SEVEN LAKES MEMORY CARE

A revisit survey was completed on 07/07/26 for all previous deficiencies cited on 04/09/26. The facility is in compliance with all regulations surveyed.

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

A licensure complaint, prompted by #CO39681, #CO41013, #CO41103, #CO41121, #CO42028 was completed on 4/9/26. One deficiency was cited.

Based on record review and interview, the residence failed to investigate allegations of abuse in accordance with its written policy, including failure to report resident-to-resident abuse allegations to Adult Protective Services (APS), affecting three of three sample residents, Resident #4 and Resident #6. Findings include:1. Record reviewa. Allegation of abuse on 3/15/26Records revealed on 3/15/26, Resident #5 and #6 argued over a purse and Resident #6 then hit Resident #5 with a book.b. Allegation of abuse on 3/24/26Records revealed on 3/24/26, staff heard yelling from two residents and found Resident #4 was bleeding from his chin. It was reported that Resident #4 and #5 got into a physical altercation resulting in a head injury for Resident #4. Record review further revealed APS was not notified after the two allegations of resident to resident abuse. 2. InterviewsInterview with the Executive Director (ED) on 4/9/2026 at 10:30 a.m. stated she received a call at approximately 7:30 p.m. regarding the 3/24/26 altercation and was told the residents had been separated. The ED further stated that at approximately 9:00 p.m. she was notified by the Wellness Director, who resigned the day after the altercation, that Resident #4 had significantly declined. The ED stated paramedics responded, hospice responded, and the decision was made for the resident to remain at the residence for end of life care. Further, the ED confirmed that she had investigated both allegations of abuse, but did not contact APS as she was unaware it was required.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.10 (C) Promote resident choice, mobility, independence and safety. Each resident care plan shall: (A) Be developed with input from the resident and the resident ' s representative; (B) Reflect the most current assessment information; (C) Promote resident choice, mobility, independence and safety; (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs; (E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence ' s visitation policy as required by Part 9.2, along with care coordination arrangements; and (F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident ' s personal choices and needs.

A revisit survey was completed on 5/6/25 for previous deficiencies cited on 3/19/25. The agency is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO38865, was completed on 3/19/25. A deficiency was cited. A change of ownership survey was completed on 10/13/23.

Based on observation, interview, and record review, the residence failed to detail personal service needs along with the staff tasks necessary to meet those needs in the care plan, affecting one sample resident (#3). Findings include:Resident #3 was admitted to the residence on 10/30/24 with a diagnosis of chronic obstructive pulmonary disease (COPD). On 3/19/25 at 1:01 p.m., Resident #3 was administered oxygen (O2) from a portable O2 concentrator. The screen of the concentrator read 2 liters per minute (L/Min). A written practitioner's order, dated 11/13/24, directed the residence to ensure the continuous administration of 4-5 L/Min of O2 to Resident #3. The care plan, dated 2/3/25, read Resident #3 used practitioner-ordered O2 at 2 L/Min via nasal cannula continuously due to a diagnosis of COPD.On 3/19/25 at 1:02 p.m., Staff #1 stated Resident #3 used O2 at 2 L/Min if that was what the portable concentrator screen read. She added that she ensured the portable concentrator was on prior to lunch; however, she did not know that the concentrator was on the incorrect level. On 3/19/25 at 1:03 p.m., Staff #2 stated that Resident #3 had O2 as ordered by the practitioner. She added that she was not sure what the practitioner's order read and thought the O2 was supposed to be 2 L/Min. On 3/19/25 at 1:11 p.m., the health services director (HSD) stated that she was a nurse and took a verbal order from the practitioner that clarified the O2 order with the practitioner that Resident #3 required 4 L/Min of O2 continuously. She stated the portable concentrator was not set at the correct L/Min as it was on 2 L/Min instead of 4 L/Min. She stated that the care plan directed staff to ensure the required L/Min the O2 for the resident. She added that she was not aware that the care plan read that the resident was to have 2 L/Min, and that level was incorrect. On 3/19/25 at 2:02 p.m., the administrator stated that the residence was required to ensure Resident #3 was administered the correct L/Min of O2. He added that the care plan should have read the correct L/Min of O2, but he was not aware that it did not.

