RESIDENCE AT SKYWAY PARK LLC, THE

A complaint revisit was completed on 11/28/25 for the previous deficiency cited on 6/3/25. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25. The deficiency cited for Event OPK813 was cited prior to the regulation revisions that were implemented on 7/1/25.

Based on record review and interview, the residence failed to ensure that each qualified medication administration person (QMAP) accurately documented each medication administration event at the time the event was completed for each resident, affecting 48 current residents. This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. 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 #29 was admitted to the residence on 7/19/15. On 11/18/25 at approximately 8:00 a.m., the medication administration record (MAR) for Resident #29 was signed off as administered by Staff #5; however, Staff #5 was in the process of dispensing medications to administer to Resident #29. The MAR was incorrectly signed off prior to dispensing the medications. a. Interviews On 11/18/25 at 8:15 a.m., staff #5 stated she had initialed all resident MARs as administered prior to dispensing any medications. She stated if a resident did not receive their medication, she would circle her initials and write a note on the back of the MAR explaining why the medication was not administered. On 11/18/25 at 3:15 p.m., the administrator stated he expected staff to only initial the residents' MAR after the medications were administered and acknowledged that signing all resident MARs prior to administering medications contributed to an inaccurate MAR.b. Similar deficient practice was found for Residents #27-#30, whose MARs had also been signed off as administered; however, their medications were not yet administered. 2. Resident #3 was admitted to the residence on 9/3/15 with diagnoses including chronic pain syndrome, lower back pain, depression, hyperlipidemia, and hypertension. A practitioner's order, dated 9/27/25, directed the residence to administer the following medications:Incruse Elpt 62.5 mcg one puff dailyMulti-Vitamin one tablet dailyPantoprazole 20 mg one tablet dailyClopidrogel 75 mg one tablet daily Citalopram 10 mg one tablet dailySimvastatin 80 mg one tablet every eveningMorphine 30 mg one tablet every 12 hrsSerevent Diskus one puff twice daily (BID)Senna 8.6-50 mg two tablets BIDThe October 2025 MAR for resident #3 revealed the QMAP failed to document the medication administration event on 10/23/25. Additionally, the November 2025 MAR revealed the QMAP failed to document the medication administration event on 11/1/25 and 11/17/25 for the simvastatin, morphine, and Senna. a. Interviews On 11/18/25 at 3:52 p.m., the RCC stated that the QMAPs were expected to document all medication administrations at the time of the event, and was unaware that this was still happening. On 11/18/25 at 3:52 p.m., the administrator confirmed the RCC's statement.b. Similar deficient practice was found for Residents #4, #23, #27, and #31.

A licensure complaint, prompted by #CO41082 was completed on 11/18/25. Deficiencies were cited.

Based on observations and interviews, the residence failed to make available a physically safe and sanitary environment, affecting seven of nine sample residents. (#14, #23, #29, #30, #32, #33, #34)Findings Include:On 11/18/25 at 2:40 p.m., during an environmental review of Resident #30 and Resident #32 ' s room, there were three black trash bags on the ground in the living room area. On one of the trash bags there was a note that read, "Please put in the dryer, do not take back to the room". There was no furniture in the living room. To the left of the door, there was a three drawer caddie which contained personal protective equipment. On 11/18/25 at approximately 2:50 p.m., an invoice from a pest control company dated 11/17/25 read in part, treatment for bedbug activity, all furniture, any open bagged items, and laundry room. Resident #23 was admitted to the residence on 3/5/25 with diagnosis of Schizophrenia. On 11/18/25 at approximately 12:45 p.m., during an environmental review of Resident #28's room, there were old stains on the carpet, a dripping liquid stain in the kitchen wall, the trash had not been removed, and there was a foul odor within the room. On 11/18/25 at approximately 3:00 p.m., the administrator stated Resident #30 and Resident #32 ' s room had been treated for bed bugs, and it should have been cleaned. He stated he expected all resident rooms to be cleaned and sanitized. Similar deficient practice was found with Resident #14, #29, #33, and #34.

Based on records review and interviews, the residence failed to comply with authorized practitioner orders for three of five sample residents (#4, #23, and #27) with medication compliance issues found. (Cross-reference U1530)Findings Include:Resident #27 was admitted to the residence on 11/1/15 with diagnoses of chronic obstructive pulmonary disease (COPD), insomnia, constipation, seizures, hypokalemia and autonomic neuropathy. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 two inhalations of tiotropium, an 18mcg cap by mouth daily every evening for COPD. The October medication administration record (MAR) indicated the medication was unavailable and "on order" from 10/8/25 fo 10/21/25. The November MAR also listed no signatures that signed off the medications were given on 11/16/25. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 100mg docusate sodium capsule in the morning and two capsules at bedtime for constipation. The October MAR indicated the medication was unavailable and "on order" on 10/3/25. The November MAR also listed no signatures that signed off the medications were given from 11/2-11/4/25. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 88mcg levothyroxine tablet in the morning, "take 30-60 minutes before food," for thyroid. The November MAR also listed no signatures that signed off the medications were given on 11/16/25. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 10mg tablet of potassium citrate twice a day for hypokalemia. The November MAR also listed no signatures that signed off the medications were given on 11/16/25. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 two 300 mg tablets of gabapentin daily at bedtime for autonomic neuropathy. The November MAR also listed no signatures that signed off the medications were given on 11/16/25. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 300mg tablet of lamotrigine daily for seizure prevention. The November MAR also listed no signatures that signed off the medications were given on 11/16/25. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 40mg tablet of simvastatin by mouth daily at bedtime for cholesterol. The November MAR also listed no signatures that signed off the medications were given on 11/16/25. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 150mg tablet of trazodone by mouth daily at bedtime for insomnia. The November MAR also listed no signatures that signed off the medications were given on 11/16/25. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 12mg tablet of austedo daily for tardive dyskinesia. The November MAR also listed no signatures that signed off the medications were given on 11/16/25. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 5mg tablet of medroxyprogesterone acetate daily at bedtime for uterine bleeding. The November MAR also listed no signatures that signed off the medications were given on 11/16/25. On 11/18/25 at approximately 3:30 p.m., the administrator admitted he was aware that the residence was not compliant with this citation prior to that date. The administrator added that he and the resident service coordinator (RCC) had attempted to educate staff several times and that compliance was still 'a work in progress.' The administrator also added that he was unaware of the specific reasons why Resident #27 did not receive her medication but did confirm that the residence expected staff to comply with practitioners' orders and would continue to work with staff about it. On 11/18/25 at 3:48 p.m., the RCC ultimately agreed that the residence failure to have the medications the practitioners orders required them to have on-site was a failure to comply with their orders. Similar deficient practice was found for Residents #5 and #23 related to missed doses of medications or not documented to indicate if medication was given.

