28-3/30/23, and 4/2-4/3/23 due to waiting on the pharmacy. On 4/5/23 at 3:55 p.m., the administrator acknowledged that Resident #19's medication could have not been administered on 3/14/23 if it was out of stock the other days due to waiting on the pharmacy. The administrator stated this would be a documentation error. 4. Resident #7 was admitted to the residence on 3/24/22, with diagnoses including Alzheimer's disease and seizures.a. Divalproex SodiumA written practitioner's order, dated 8/10/22, directed the residence to administer 500 mg tablets of divalproex 500 mg once daily at bedtime. However, the March 2023 MAR read that the residence administered divalproex sodium on 3/14/23. However on 3/12-3/13/23 and 3/15/23 divalproex sodium was not administered due to waiting on the pharmacy to deliver. On 4/5/23 at 3:55 p.m., the administrator acknowledged that there was no way Resident #7's medication could have been administered on 3/14/23 if it was out of stock the other days due to waiting on the pharmacy. The administrator stated this would be a documentation error. 5. Resident #12 was admitted to the residence on 6/30/22 with diagnoses that included hypocalcemia.a. AcetaminophenA written practitioner's order, dated 3/19/23, directed the residence to administer acetaminophen 325 mg three times daily. However, the April 2023 MAR for Resident #12 revealed no evidence of administration on 4/3/23 in the afternoon.b. Calcium Antacid A written practitioner's order, dated 3/19/23, directed the residence to administer calcium antacid 100 mg three times daily. However, the April 2023 eMAR for Resident #12 revealed no evidence of documentation on 4/3/23 in the afternoon. On 4/5/23 at approximately 3:00 p.m., the administrator said a blank space on the MAR for residents was considered medications that were not documented by the qualified medication administration persons, as required.

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration (QMAP) supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records, affecting six of seven sample residents (#4, #7, #11, #12, #18, #19) and one former resident (#10). (Cross-reference Q1468, Q1510)Findings include:On 4/4/23 at approximately 9:30 a.m., the residence's quarterly audits of medication administration records', controlled substance lists, medication error reports, and medication disposal records were requested. On 4/4/23 at approximately 10:30 a.m., the administrator provided a binder that included a medication count that included residents who received medications from the residence's preferred pharmacy and family members. The contents included a specific medication cart audit. The binder did not include an audit of the accuracy and completeness of the MARs, controlled substance lists, medication error reports or medication disposal records. On 4/5/23 at approximately 3:00 p.m., the administrator said the residence completed a couple of different audits that included cart organization, expired medications, over the counter medication labeling a count of the remaining medication supply for residents who were enrolled with external hospice and for residents whose family members provided mediation. The administrator said she reviewed the audits completed and had not participated in an audit of the accuracy and completeness of the MARs, controlled substance lists, medication error reports, and medication disposal records.

Based on record review, observation and interview, the residence failed to ensure resident records contained progress notes regarding any out-of-the-ordinary event or issue that affected a resident's physical, behavioral, cognitive, and/or functional condition, along with the action taken by staff to address that resident's changing needs, affecting two of five sample residents whose full records were reviewed (#12 and #19). (Cross-reference Q1362 Q1146, Q1150 and Q1180). Findings include:1. Resident #19 was admitted to the residence on 1/26/23, with a diagnosis of late Alzheimer's disease with behavioral disturbance. On 4/4/23 at approximately 3:44 p.m., Staff #14 pointed out a bruise on Resident #19's calf, and the bruise contained 4 finger marks in the shape of a hand. A skin integrity form written by Staff #13, dated 4/2/23, read in part: "bruise on arm between shoulder and elbow on right arm, bruise on forearm of left arm between elbow and wrist, bruise on the top of right foot, and bruise on left leg between ankle and knee and four bruises on inside of his left leg."However, Resident #19's record contained no progress notes of the incident, with his last progress note dated 3/31/23. On 4/5/23 at 3:45 p.m., the administrator stated that she would not consider skin integrity notes to be progress notes, and there should have been a note in Resident #19's chart of the bruising discovered on 4/2/23 as well as any and all action taken by staff. 2. Resident #12 was admitted to the residence on 6/30/22. A progress note in Resident #12's record, dated 3/19/23 read she returned from the hospital around 6:00 p.m. There was no other progress note in the record for Resident #12 that listed the reason for Resident #12 being sent out to the hospital. Hospital discharge paperwork in Resident #12's record, dated 3/14-3/19/23, read Resident #12 was in the hospital for pneumonia. On 4/5/23 at 1:30 p.m., the generations program director said she expected staff to add a progress note for the reason Resident #12 went to the hospital. She added that Resident #12 returned and was in isolation for a week. On 4/5/23 at approximately 3:00 p.m., the administrator said she expected progress notes, practitioner notes and hospital discharge notes to be included in a resident record.

Based on record review and interview, the residence failed to ensure face sheets contained required information, affecting two of five sample residents (#18-#19) and one former resident (#10). Findings include: 1. Record Reviewsa. Resident #18 was admitted to the residence on 9/26/20. The face sheet for Resident #18 had an inaccurate room number, no diagnoses, and no hospice contact information.b. Resident #19 was admitted to the residence on 1/26/23, with a diagnosis of late Alzheimer's disease with behavioral disturbance. The face sheet for Resident #19 had no diagnoses.c. Former Resident #10 was admitted to the residence on 12/31/20, with diagnoses including Alzheimer's disease. The face sheet for former Resident #10 had no external hospice contact information. 2. InterviewOn 4/5/23 at approximately 3:40 p.m., the administrator stated that resident name, diagnoses, provider information and emergency contact information was all required to be on resident face sheets and stated she was not sure why Residents #18 and #19 and former Resident #10's face sheets did not contain the required information.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. 7.20 Before a personal care worker independently performs personal services for a resident, the supervisor designated by the assisted living residence shall observe and document that the worker has demonstrated his or her ability to competently perform every personal task assigned. This competency check shall be repeated each time a worker is assigned a new or additional personal care task that he or she has not previously performed.