A revisit survey was completed on 9/19/23 for all previous deficiencies cited on 2/15/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 9/19/23 for all previous deficiencies cited on 2/15/23. The facility is in compliance with all deficiencies that were cited.

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

A licensure revisit was completed on 2/15/23 for all previous deficiencies cited on 4/13/22. A deficiency cited.

Based on record review and interview, the residence failed to immediately comply with all conditions issued by the department, affecting 46 current residents. Findings include:The department completed a licensure complaint on 4/13/22. The event resulted in tag Q540 being cited at a B level for the residence's failure to comply with all applicable state laws and ensure infection control processes were established and maintained to help prevent the possible development and transmission of Covid-19. The department imposed a $500 civil fine payable by June 30, 2022. The residence did not appeal the immediate condition. Review of the department database revealed the administrator had reviewed the intermediate condition letter through the department's database on 5/31/22. Review of the department database revealed the residence had not yet paid the civil fine as of 2/14/23. A department representative confirmed the residence had not paid the civil fine as of 2/14/23. On 2/14/23 at 4:20 p.m., the administrator stated she was not aware the residence was required to pay a civil fine by 6/30/23. She stated she was not responsible for paying the fines, adding that someone from the residence's corporate office paid them. The administrator stated that she did not receive a fine notification via the department's database nor the postal mail.

Based on record review and interview, the residence failed to ensure each staff member received an initial orientation prior to providing any care or services to a resident, affecting one of three sample staff (#11). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" means employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.b. The residence's Staff Education and Training policy, dated 8/27/12, read, in part, "Connections for Living staff will receive training and education in the core concepts of dementia care at orientation ... In addition staff will be oriented to Connections for Living policies, procedures and practices. A core curriculum will be provided to each Connection for Living staff member during orientation specific to the care of dementia residents. The following topics will be covered ... Connections for Living policies and procedures."2. Record ReviewOn 2/14/23 at approximately 8:00 a.m., Staff #11 was identified by the administrator as a contracted staff member. His initial start date was 2/6/23. According to the February 2023 staffing schedule, Contracted Staff #11 worked the following days:2/6/23 from 2:00 p.m. to 10:00 p.m. 2/10/23 from 2:00 p.m. to 10:00 p.m. 2/11/23 from 2:00 p.m. to 10:00 p.m. 2/12/23 from 6:00 a.m. to 2:00 p.m. An Agency Orientation and Rules of Conduct document, dated 2/6/23, was in Contracted Staff #11's personnel file. The document included orientation topics reviewed and completed by Contracted Staff #11. The document did not include any training on the following required topics:The care and services provided by the assisted living residenceAssignment of duties and responsibilities specific to the staff memberHand hygieneRelevant emergency contact numbersBasic first aidReporting requirements, including occurrence reporting procedures within the residenceHouse rulesWhere to immediately locate a resident's advance directiveOverview of the assisted living residence's policies and procedures and how to access them for reference. 3. InterviewsOn 2/14/23 at approximately 3:30 p.m., the director of health services (DHS) stated any manager completed new staff members' orientation prior to providing care and services to residents. She added there was a contracted staff binder that included all orientation topics. The DHS acknowledged that some of the required orientation elements were missing and not completed from the residences orientation training program. On 2/14/23 at approximately 4:30 p.m., the administrator stated the DHS, the connections for living director and qualified medication administration persons (QMAPs) were responsible for orienting new staff members. She added, most of the required orientation elements were completed by the QMAPs and not contracted staff. She added contracted staff did not need to know some of the orientation training and therefore were not trained on certain topics.