Based on record review and interview, the residence failed to ensure that each qualified medication administration person (QMAP) accurately documented each medication administration event at the time the event was completed for each resident, affecting 48 current residents. Findings include:1. Resident #29 was admitted to the residence on 7/19/15. On 11/18/25 at approximately 8:00 a.m., the medication administration record (MAR) for Resident #29 was signed off as administered by Staff #5; however, Staff #5 was in the process of dispensing medications to administer to Resident #29. The MAR was incorrectly signed off prior to dispensing the medications. a. Interviews On 11/18/25 at 8:15 a.m., staff #5 stated she had initialed all resident MARs as administered prior to dispensing any medications. She stated if a resident did not receive their medication, she would circle her initials and write a note on the back of the MAR explaining why the medication was not administered. On 11/18/25 at 3:15 p.m., the administrator stated he expected staff to only initial the residents' MAR after the medications were administered and acknowledged that signing all resident MARs prior to administering medications contributed to an inaccurate MAR.b. Similar deficient practice was found for Residents #27-#30, whose MARs had also been signed off as administered; however, their medications were not yet administered. 2. Resident #3 was admitted to the residence on 9/3/15 with diagnoses including chronic pain syndrome, lower back pain, depression, hyperlipidemia, and hypertension. A practitioner's order, dated 9/27/25, directed the residence to administer the following medications:Incruse Elpt 62.5 mcg one puff dailyMulti-Vitamin one tablet dailyPantoprazole 20 mg one tablet dailyClopidrogel 75 mg one tablet daily Citalopram 10 mg one tablet dailySimvastatin 80 mg one tablet every eveningMorphine 30 mg one tablet every 12 hrsSerevent Diskus one puff twice daily (BID)Senna 8.6-50 mg two tablets BIDThe October 2025 MAR for resident #3 revealed the QMAP failed to document the medication administration event on 10/23/25. Additionally, the November 2025 MAR revealed the QMAP failed to document the medication administration event on 11/1/25 and 11/17/25 for the simvastatin, morphine, and Senna. a. Interviews On 11/18/25 at 3:52 p.m., the RCC stated that the QMAPs were expected to document all medication administrations at the time of the event, and was unaware that this was still happening. On 11/18/25 at 3:52 p.m., the administrator confirmed the RCC's statement.b. Similar deficient practice was found for Residents #4, #23, #27, and #31.

Based on record review and interview, the residence failed to ensure staff documented, before the end of their shift, any out-of-the-ordinary event or issue regarding a resident that they personally observed, or was reported to them, affecting four of six residents whose environment was viewed. (#14, #23, #28, #30)Findings include:On 11/18/25 at 2:40 p.m., during an environmental review of Resident #30 and Resident #32 ' s room, there were three black trash bags on the ground in the living room area. On one of the trash bags, there was a note that read, "Please put in the dryer, do not take it back to the room". There was no furniture in the living room. To the left of the door, there was a three-drawer caddie that contained personal protective equipment. On 11/18/25 at approximately 2:50 p.m., an invoice from a pest control company dated 11/17/25 read in part, treatment for bedbug activity, all furniture, any open bagged items, and laundry room. On 11/18/25 at approximately 10:00 a.m., progress notes were requested for Resident #30 and Resident #32; however, no progress notes were provided. On 11/18/25 at approximately 3:00 p.m., the administrator stated Resident #30 and Resident #32 ' s room had been treated for bed bugs, and it should have been cleaned. The administrator stated bed bugs were an out-of-ordinary event; however, staff did not document the finding of bed bugs in the resident's chart. He further stated that staff did not create progress notes for any residents when an out-of-ordinary event occurred.

A complaint revisit was completed on 11/18/25 for all previous deficiencies cited on 6/23/25. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event QV0812 were cited prior to the regulation revision that was implemented on 7/1/25.

A complaint revisit was completed on 11/18/25 for all previous deficiencies cited on 6/3/25. Deficiencies were cited. The deficiency cited for Event KBZV11 was cited prior to the regulation revision that was implemented 9/30/25.

Based on interview and record review, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription and non-prescription medications, affecting five of nine sample residents (#3, #4, #23, #27, and #31). This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Administration of medications without authorized practitioner's orders.a. Resident #31 was admitted to the residence on 2/2/21. The August 2025 and September 2025 medication administration records (MAR) had the following medications listed and were being administered with no signed and dated practitioners' orders on file: ferrous gluconate, preserVision, and tamsulosin HCl.b. Similar deficient practice was found for Resident #3. Additionally, Resident #3's MAR did not match the signed and dated practitioner orders provided.c. InterviewOn 9/16/25 at 1:06 p.m., the resident care coordinator acknowledged they did not have all the practitioners' orders for the medications being administered by the residence. He explained that the residence received the medication orders from the practitioner, and what was listed on the MAR was correct. He stated he was unsure why they had missing orders for the medications being administered or why the MAR had not matched the practitioner's orders provided specifically for Resident #3. He stated he would expect the MAR to match the practitioner's order and to have all the practitioner's orders for medications being administered. On 9/16/25 at 3:16 p.m., the administrator explained that the residence received practitioners' orders from the practitioners, the residents had their medication list signed by the practitioner when they had a practitioner's appointment, or the residence received a signed medication list from the practitioner quarterly. The administrator stated she was aware the residence did not have all the practitioners' orders signed and dated, and would expect to have them. 2. Failure to comply with authorized practitioner's ordersa. Resident #27 was admitted to the residence on 11/1/15 with diagnoses of chronic obstructive pulmonary disease (COPD), insomnia, constipation, seizures, hypokalemia and autonomic neuropathy. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 two inhalations of tiotropium, an 18mcg cap by mouth daily every evening for COPD.A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 100mg docusate sodium capsule in the morning and two capsules at bedtime for constipation. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 88mcg levothyroxine tablet in the morning, "take 30-60 minutes before food," for thyroid. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 10mg tablet of potassium citrate twice a day for hypokalemia. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 two 300 mg tablets of gabapentin daily at bedtime for autonomic neuropathy. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 300mg tablet of lamotrigine daily for seizure prevention. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 40mg tablet of simvastatin by mouth daily at bedtime for cholesterol. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 150mg tablet of trazodone by mouth daily at bedtime for insomnia. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 12mg tablet of austedo daily for tardive dyskinesia. A practitioner's order, dated 9/22/25, directed the residence to administer toResident #27 one 5mg tablet of medroxyprogesterone acetate daily at bedtime for uterine bleeding. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 600mg tablet of oxcarbazepine every 12 hours for seizures. The October 2025 medication administration record (MAR) indicated that Resident #27 did not receive the following medications on the listed dates because the medication was unavailable and "on order":Tiotropium - two inhalations by mouth, from 10/8/25 to 10/21/25. Docusate sodium- 100mg on 10/3/25. The November 2025 MAR did not indicate that Resident #27 received the following medication on the listed dates with no note or explanation included:Docusate sodium 100mg on 11/2-11/4. Tiotropium two inhalations by mouth, on 11/16. Levothyroxine 88mcg on 11/16. Potassium citrate 10mg on 11/16. Gabapentin 300mg on 11/16. Lamotrigine 300mg on 11/16. Simvastatin 40mg on 11/16. Trazadone 150mg on 11/16. Austedo 12mg on 11/16. Medroxyprogesterone acetate 5mg on 11/16. b. Interviews On 11/18/25 at approximately 3:30 p.m., the administrator admitted he was aware that the residence was not compliant with this citation prior to that date. The administrator added that he and the resident service coordinator (RCC) had attempted to educate staff several times and that compliance was still 'a work in progress.' The administrator also added that he was unaware of the specific reasons why Resident #27 did not receive her medication but did confirm that the residence expected staff to comply with practitioners' orders and would continue to work with staff about it. On 11/18/25 at 3:48 p.m., the RCC agreed that the residence's failure to have the medications the practitioners orders required them to have on-site was a failure to comply with their orders. c. Similar deficient practice was found for Residents #5 and #23 related to missed doses of medications or not documented to indicate if medication was given. 3. Inaccurate documentation on Medication Administration Record (MAR).a. Resident #29 was admitted to the residence on 7/19/15. On 11/18/25 at approximately 8:00 a.m., the medication administration record (MAR) for Resident #29 was signed off as administered by Staff #5; however, Staff #5 was in the process of dispensing medications to administer to Resident #29. The MAR was incorrectly signed off prior to dispensing the medications. b. Interviews On 11/18/25 at 8:15 a.m., staff #5 stated she had initialed all resident MARs as administered prior to dispensing any medications. She stated that if a resident did not receive their medication, she would circle her initials and write a note on the back of the MAR explaining why the medication was not administered. On 11/18/25 at 3:15 p.m., the administrator stated he expected staff to only initial the residents' MAR after the medications were administered and acknowledged that signing all resident MARs prior to administering medications contributed to an inaccurate MAR.c. Similar deficient practice was found for Residents #34-#37, whose MARs had also been signed off as administered; however, their medications were not yet administered.d. Resident #3 was admitted to the residence on 9/3/15 with diagnoses including chronic pain syndrome, lower back pain, depression, hyperlipidemia, and hypertension. A practitioner's order, dated 9/27/25, directed the residence to administer the following medications:Incruse Elpt 62.5 mcg one puff dailyMulti-Vitamin one tablet dailyPantoprazole 20 mg one tablet dailyClopidrogel 75 mg one tablet daily Citalopram 10 mg one tablet dailySimvastatin 80 mg one tablet every eveningMorphine 30 mg one tablet every 12 hrsSerevent Diskus one puff twice daily (BID)Senna 8.6-50 mg two tablets BIDThe October 2025 MAR for resident #3 revealed the QMAP failed to document the medication administration event on 10/23/25. Additionally, the November 2025 MAR revealed the QMAP failed to document the medication administration event on 11/1/25 and 11/17/25 for the simvastatin, morphine, and Senna. e. Interviews On 11/18/25 at 3:52 p.m., the RCC stated that the QMAPs were expected to document all medication administrations at the time of the event, and was unaware that this was still happening. On 11/18/25 at 3:52 p.m., the administrator confirmed the RCC's statement.f. Similar deficient practice was found for Residents #4, #23, #27, and #31.