A relicensure survey with complaint #CO30699 was completed on 2/15/23. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting two of seven sample residents (#8, #12). (Cross-reference Q1360, Q1362)Findings include:1. References and Residence Policya. According to the Health Facilities and Emergency Medical Services Division Occurrence Reporting Manual (2018), "Abuse, Physical ... Any occurrence involving physical ... abuse of a patient or resident, as described in Section 18-3-202, 18-3-203, and 18-3-204 ...C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility. Section 25-1-124(2)(d), C.R.S. Staff, visitors, and other consumers can all commit physical abuse ... (it is) the allegation of the event, not the outcome of the provider's investigation, which makes it reportable. It is the licensed entity's responsibility to protect consumers from physical abuse, no matter the source." Retrieved from: https://cdphe.colorado.gov/health-facility-reported-incidentsb. On 2/13/22, the department's database revealed the residence had not reported any occurrences for Resident #8 in October 2022 and for Resident #8 and #12 in February 2023. c. The residence's undated Occurrence Reporting policy read, in part, "An assisted living residence shall comply with all occurrence reporting required by state law and shall follow the reporting procedures set forth in 6 CCR-1011-1 ... An assisted living residence shall investigate an occurrence to determine the circumstances of the event and institute appropriate measure to prevent similar future situations ... The following occurrences shall be reported to the Department within one business day after the occurrence of when the licensee becomes aware of the occurrence, in the format required by the Department ... any occurrence involving physical ... abuse ... as described in regulations by another client, an employee of the licensee or a visitor to the facility or agency."2. Resident #8 was admitted to the residence on 9/12/22 with diagnoses including Alzheimer's disease.a. Incident involving Staff #5 and Resident #8On 2/14/23 at approximately 7:50 a.m., Staff #5 stated in September or October 2022 during the day, Resident #8 attempted to punch Former Resident #4 and Staff #5 stepped in front of Resident #8 and blocked her. Staff #5 stated Resident #8 had an assisted fall to the floor, Staff #5 placed her foot under Resident #8's bottom. She added later on that same day in the evening she noticed a bruise on Resident #8's arm that looked like big fingerprints. On 2/14/23 at approximately 4:30 p.m., the administrator stated in October 2022 there was an incident with Resident #8 and Staff #5. She added someone had recently notified adult protective services about suspicious bruising on Resident #8. The administrator said she was told by Staff #5 that Resident #8's fall resulted in a bruise. She added, an unidentified staff member reported alleged abuse against Staff #5 because of the bruise found on Resident #8 in October 2022. The administrator said she did not file an occurrence report with the department and had only interviewed staff during that time. On 2/14/23 at approximately 4:30 p.m., the administrator was asked to provide the unidentified staff member's allegation documentation. However, by the time of exit on 2/14/23 at 6:00 p.m., no documentation was provided. On 2/15/23 at 9:22 a.m., a representative of the department provided an email that read the event regarding Resident #8 in September/October 2022 was a reportable occurrence.b. Incident Involving Resident #8 and Resident #12A progress note in Resident #8's record, dated 2/5/23, read that another resident pushed Resident #8 out of the kitchen. Resident #8 fell to the floor, hit her head and complained of right hip pain. On 2/14/23 at approximately 4:30 p.m., the administrator stated Resident #12 pushed Resident #8 to the ground and caused injury. She added she interviewed staff, local law enforcement were notified but no occurrence report was submitted to the Department because she felt Resident #12 had not intended to hurt Resident #8.

Based on the record review and interview the residence failed to have a quality management program designed to improve resident safety and well-being, affecting 46 current residents. Findings include:The residence's dated Quality Improvement (QI) Program Report read, in part: "The program evaluates the community's performance against nationally published data (where available) and serves as a baseline to determine performance improvement goals to provide the best care possible for residents."On 2/14/23 at approximately 7:00 a.m.,the administrator was asked to provide the residence's quality management program (QMP). However, no QMP documentation was provided. On 2/14/23 4:30 p.m.,the administrator stated she knew what was required for QMP. She stated the residence completed weekly quality improvement meetings. However, the meetings had not been documented.