Based on record review and interview, the facility (residence) failed to meet minimum staffing numbers, affecting 49 current members (residents). This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Record Review The staff schedule for October and November 2025 revealed that there were fewer than one staff for every 16 members during the overnight shift for the following dates: 10/1/25-10/31/25 from 10:00 p.m. to 6:00 a.m. 11/1/25-11/18/25 from 10:00 p.m. to 6:00 a.m. 2. Interviews On 11/18/25 at 3:42 p.m., the administrator stated he was not aware of the staffing ratio regulation. On 11/18/25 at 3:55 p.m., the resident care coordinator stated she was not aware of the staffing ratio regulation and thought the residence only needed a certain number of staff based on resident needs.

A certification complaint, prompted by #CO41081 was completed on 11/18/25. Deficiencies were cited.

Based on interview and record review, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription and non-prescription medications, affecting five of nine sample residents (#3, #4, #23, #27, and #31). This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Administration of medications without authorized practitioner's orders.a. Resident #31 was admitted to the residence on 2/2/21. The August 2025 and September 2025 medication administration records (MAR) had the following medications listed and were being administered with no signed and dated practitioners' orders on file: ferrous gluconate, preserVision, and tamsulosin HCl.b. Similar deficient practice was found for Resident #3. Additionally, Resident #3's MAR did not match the signed and dated practitioner orders provided.c. InterviewOn 9/16/25 at 1:06 p.m., the resident care coordinator acknowledged they did not have all the practitioners' orders for the medications being administered by the residence. He explained that the residence received the medication orders from the practitioner, and what was listed on the MAR was correct. He stated he was unsure why they had missing orders for the medications being administered or why the MAR had not matched the practitioner's orders provided specifically for Resident #3. He stated he would expect the MAR to match the practitioner's order and to have all the practitioner's orders for medications being administered. On 9/16/25 at 3:16 p.m., the administrator explained that the residence received practitioners' orders from the practitioners, the residents had their medication list signed by the practitioner when they had a practitioner's appointment, or the residence received a signed medication list from the practitioner quarterly. The administrator stated she was aware the residence did not have all the practitioners' orders signed and dated, and would expect to have them. 2. Failure to comply with authorized practitioner's ordersa. Resident #27 was admitted to the residence on 11/1/15 with diagnoses of chronic obstructive pulmonary disease (COPD), insomnia, constipation, seizures, hypokalemia and autonomic neuropathy. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 two inhalations of tiotropium, an 18mcg cap by mouth daily every evening for COPD.A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 100mg docusate sodium capsule in the morning and two capsules at bedtime for constipation. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 88mcg levothyroxine tablet in the morning, "take 30-60 minutes before food," for thyroid. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 10mg tablet of potassium citrate twice a day for hypokalemia. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 two 300 mg tablets of gabapentin daily at bedtime for autonomic neuropathy. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 300mg tablet of lamotrigine daily for seizure prevention. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 40mg tablet of simvastatin by mouth daily at bedtime for cholesterol. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 150mg tablet of trazodone by mouth daily at bedtime for insomnia. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 12mg tablet of austedo daily for tardive dyskinesia. A practitioner's order, dated 9/22/25, directed the residence to administer toResident #27 one 5mg tablet of medroxyprogesterone acetate daily at bedtime for uterine bleeding. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 600mg tablet of oxcarbazepine every 12 hours for seizures. The October 2025 medication administration record (MAR) indicated that Resident #27 did not receive the following medications on the listed dates because the medication was unavailable and "on order":Tiotropium - two inhalations by mouth, from 10/8/25 to 10/21/25. Docusate sodium- 100mg on 10/3/25. The November 2025 MAR did not indicate that Resident #27 received the following medication on the listed dates with no note or explanation included:Docusate sodium 100mg on 11/2-11/4. Tiotropium two inhalations by mouth, on 11/16. Levothyroxine 88mcg on 11/16. Potassium citrate 10mg on 11/16. Gabapentin 300mg on 11/16. Lamotrigine 300mg on 11/16. Simvastatin 40mg on 11/16. Trazadone 150mg on 11/16. Austedo 12mg on 11/16. Medroxyprogesterone acetate 5mg on 11/16. b. Interviews On 11/18/25 at approximately 3:30 p.m., the administrator admitted he was aware that the residence was not compliant with this citation prior to that date. The administrator added that he and the resident service coordinator (RCC) had attempted to educate staff several times and that compliance was still 'a work in progress.' The administrator also added that he was unaware of the specific reasons why Resident #27 did not receive her medication but did confirm that the residence expected staff to comply with practitioners' orders and would continue to work with staff about it. On 11/18/25 at 3:48 p.m., the RCC ultimately agreed that the residence failure to have the medications the practitioners orders required them to have on-site was a failure to comply with their orders. c. Similar deficient practice was found for Residents #5 and #23 related to missed doses of medications or not documented to indicate if medication was given. 3. Inaccurate documentation on Medication Administration Record (MAR).a. Resident #29 was admitted to the residence on 7/19/15. On 11/18/25 at approximately 8:00 a.m., the medication administration record (MAR) for Resident #29 was signed off as administered by Staff #5; however, Staff #5 was in the process of dispensing medications to administer to Resident #29. The MAR was incorrectly signed off prior to dispensing the medications. b. Interviews On 11/18/25 at 8:15 a.m., staff #5 stated she had initialed all resident MARs as administered prior to dispensing any medications. She stated if a resident did not receive their medication, she would circle her initials and write a note on the back of the MAR explaining why the medication was not administered. On 11/18/25 at 3:15 p.m., the administrator stated he expected staff to only initial the residents MAR after the medications were administered and acknowledged that signing all resident MARs prior to administering medications contributed to an inaccurate MAR.c. Similar deficient practice was found for Residents #34-#37 whose MARs had also been signed off as administered; however, their medications were not yet administered.d. Resident #3 was admitted to the residence on 9/3/15 with diagnoses including chronic pain syndrome, lower back pain, depression, hyperlipidemia, and hypertension. A practitioner's order, dated 9/27/25, directed the residence to administer the following medications:Incruse Elpt 62.5 mcg one puff dailyMulti-Vitamin one tablet dailyPantoprazole 20 mg one tablet dailyClopidrogel 75 mg one tablet daily Citalopram 10 mg one tablet dailySimvastatin 80 mg one tablet every eveningMorphine 30 mg one tablet every 12 hrsSerevent Diskus one puff twice daily (BID)Senna 8.6-50 mg two tablets BIDThe October 2025 MAR for resident #3 revealed the QMAP failed to document the medication administration event on 10/23/25. Additionally, the November 2025 MAR revealed the QMAP failed to document the medication administration event on 11/1/25 and 11/17/25 for the simvastatin, morphine, and Senna. e. Interviews On 11/18/25 at 3:52 p.m., the RCC stated that the QMAPs were expected to document all medication administrations at the time of the event, and was unaware that this was still happening. On 11/18/25 at 3:52 p.m., the administrator confirmed the RCC's statement.f. Similar deficient practice was found for Residents #4, #23, #27, and #31.

Based on record review and interview, the facility (residence) failed to meet minimum staffing numbers affecting 49 current members (residents). Findings include: 1. Record Review The staff schedule for October and November 2025 revealed that there were fewer than one staff member for every 16 members during the overnight shift for the following dates: 10/1/25-10/31/25 from 10:00 p.m. to 6:00 a.m. 11/1/25-11/18/25 from 10:00 p.m. to 6:00 a.m. 2. Interviews On 11/18/25 at 3:42 p.m., the administrator stated he was not aware of the staffing ratio regulation. On 11/18/25 at 3:55 p.m., the resident care coordinator stated she was not aware of the staffing ratio regulation and thought the residence only needed a certain number of staff based on resident needs.

A complaint revisit was completed on 11/18/25 for the previous deficiency cited on 6/3/25. A deficiency was cited. The deficiency cited for Event J5OT13 was cited prior to the regulation revision that was implemented 9/30/25.

Based on interview and record review, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription and non-prescription medications, affecting five of nine sample residents (#3, #4, #23, #27, and #31). This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Administration of medications without authorized practitioner's orders.a. Resident #31 was admitted to the residence on 2/2/21. The August 2025 and September 2025 medication administration records (MAR) had the following medications listed and were being administered with no signed and dated practitioners' orders on file: ferrous gluconate, preserVision, and tamsulosin HCl.b. Similar deficient practice was found for Resident #3. Additionally, Resident #3's MAR did not match the signed and dated practitioner orders provided.c. InterviewOn 9/16/25 at 1:06 p.m., the resident care coordinator acknowledged they did not have all the practitioners' orders for the medications being administered by the residence. He explained that the residence received the medication orders from the practitioner, and what was listed on the MAR was correct. He stated he was unsure why they had missing orders for the medications being administered or why the MAR had not matched the practitioner's orders provided specifically for Resident #3. He stated he would expect the MAR to match the practitioner's order and to have all the practitioner's orders for medications being administered. On 9/16/25 at 3:16 p.m., the administrator explained that the residence received practitioners' orders from the practitioners, the residents had their medication list signed by the practitioner when they had a practitioner's appointment, or the residence received a signed medication list from the practitioner quarterly. The administrator stated she was aware the residence did not have all the practitioners' orders signed and dated, and would expect to have them. 2. Failure to comply with authorized practitioner's ordersa. Resident #27 was admitted to the residence on 11/1/15 with diagnoses of chronic obstructive pulmonary disease (COPD), insomnia, constipation, seizures, hypokalemia and autonomic neuropathy. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 two inhalations of tiotropium, an 18mcg cap by mouth daily every evening for COPD.A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 100mg docusate sodium capsule in the morning and two capsules at bedtime for constipation. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 88mcg levothyroxine tablet in the morning, "take 30-60 minutes before food," for thyroid. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 10mg tablet of potassium citrate twice a day for hypokalemia. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 two 300 mg tablets of gabapentin daily at bedtime for autonomic neuropathy. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 300mg tablet of lamotrigine daily for seizure prevention. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 40mg tablet of simvastatin by mouth daily at bedtime for cholesterol. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 150mg tablet of trazodone by mouth daily at bedtime for insomnia. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 12mg tablet of austedo daily for tardive dyskinesia. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 5mg tablet of medroxyprogesterone acetate daily at bedtime for uterine bleeding. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 600mg tablet of oxcarbazepine every 12 hours for seizures. The October 2025 medication administration record (MAR) indicated that Resident #27 did not receive the following medications on the listed dates because the medication was unavailable and "on order":Tiotropium - two inhalations by mouth, from 10/8/25 to 10/21/25. Docusate sodium- 100mg on 10/3/25. The November 2025 MAR did not indicate that Resident #27 received the following medication on the listed dates with no note or explanation included:Docusate sodium 100mg on 11/2-11/4. Tiotropium two inhalations by mouth, on 11/16. Levothyroxine 88mcg on 11/16. Potassium citrate 10mg on 11/16. Gabapentin 300mg on 11/16. Lamotrigine 300mg on 11/16. Simvastatin 40mg on 11/16. Trazadone 150mg on 11/16. Austedo 12mg on 11/16. Medroxyprogesterone acetate 5mg on 11/16. b. Interviews On 11/18/25 at approximately 3:30 p.m., the administrator admitted he was aware that the residence was not compliant with this citation prior to that date. The administrator added that he and the resident service coordinator (RCC) had attempted to educate staff several times and that compliance was still 'a work in progress.' The administrator also added that he was unaware of the specific reasons why Resident #27 did not receive her medication but did confirm that the residence expected staff to comply with practitioners' orders and would continue to work with staff about it. On 11/18/25 at 3:48 p.m., the RCC ultimately agreed that the residence failure to have the medications the practitioners orders required them to have on-site was a failure to comply with their orders. c. Similar deficient practice was found for Residents #5 and #23 related to missed doses of medications or not documented to indicate if medication was given. 