Based on record review and interview, the residence failed to ensure each staff member received an initial orientation prior to providing any care or services to a resident, affecting one of three sample staff (#11). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" means employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.b. The residence's Staff Education and Training policy, dated 8/27/12, read, in part, "Connections for Living staff will receive training and education in the core concepts of dementia care at orientation ... In addition staff will be oriented to Connections for Living policies, procedures and practices. A core curriculum will be provided to each Connection for Living staff member during orientation specific to the care of dementia residents. The following topics will be covered ... Connections for Living policies and procedures."2. Record ReviewOn 2/14/23 at approximately 8:00 a.m., Staff #11 was identified by the administrator as a contracted staff member. His initial start date was 2/6/23. According to the February 2023 staffing schedule, Contracted Staff #11 worked the following days:2/6/23 from 2:00 p.m. to 10:00 p.m. 2/10/23 from 2:00 p.m. to 10:00 p.m. 2/11/23 from 2:00 p.m. to 10:00 p.m. 2/12/23 from 6:00 a.m. to 2:00 p.m. An Agency Orientation and Rules of Conduct document, dated 2/6/23, was in Contracted Staff #11's personnel file. The document included orientation topics reviewed and completed by Contracted Staff #11. The document did not include any training on the following required topics:The care and services provided by the assisted living residenceAssignment of duties and responsibilities specific to the staff memberHand hygieneRelevant emergency contact numbersBasic first aidReporting requirements, including occurrence reporting procedures within the residenceHouse rulesWhere to immediately locate a resident's advance directiveOverview of the assisted living residence's policies and procedures and how to access them for reference. 3. InterviewsOn 2/14/23 at approximately 3:30 p.m., the director of health services (DHS) stated any manager completed new staff members' orientation prior to providing care and services to residents. She added there was a contracted staff binder that included all orientation topics. The DHS acknowledged that some of the required orientation elements were missing and not completed from the residences orientation training program. On 2/14/23 at approximately 4:30 p.m., the administrator stated the DHS, the connections for living director and qualified medication administration persons (QMAPs) were responsible for orienting new staff members. She added, most of the required orientation elements were completed by the QMAPs and not contracted staff. She added contracted staff did not need some of the orientation and therefore were not trained on certain topics.

Based on observation, record review and interview, the residence failed to ensure each staff member completed an overview of state regulatory oversight applicable to the assisted living residence, person-centered care, the role and communication with external service providers, recognizing behavioral expressions and management techniques, how to effectively communicate with residents that have hearing loss and limited English proficiency, training related to fall prevention, maintenance of a clean, safe and sanitary environment, food safety, and understanding the staff's role in end of life care including hospice, affecting three of three sample staff (#10, #11, #12). Findings include:1. Reference and Residence Policy a. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" means employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.b. The residence's undated Staff Education and Training policy, read, in part, "Connections for Living staff will receive training and education in the core concepts of dementia care at orientation ... In addition staff will be oriented to Connections for Living policies, procedures and practices. A core curriculum will be provided to each Connection for Living staff member during orientation specific to the care of dementia residents ... The following topics will be covered ... dementia overview, communication techniques ... physical care and activities of daily living ... positive solutions to challenging behaviors ... service planning for resident centered care ... palliative care ... volunteers in programming."2. ObservationOn 2/14/23 from approximately 7:00 a.m. to 2:00 p.m., Staff #10 and #12 provided care and services to residents. 3. Record ReviewStaff #10, #12 and Contracted Staff #11 were hired on 10/7/22, 8/5/22 and 2/6/23, respectively. Review of the February 2023 staffing scheduled revealed Staff #10, #12 and Contracted Staff #11 provided care and services to residents, as follows:Staff #10 worked on 2/1, 2/3, 2/5-2/9, 2/12 and 2/13/23. Contracted Staff #11 worked on 2/6 and 2/10-2/12/23. Staff #12 worked on 2/1-2/3 and 2/7-2/11/23. Review of Staff #10, #12 and Contracted Staff #11's personnel files revealed no training documentation on the following required topics:Overview of state regulatory oversight applicable to the assisted living residence;Person-centered care;The role and communication with external service providers;Recognizing behavioral expressions and management techniques;How to effectively communicate with residents that have hearing loss and limited English proficiency;Training related to fall prevention;Maintenance of a clean, safe and sanitary environment;Food safety; and Understanding the staff's role in end of life care including hospice. 3. InterviewsOn 2/14/23 at approximately 3:30 p.m., the director of health services (DHS) stated she was not aware of all the training requirements for contracted staff or residence staff. On 2/14/23 at approximately 4:30 p.m., the administrator stated she was not aware of the required training elements for newly hired staff to complete before they worked independently. The administrator acknowledged that the training was not completed and there was no new hire checklist that included the required training for newly hired staff to complete before they worked independently.