3. Inaccurate documentation on Medication Administration Record (MAR).a. Resident #29 was admitted to the residence on 7/19/15. On 11/18/25 at approximately 8:00 a.m., the medication administration record (MAR) for Resident #29 was signed off as administered by Staff #5; however, Staff #5 was in the process of dispensing medications to administer to Resident #29. The MAR was incorrectly signed off prior to dispensing the medications. b. Interviews On 11/18/25 at 8:15 a.m., staff #5 stated she had initialed all resident MARs as administered prior to dispensing any medications. She stated if a resident did not receive their medication, she would circle her initials and write a note on the back of the MAR explaining why the medication was not administered. On 11/18/25 at 3:15 p.m., the administrator stated he expected staff to only initial the residents MAR after the medications were administered and acknowledged that signing all resident MARs prior to administering medications contributed to an inaccurate MAR.c. Similar deficient practice was found for Residents #34-#37 whose MARs had also been signed off as administered; however, their medications were not yet administered.d. Resident #3 was admitted to the residence on 9/3/15 with diagnoses including chronic pain syndrome, lower back pain, depression, hyperlipidemia, and hypertension. A practitioner's order, dated 9/27/25, directed the residence to administer the following medications:Incruse Elpt 62.5 mcg one puff dailyMulti-Vitamin one tablet dailyPantoprazole 20 mg one tablet dailyClopidrogel 75 mg one tablet daily Citalopram 10 mg one tablet dailySimvastatin 80 mg one tablet every eveningMorphine 30 mg one tablet every 12 hrsSerevent Diskus one puff twice daily (BID)Senna 8.6-50 mg two tablets BIDThe October 2025 MAR for resident #3 revealed the QMAP failed to document the medication administration event on 10/23/25. Additionally, the November 2025 MAR revealed the QMAP failed to document the medication administration event on 11/1/25 and 11/17/25 for the simvastatin, morphine, and Senna. e. Interviews On 11/18/25 at 3:52 p.m., the RCC stated that the QMAPs were expected to document all medication administrations at the time of the event, and was unaware that this was still happening. On 11/18/25 at 3:52 p.m., the administrator confirmed the RCC's statement.f. Similar deficient practice was found for Residents #4, #23, #27, and #31.

A complaint revisit was completed on 11/18/25 for all previous deficiencies cited on 6/3/25. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/25. The deficiencies cited for Event 8BP412 were cited prior to the regulation revisions that were implemented on 7/1/25.

Based on record review and interview the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting three of five sample residents (#29-#31). (Cross Reference U1568)This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. 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 #31 was admitted to the residence on 2/2/21. The October 2025 and November 2025 medication administration records (MAR) had the following medications listed and were being administered with no signed and dated practitioners' orders on file: clopidogrel, oxybutynin, losartan, rosuvastatin, naproxen, zofran, and voltaren gel. 2. Similar deficient practice was found for Resident #29 and #30 as it relates to the residence failure to have authorized practitioner orders for the medications being given to the residents. 3. InterviewOn 11/18/25 at 3:48 p.m., the resident service coordinator confirmed that the practitioners' orders for Resident #31 was not given during the onsite visit.

Based on records review and interviews, the residence failed to comply with authorized practitioner orders for three of five sample residents (#4, #23, and #27) with medication compliance issues found. This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings Include:Resident #27 was admitted to the residence on 11/1/15 with diagnoses of chronic obstructive pulmonary disease (COPD), insomnia, constipation, seizures, hypokalemia and autonomic neuropathy. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 two inhalations of tiotropium, an 18mcg cap by mouth daily every evening for COPD.A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 100mg docusate sodium capsule in the morning and two capsules at bedtime for constipation. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 88mcg levothyroxine tablet in the morning, "take 30-60 minutes before food," for thyroid. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 10mg tablet of potassium citrate twice a day for hypokalemia. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 two 300 mg tablets of gabapentin daily at bedtime for autonomic neuropathy. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 300mg tablet of lamotrigine daily for seizure prevention. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 40mg tablet of simvastatin by mouth daily at bedtime for cholesterol. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 a 150mg tablet of trazodone by mouth daily at bedtime for insomnia. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 12mg tablet of austedo daily for tardive dyskinesia. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 5mg tablet of medroxyprogesterone acetate daily at bedtime for uterine bleeding. A practitioner's order, dated 9/22/25, directed the residence to administer to Resident #27 one 600mg tablet of oxcarbazepine every 12 hours for seizures. The October 2025 medication administration record (MAR) indicated that Resident #27 did not receive the following medications on the listed dates because the medication was unavailable and "on order":Tiotropium - two inhalations by mouth, from 10/8/25 to 10/21/25. Docusate sodium- 100mg on 10/3/25. The November 2025 MAR did not indicate that Resident #27 received the following medication on the listed dates with no note or explanation included:Docusate sodium 100mg on 11/2-11/4. Tiotropium two inhalations by mouth, on 11/16. Levothyroxine 88mcg on 11/16. Potassium citrate 10mg on 11/16. Gabapentin 300mg on 11/16. Lamotrigine 300mg on 11/16. Simvastatin 40mg on 11/16. Trazadone 150mg on 11/16. Austedo 12mg on 11/16. Medroxyprogesterone acetate 5mg on 11/16. On 11/18/25 at approximately 3:30 p.m., the administrator admitted he was aware that the residence was not compliant with this citation prior to that date. The administrator added that he and the resident service coordinator (RCC) had attempted to educate staff several times and that compliance was still 'a work in progress.' The administrator also added that he was unaware of the specific reasons why Resident #27 did not receive her medication but did confirm that the residence expected staff to comply with practitioners' orders and would continue to work with staff about it. On 11/18/25 at 3:48 p.m., the RCC ultimately agreed that the residence failure to have the medications the practitioners orders required them to have on-site was a failure to comply with their orders. Similar deficient practice was found for Residents #5 and #23 related to missed doses of medications or not documented to indicate if medication was given.

Based on record review and interview, the residence failed to ensure that each qualified medication administration person (QMAP) accurately documented each medication administration event at the time the event was completed for each resident, affecting 48 current residents. This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. 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 #29 was admitted to the residence on 7/19/15. On 11/18/25 at approximately 8:00 a.m., the medication administration record (MAR) for Resident #29 was signed off as administered by Staff #5; however, Staff #5 was in the process of dispensing medications to administer to Resident #29. The MAR was incorrectly signed off prior to dispensing the medications. a. Interviews On 11/18/25 at 8:15 a.m., staff #5 stated she had initialed all resident MARs as administered prior to dispensing any medications. She stated if a resident did not receive their medication, she would circle her initials and write a note on the back of the MAR explaining why the medication was not administered. On 11/18/25 at 3:15 p.m., the administrator stated he expected staff to only initial the residents' MAR after the medications were administered and acknowledged that signing all resident MARs prior to administering medications contributed to an inaccurate MAR.b. Similar deficient practice was found for Residents #27-#30, whose MARs had also been signed off as administered; however, their medications were not yet administered. 2. Resident #3 was admitted to the residence on 9/3/15 with diagnoses including chronic pain syndrome, lower back pain, depression, hyperlipidemia, and hypertension. A practitioner's order, dated 9/27/25, directed the residence to administer the following medications:Incruse Elpt 62.5 mcg one puff dailyMulti-Vitamin one tablet dailyPantoprazole 20 mg one tablet dailyClopidrogel 75 mg one tablet daily Citalopram 10 mg one tablet dailySimvastatin 80 mg one tablet every eveningMorphine 30 mg one tablet every 12 hrsSerevent Diskus one puff twice daily (BID)Senna 8.6-50 mg two tablets BIDThe October 2025 MAR for resident #3 revealed the QMAP failed to document the medication administration event on 10/23/25. Additionally, the November 2025 MAR revealed the QMAP failed to document the medication administration event on 11/1/25 and 11/17/25 for the simvastatin, morphine, and Senna. a. Interviews On 11/18/25 at 3:52 p.m., the RCC stated that the QMAPs were expected to document all medication administrations at the time of the event, and was unaware that this was still happening. On 11/18/25 at 3:52 p.m., the administrator confirmed the RCC's statement.b. Similar deficient practice was found for Residents #4, #23, #27, and #31.

Based on record review and interview, the residence failed to ensure staff documented, before the end of their shift, any out-of-the-ordinary event or issue regarding a resident that they personally observed, or was reported to them, affecting four of six residents whose environment was viewed. (#14, #23, #28, #30)This deficiency was cited previously during a complaint investigation that concluded on 6/3/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 11/18/25 at 2:40 p.m., during an environmental review of Resident #30 and Resident #32 ' s room, there were three black trash bags on the ground in the living room area. On one of the trash bags, there was a note that read, "Please put in the dryer, do not take it back to the room". There was no furniture in the living room. To the left of the door, there was a three-drawer caddie that contained personal protective equipment. On 11/18/25 at approximately 2:50 p.m., an invoice from a pest control company dated 11/17/25 read in part, treatment for bedbug activity, all furniture, any open bagged items, and laundry room. On 11/18/25 at approximately 10:00 a.m., progress notes were requested for Resident #30 and Resident #32; however, no progress notes were provided. On 11/18/25 at approximately 3:00 p.m., the administrator stated Resident #30 and Resident #32 ' s room had been treated for bed bugs, and it should have been cleaned. The administrator stated bed bugs were an out-of-ordinary event; however, staff did not document the finding of bed bugs in the resident's chart. He further stated that staff did not create progress notes for any residents when an out-of-ordinary event occurred.

A certification complaint, prompted by #CO40349, #CO40351, #CO40396, was completed on 6/23/25. No deficiencies were cited.

A licensure complaint, prompted by #CO40346, #CO40350, #CO40395, was completed on 6/23/25. Deficiencies were cited.

Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting eight residents (#6, #9, #20-#25), whose medications were administered by (Staff #5, Staff #10). Findings include: On 6/17/25, from approximately 7:30 a.m. to 8:30 a.m., the following was observed during medication administration: Staff #10 prepared medications for Resident #9 and did not perform any hand hygiene. Staff #10 touched their keys, the medication cart handle, medication containers, and the medication administration record (MAR) book. Staff #10 dropped a total of four pills on the medication cart counter, picked the pills up with her bare hands, and then placed the pills in the medication cup. Staff #10 administered the medications to Resident #20 and did not perform hand hygiene before or after administering the medications. Additionally, Staff #10 administered eye drops to Resident #9 and did not perform hand hygiene or don gloves before administration. Staff #10 prepared medications for Resident #20 and did not perform any hand hygiene. Staff #10 touched their keys, the medication cart handle, medication containers, and the medication administration record (MAR) book. Staff #10 dropped a pill on the medication cart counter, picked the pill up with her bare hands, then placed it in the medication cup. Staff #10 administered the medications to Resident #20 and did not perform hand hygiene before or after administering the medications. Staff #10 prepared medications for Resident #21 and did not perform any hand hygiene. Staff #10 touched their keys, the medication cart handle, medication containers, and the medication administration record (MAR) book. Staff #10 dropped a pill on the medication cart counter, picked the pill up with her bare hands, then placed it in the medication cup. Staff #10 administered the medications to Resident #21 and did not perform hand hygiene before or after administering the medications. On 6/17/25 at approximately 8:00 a.m., Staff #5 stated that she was aware that she was required to wash or sanitize her hands before and after each medication pass. She added that she had forgotten to wash her hands before putting on the gloves. On 6/17/25 at 8:30 a.m., Staff #10 stated she was not aware she was required to wash or sanitize her hands before and after each medication pass. She stated she had not been trained on basic infection control; however, contrary to her statement, training records showed Staff #10 had indeed been trained on basic infection control. On 6/23/25 at 11:59 a.m., the administrator stated all staff, including agency staff, were trained on basic infection control prior to them being allowed on the floor and providing personal care services to the residents. She stated that Staff #10 was well aware of the infection control protocols and was unsure why the protocols had not been followed. Similar deficient practice occurred with Staff #5 while preparing and administering medications to Residents #6, and #22-#25.

Based on observation and interview, the residence failed to follow their policy and procedure in place regarding the destruction and disposal of unused medications, affecting one (#18) of six sample residents. Findings include:1. Residence Policya. The residence's Medication Destruction and Disposal Policy, dated 4/1/25, read in part "The assisted living residence follows the procedure below regarding the destruction and disposal of outdated, unused, discontinued and/or expired medications may be returned to the pharmacy if they are unopened and not expired, if they arenot controlled substances, and if the pharmacy agrees to accept them. The return of such medications to a pharmacy will also need to be documented using a Medication Destruction/Disposal Form. Completed Medication Destruction/Disposal Forms will be forwarded to the RCC."2. Record ReviewResident #18 was admitted to the residence on 2/28/25. A written practitioner's order, dated 3/18/25, directed the residence to administer antacid twice daily. 3. ObservationOn 6/17/25 at 7:38 a.m., during the medication administration observation, Staff #5 administered the scheduled antacid medication to Resident #18. Resident #18 refused the antacid medication. Staff #5 threw the antacid medication in a trash receptacle attached to the medication cart. 3. InterviewOn 6/17/25 at 10:30 a.m., Staff #5 acknowledged that she should have properly discarded the medication using the medication disposal tub and filled out the medication disposal form in the medication room. On 6/23/25 at 11:00 a.m., the administrator was unaware that Staff #5 threw the refused medication in the trash receptacle. She added that she expects the qualified medication administration persons (QMAPs) to follow the medication disposal policy.