Based on observation, record review and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation), so that the information was readily available to staff at all times, affecting 46 current residents. Findings include:1. Residence PoliciesThe residence's Cardiopulmonary Resuscitation policy, dated 5/9/22, read in part: "This assisted living residence places a list of all staff who have current certification in first aid or CPR in a visible location so that the information is readily available to staff at all times."The residence's Emergency Care/First Aid policy, dated 5/9/22, read in part: "A list of all staff who have current certification in First Aid or CPR is posted so that the information is readily available to staff at all times." 2. ObservationOn 2/14/23, throughout the onsite visit, no list of staff who had current certification in first aid or CPR was posted in a visible location 3. Record review Documentation of staff CPR and first aid certifications revealed that 17 staff had current certification in first aid and 19 staff had current certification in CPR from nationally recognized organizations. 4. Interviews On 2/14/23 at 3:40 p.m., the director of health services confirmed there was no list of staff certified in CPR/first aid posted at the residence. On 2/14/23 at 4:10 p.m., the administrator also confirmed there was no posted list of staff certified in CPR/first aid. The administrator added that she had not known the posting was required.

Based on record review and interview, the residence failed to investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy, affecting two of two sample residents with allegations of abuse (#8, #12). (Cross-reference Q414)Findings include:1. Residence PolicyThe residence's abuse policy, dated 12/7/22, read in part that staff took seriously all residents' comments about potential abuse or unusual physical or mental signs that may indicate possible abuse. Upon notice of the abuse, the administrator or director of health services conducted a formal investigation to include the following: Interviews of the residents, witnesses, family members, and staff; appropriate protection for the resident to ensure their safety during the investigation; the residence contacted the resident's responsible party; the residence immediately notified the resident's practitioner (which was documented with the investigation); and the residence notified social services and adult protective services (which also was documented with the investigation). 2. Resident #12 was admitted to the residence on 6/1/21.a. Record ReviewA residence document, titled Concern Form and dated 2/2/23, read in part that on 2/1/23 at approximately 5:30 p.m., Resident #12 requested that Staff #13 "please not let that man come into my room again. He took all of my clothes off and laid me on the floor. He has done it twice now." Furthermore, it read that Staff #13 notified their supervisor. The document included a section titled "Follow up section (to be completed by director assigned to concern)." This section included the following headings with space to document:Additional Information Discovered:Outcome of Investigation/Actions taken:Person(s) notified:Completed Form filed in:However, there was no documentation in any of the provided spaces, and the residence provided no additional documentation that any of the regulatory requirements or residence policy were met.b. InterviewsOn 2/14/23 at 2:08 p.m., Staff #13 stated Resident #12 was scared when she reported that a man had taken her clothing off and laid her down, and that it had happened on two occasions. She stated there was no investigation that she was aware of. On 2/14/23 at 3:36 p.m., the director of health services (DHS) stated Resident #12's accusations were not brought to her attention. She stated she would have interviewed the resident, despite the fact that she had a diagnosis of dementia, as well as the staff to investigate what they witnessed. On 2/14/23 at 4:20 p.m., the administrator stated she spoke with Resident #12's family about her history and checked to see whether any male staff provided care and services to her. She stated that she interviewed the staff who were on shift at that time but did not document the interviews. The administrator acknowledged there was no other documentation completed for an investigation into the alleged abuse. 3. Resident #8 was admitted to the residence on 9/12/22. On 2/14/23 at 9:20 a.m., the administrator was asked to provide the residence's investigations of abuse and neglect.a. Incident Involving Staff #5 and Resident #8There was no investigation documentation in Resident #8's record about an incident that involved Resident #8 and Staff #5. On 2/14/23 at 1:10 p.m., the DHS stated the incident reports in the resident records were the residence's documentation of abuse and neglect investigations. On 2/14/23 at approximately 7:50 a.m., Staff #5 stated in September or October 2022 during the day, Resident #8 attempted to punch Former Resident #4 and Staff #5 stepped in front of Resident #8 and blocked her. Staff #5 stated Resident #8 had an assisted fall to the floor, Staff #5 placed her foot under Resident #8's bottom. She added later on that same day in the evening she noticed a bruise on Resident #8's arm that looked like big fingerprints. On 2/14/23 at approximately 3:30 p.m., the DHS stated she was not aware ifthe administrator conducted interviews with staff after the alleged abuse between Staff #5 and Resident #8. She added the residence's process for investigating abuse and neglect allegations were to complete interviews, call local law enforcement, notify the responsible parties and suspend the staff member involved. The DHS said the administrator kept track of the interviews. On 2/14/23 at approximately 4:30 p.m., the administrator stated in October 2022 there was an incident with Resident #8 and Staff #5. She added someone had recently notified adult protective services about suspicious bruising on Resident #8. The administrator said she was told by Staff #5 that Resident #8's fall resulted in a bruise. She added, an unidentified staff member reported alleged abuse against Staff #5 because of the bruise found on Resident #8 in October 2022. The administrator stated she only interviewed staff during that time, had not notified local law enforcement and had not suspended Staff #5 during her investigation. The administrator said that adult protective services had come out to the residence a few weeks prior to the onsite visit. She added the allegation of abuse was not investigated according to the residence's policy.b. Incident Involving Resident #8 and Resident #14A progress note in Resident #8's record, dated 2/5/23, read that another resident pushed Resident #8 out of the kitchen. Resident #8 fell to the floor, hit her head and complained of right hip pain. On 2/14/23 at approximately 4:30 p.m., the administrator stated Resident #14 pushed Resident #8 to the ground and caused injury. She added she interviewed staff and local law enforcement were notified. The administrator stated she had no documentation of the investigation or staff interviews, just the incident report. She added, adult protective services and the ombudsman were not notified. The administrator acknowledged the abuse investigation was not investigated according to the residence policy.

Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting three of three sample residents with documented injuries of unknown origin (#8-#10). Findings include:1. Residence PolicyThe residence's Identification, Reporting, and Investigation of Injuries of Unknown Origin policy, dated 12/7/22, read in part that the residence documented the investigation, outcome, and steps taken by the residence including, but not limited to details of any interviews and/or records used in the investigation. 2. Resident #10 was admitted to the residence on 5/28/21. A progress note, dated 2/7/23, read in part that at approximately 7:30 a.m., while assisting Resident #10 with bathing, staff observed a large bruise on the resident's right bicep/elbow. The bruise was dark purple/red in color; the cause of the bruise was unknown. An incident report, dated 2/7/23, read in part that Resident #10 sustained an injury of unknown origin. It read that while assisting the resident with bathing, an unidentified staff member noticed a large bruise that was dark purple/red in color on her upper right bicep from an unknown cause. The incident report read that two staff were interviewed. However, it did not include the content of the interviews, nor the identification of who conducted the interviews. 3. Resident #9 was admitted to the residence on 9/19/22. A progress note, dated 1/20/23, read in part that a staff noticed dark bruising over Resident #9's right eye. An incident report, dated 1/20/23, read in part that Resident #9 sustained an injury of unknown origin. It read in part that the resident was seated at the dining room table when an unknown staff observed bruising on the right side of Resident #9's forehead, above her eye and near her hairline. The incident report read that two staff were interviewed. However, it did not include the content of the interviews, nor the identification of who conducted the interviews. 4. Resident #8 was admitted to the residence on 9/12/22. An incident report in Resident #8's record, dated 1/9/23, read that a staff member noticed a quarter sized bruise on Resident #8's left forearm. A progress note in Resident #8's record, dated 2/6/23, read that Resident #8 resisted personal care services, was unsteady and weak and had a small bruise on her right wrist that was purple in color. 5. InterviewsOn 2/14/23 at 3:36 p.m., the director of health services (DHS) stated for Residents #9 and #10, she conducted interviews with the staff but did not keep a record of the interviews and what was said. She stated she did not conduct a full investigation for Resident #8's injuries of unknown origin like she should have. The DHS stated she assumed the injury was due to a fall, and she acknowledged that should have been a part of the investigation. She stated she interviewed staff but was not aware of the requirement to document the interviews. On 2/14/23 at 4:20 p.m., the administrator stated several current residents walked around the residence independently, adding Resident #10 told her that she had run into the doorway. She stated there were a fair number of residents who fell and were able to get themselves off of the floor. The administrator acknowledged that staff should have documented these instances as part of the above investigations but did not do so.

Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of five sample residents (#5). Findings include:1. Residence PolicyThe residence's Medication policy, dated 12/7/22, read in part that the residence was responsible for complying with authorized practitioner orders associated with medication administration, except for those medications which a resident self-administers. 2. Resident #5 was admitted to the residence on 12/23/21 with diagnoses including spinal stenosis.a. OxycodoneA written practitioner's order, dated 9/6/22, directed the residence to administer oxycodone 5 mg twice daily. However, the February 2023 electronic medication administration record (eMAR) for Resident #5 read oxycodone 5 mg was not available and not administered on 2/13/23, for a total of two missed doses.b. Diclofenac SodiumA written practitioner's order, dated 9/6/22, directed the residence to administer diclofenac sodium 2 gm twice daily. However, the January 2023 eMAR for Resident #5 read diclofenac sodium was not available and not administered on 1/22/23 morning dose, for a total of one missed dose. On 2/14/23 at 3:30 p.m., the director of health services acknowledged both the medications for Resident #5 were out of stock and not administered, as required. She added it was staffs' responsibility to follow practitioner orders even if there was a pharmacy issue. On 2/14/23 at 4:30 p.m., the administrator stated she expected medications to be administered as ordered and not run out of stock, regardless of pharmacy issues.

Based on record review and interview, the administrator failed to, along with the qualified medication administration personnel (QMAP) supervisor, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Additionally, the residence failed to document and routinely include the audits as part of the residence's Quality Management Program assessment and review, affecting one of five sample residents (#5). (Cross-reference Q1468)Findings include:1. Residence PolicyThe residence's Medication Records policy, dated 6/18/21, read in part: "The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's quality management program assessment and review." 2. Record ReviewOn 2/14/23 at 7:00 a.m., documentation of the quarterly medication audits from the two quarters prior to the date of the onsite visit was requested. Documentation, titled Cart Audits, were provided. Each document was dated as follows: 10/20/22, 10/27/22, 11/10/22, 11/22/22, 12/7/22, 12/21/22, 12/28/22, 1/4/23, 1/11/23, 1/18/23, and 2/2/23. Each document included a checklist as follows:Eye drops?Creams/Ointments?Powders?Narcotics?Routine Medications?Expired and discontinued medications removed?Cart stocked with supplies?Refill request sent to pharmacy?The residence provided no documentation that the administrator participated in any of the above audits. The residence provided no evidence that the administrator and the QMAP supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. 3. InterviewsOn 2/14/23 at 3:36 p.m., the director of health services (DHS) stated that she was the QMAP supervisor. She stated she and one or two QMAPs completed weekly medication cart audits; however, she added the administrator had not participated in a medication audit with her since she started in the position in October 2022. On 2/14/23 at 4;20 p.m., the administrator stated she did not participate in any medication audits, adding that she was unaware of the requirement that the administrator participate in quarterly medication audits. She stated the residence's preferred pharmacy and a nurse consultant group each completed regular medication audits at the residence in addition to the weekly audits completed by the DHS and the QMAPs.

Based on observation and interview, the residence failed to ensure exterior grounds were kept free of rubbish, affecting 22 residents with access to the west courtyard. Findings include:On 2/14/23 at approximately 2:00 p.m., an environmental tour of the residence's external environment revealed an area between the asphalt and the residence's exterior courtyard, which ran the length of the residence building, contained approximately 75 cigarette butts. The area immediately adjacent to the smoking area had two piles of cigarette butts on the ground, cigarette butts among the rocks next to the designated smoking area, and cigarette butts on the ground all around the designated smoking area. On 2/14/23 at 3:28 p.m., the director of health services stated the maintenance team tried to clean up the cigarette butts twice weekly. She said there are two residents who smoke at the residence. She stated that although there were cigarette receptacles in the designated smoking area, one of the residents had a habit of not using it and throwing the cigarette butts on the ground. On 2/14/23 at 4:20 pm., the administrator stated the residence tried to clean up the cigarette butts twice weekly. She said that the maintenance team did daily rounds, and the maintenance director should have made sure that all grounds were maintained. The administrator stated she had not visited the courtyard recently and was unaware that so many cigarette butts littered the ground. She acknowledged the staff should have ensured that residents extinguished and disposed of cigarettes properly.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised they must review and maintain the following processes in accordance with existing Assisted Living Residences program regulations: 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (C) Personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or on-going monitoring and possible re-assessment. 14.15 The assisted living residence shall ensure each resident's right to privacy and dignity with respect to medication monitoring and administration.