A certification complaint prompted by #CO40091 and #CO40093 was completed on 6/3/25. Deficiencies were cited.

Based on record review and interview, the facility (residence) failed to complete timely reporting, recording, orreviewing of incidents, affecting seven of nine sample members (residents) ( #2, #6, #9, #10, #12,#13, #15). Findings include:Resident #13 was admitted to the residence on 1/25/21 with diagnoses including congestive heart failure (CHF). On 6/3/25 at approximately 8:00 a.m., Staff #5 was observed attempting to pass medication to Resident #13. Resident #13 was confused and scared and could not understand why the Staff #5 was attempting to do so. On 6/3/25 at approximately 8:45 a.m., Staff #4 stated Resident #13 had been more confused lately and her dementia seems to be increasing. On 6/3/25 at approximately 10:00 a.m., resident records were requested and reviewed for Resident #13. After review, the records revealed no progress notes for the resident. On 6/3/25 at 12:30 p.m., Staff #4 stated that the residence staff were not documenting progress notes in the provided binders and that there would not be any updates in the binders. On 6/3/25 at approximately 2:30 p.m., the administrator stated she expected the staff to be documenting out of the ordinary events in the residents progress notes. Similar deficient practice was found for Residents #2, #6, #9, #10, #12, #15.

Based on interview and record review, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription and non-prescription medications, affecting six of eight sample residents (#2, #10, #11, #12, #13, #15). Findings include:Resident #13 was admitted to the residence on 1/25/21 with diagnoses including congestive heart failure (CHF). A written practitioner's order, dated 3/20/25, directed the residence to administer the following medications: Calcium 600 D3 800 tab once daily Metoprolol 75 mg once dailyFurosemide 30 mg once dailyAspirin 81mg once dailyMyrbetriq 50 mg once daily Glucosamine Complex once daily Senna Plus 50 mg twice daily Acetaminophen 650 mg twice dailyPravastatin 20 mg once dailyTrelegy Ellipta inhale one buff 25 mg dailyHowever, the May and June medication administration records (MARs) for Resident #13 read the following medications had blank entries on the MAR. Calcium 600 D3 800 tab once daily 5/14, 5/19, 5/31, 6/1Metoprolol 75 mg once daily 5/14, 5/19, 5/31, 6/1 Furosemide 30 mg once daily 5/14, 5/19, 5/31, 6/1 Aspirin 81mg once daily 5/14, 5/19, 5/31, 6/1 Myrbetriq 50 mg once daily 5/14, 5/19, 5/31, 6/1 Glucosamine Complex once daily 5/14, 5/19, 5/31, 6/1 Senna Plus 50 mg twice daily 5/16pm, 5/17pm, 5/19am, 5/23pm, 5/24pm, 5/28pm, 5/29pm, 5/31am, 5/31pm, 6/1 Acetaminophen 650 mg twice daily 5/14am, 5/16pm, 5/17pm, 5/19am, 5/23pm, 5/24pm, 5/28pm, 5/29pm, 5/31am, 5/31pm, 6/1 Pravastatin 20 mg once daily 5/4, 5/5, 5/11, 5/12, 5/16, 5/17, 5/23, 5/24, 5/28, 5/29, 5/31, 6/1 Trelegy Ellipta inhale one buff 25 mg daily 5/13, 5/14, 5/15, 5/16, 5/18, 5/19, 5/21, 5/22, 5/23, 5/31, 6/1 On 6/3/25 at approximately 2:30 p.m., the administrator stated blank spaces on the MAR indicated that the medication was not administered. She also acknowledged Resident #13 not receiving cardiac medications could potentially cause problems to Resident #13's health. Similar deficient practice was found for Residents #2, #10, #11, #12, #15.

Based on record review and interview the facility (residence) failed to meet minimum staffing numbers affecting53 current residents. Findings Include:1. Record ReviewThe staff schedule for May 2025 revealed that there were less than one staff for every 10 members on day shift for the following dates: 5/2 from 2:00 p.m. to 10:00 p.m., 5/3-5/4 from 6:00 a.m. to 10:00 p.m., 5/11 from 6:00 a.m. to 10:00 p.m., 5/14 from 6:00 a.m. to 10:00 p.m., 5/17-5/20 from 6:00 a.m. to 10:00 p.m., 5/23 and 5/31 from 6:00 a.m. to 2:00 p.m., 5/20-5/25, 5/27, 5/29-5/31/25 from 2:00 p.m. to 10:00 p.m. The same document revealed that there were less than one staff for every 15 members on the following night shifts: 5/1- 5/3, 5/5,5/8-5/10, 5/12, and 5/16-5/31/25 from 10:00 p.m. to 6:00 a.m. The staff schedule for June 2025 revealed that there were less than one staff for every 10 members on day shift for the following dates: 6/1-6/9/25 from 6:00 a.m. to 10:00 p.m. The same document revealed that there were less than one staff for every 15 members on the following night shifts: 6/1-6/9/25. 2. InterviewOn 6/3/25 at approximately 2:30 p.m., the administrator stated that she was not aware of the staffing ratio regulation and that the residence did not adhere to twelve hour shift blocks

A complaint revisit was completed on 6/3/25 for all previous deficiencies cited on 3/26/25. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 3/17/25.

Based on record review and interview, the residence failed to ensure that each qualified medication administration person (QMAP) documented accurate information on the medication administration record (MAR) including any medication omissions, affecting three of eight sample residents (#6, #11, #14). (Cross-reference T1530, T1568, T1604, T1612, and T2230)This deficiency was cited previously during a complaint investigation on 3/26/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The May 2025 MAR for Resident #6 had a hand-written line drawn through each medication administration on dates 5/7/25 through 5/18/25. The QMAPs failed to document the medication omissions, along with the reasons for the omissions, on the MAR as required. On 6/3/25 at 12:55 p.m., Resident #16 (who shared a double-occupancy room with Resident #6) stated that Resident #6 was admitted at the hospital for the above time frame. On 6/3/25 at 2:30 p.m., the administrator stated that Resident #6 had herself admitted for a hospital stay during the above time frame. She acknowledged that the QMAPs drew the line to document that they did not administer the medications, but they did not document the reason on the back of the MAR. The administrator stated that she expected the QMAPs to have done so. Evidence revealed the residence additionally failed to accurately document medication administration in the MAR for Residents #11 and #14.

A complaint revisit was completed on 6/3/25 for all previous deficiencies cited on 3/26/25. A deficiency was cited.

Based on interview and record review, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription and non-prescription medications, affecting six of eight sample residents (#2, #10, #11, #12, #13, #15). This deficiency was cited previously during a complaint investigation on 3/26/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #13 was admitted to the residence on 1/25/21 with diagnoses including congestive heart failure (CHF). A written practitioner's order, dated 3/20/25, directed the residence to administer the following medications: Calcium 600 D3 800 tab once daily Metoprolol 75 mg once dailyFurosemide 30 mg once dailyAspirin 81mg once dailyMyrbetriq 50 mg once daily Glucosamine Complex once daily Senna Plus 50 mg twice daily Acetaminophen 650 mg twice dailyPravastatin 20 mg once dailyTrelegy Ellipta inhale one buff 25 mg dailyHowever, the May and June medication administration records (MARs) for Resident #13 read the following medications had blank entries on the MAR. Calcium 600 D3 800 tab once daily 5/14, 5/19, 5/31, 6/1Metoprolol 75 mg once daily 5/14, 5/19, 5/31, 6/1 Furosemide 30 mg once daily 5/14, 5/19, 5/31, 6/1 Aspirin 81mg once daily 5/14, 5/19, 5/31, 6/1 Myrbetriq 50 mg once daily 5/14, 5/19, 5/31, 6/1 Glucosamine Complex once daily 5/14, 5/19, 5/31, 6/1 Senna Plus 50 mg twice daily 5/16pm, 5/17pm, 5/19am, 5/23pm, 5/24pm, 5/28pm, 5/29pm, 5/31am, 5/31pm, 6/1 Acetaminophen 650 mg twice daily 5/14am, 5/16pm, 5/17pm, 5/19am, 5/23pm, 5/24pm, 5/28pm, 5/29pm, 5/31am, 5/31pm, 6/1 Pravastatin 20 mg once daily 5/4, 5/5, 5/11, 5/12, 5/16, 5/17, 5/23, 5/24, 5/28, 5/29, 5/31, 6/1 Trelegy Ellipta inhale one buff 25 mg daily 5/13, 5/14, 5/15, 5/16, 5/18, 5/19, 5/21, 5/22, 5/23, 5/31, 6/1 On 6/3/25 at approximately 2:30 p.m., the administrator stated blank spaces on the MAR indicated that the medication was not administered. She also acknowledged Resident #13 not receiving cardiac medications could potentially cause problems to Resident #13's health. Similar deficient practice was found for Residents #2, #10, #11, #12, #15.

A licesnsure complaint promted by #CO40090 and #CO40092, was completed on 6/3/25. Deficiencies were cited.

Based on record review and interview the residence failed to ensure that each staff member received orientation, affecting 53 current residents. (Cross-reference T1410)Findings Include:1. Record ReviewOn 6/3/25 at 2:00 p.m., staff files were requested. On 6/3/25 at approximately 3:00 p.m., Staff #6's files were reviewed. The file did not include orientation. 2. InterviewsOn 6/3/25 at approximately 3:00 p.m., the administrator stated that staff #6 did not receive any orientation or training. On 6/3/25 at 4:15 p.m., staff #6 stated that because she was agency staff, she only administered medication and did not know about anything that was occurring at the residence.

Based on interview and record review, the residence failed to ensure staff were sufficient in number to helpresidents needing or potentially needing assistance, affecting 21 of 53 current residents. (Cross-reference T1530, T1568, T1600)Findings include:An electronic message, dated 5/24/25, read in part that on 5/23/25, the former resident care coordinator (RCC) abandoned her shift without completing medication administration, and the residence did not have another qualified medication administration person (QMAP) to work the rest of that day. Twenty-one resident names and dates of birth were listed in the correspondence, identified as "victims" of this occurrence. The May 2025 medication administration record for Resident #11 revealed blank spaces for all medications that were to be administered on 5/23/25. On 6/3/25 at 7:28 a.m., Staff #4 stated that the former RCC had left her position at the residence with no notice approximately two weeks prior to the onsite investigation, leaving the residence with an insufficient number of QMAPs to administer medications to all residents as ordered. On 6/3/25 at 8:15 a.m., Resident #5 stated that the residence had a "QMAP problem" during approximately thethree weeks prior to the onsite investigation, adding that residents were not getting their medications. She stated the former RCC "was overworked bad and was not getting help from anyone." Resident #5 stated that within this time on a Saturday night, no one administered medications, so she did not get her sleep aid as ordered. She stated that she remembered this because she was attending church service the following morning and was annoyed that she would not get enough rest. On 6/3/25 at 8:40 a.m., Resident #17 stated that during Memorial Day weekend, the residence did not administer any of his medication because there was no QMAP on duty. He said that the residence had lost so many staff that medications were either not administered or administered late. On 6/3/25 at 8:53 a.m., Resident #14 stated the residence had a problem with administering medications as ordered since the former RCC quit working at the residence unexpectedly (approximately three weeks prior to the onsite investigation). She stated that during this time there were days when there was no QMAP on duty at all. On 6/3/25 at 9:36 a.m., Resident #11 stated that the residence did not have enough staff, often causing residents to not get their medications. On 6/3/25 at approximately 2:30 p.m., the administrator stated that the former RCC came in on the morning of 5/23/25 and at approximately 10:00 a.m., she abandoned her shift. She stated that despite trying to find a QMAP to complete medication administration, she was not able to ensure a QMAP was on site until 2:00 p.m. that day. The administrator stated that this QMAP was from a staffing agency, and was not able to administer all medications to all residents because they were slower and did not have time to do so. She stated that any blank space on a MAR meant that the residence did not administer the medication.

Based on record review and interview the residence failed to investigate an allegation of abuse affecting 53 current residents. (Cross-reference T0640)Specifically, on 6/3/25 Resident #10 reported to residence staff, at approximately 2:00 a.m. on 6/3/25, that she was sexually abused by Resident #9. Staff called local law enforcement to report the incident. On 6/3/25 at approximately 7:00 a.m., all investigations of abuse and neglect for April 2025 and June 2025 were requested; none were provided. On 6/3/25 at approximately 4:00 p.m. the administrator stated that local law enforcement were in the building to follow up on an abuse allegation. She then stated that precautions were put in place to keep Resident #9 separate from Resident #10, and other residents, by frequent checks that were being documented, however, when asked to present the documentation the residence was unable to provide the documentation that the frequent checks were accomplished. Furthermore, interviews revealed that morning shift staff were unaware of the frequent checks in place and the alleged abuse to Resident #10 by Resident #9. This failure created an immediate jeopardy risk of abuse to 53 current residents residing in the residence. On 6/3/25, the department directed the residence to provide written evidence that the risk had been removed. Findings Include:1. Record ReviewResident #10 was admitted to the residence on 11/1/24 with a diagnosis of major depressive disorder, anxiety, and mild dementia. A staff statement dated 6/3/25 at 2:00 a.m., read that Resident #10 told staff #7 that Resident #9 was rough with her and that Resident #9 put his hand up her rectum which caused her pain. A staff statement dated 6/3/25 at 2:00 a.m., read that an unnamed staff member went to Resident #10's room to do a routine two hour check and Resident #10 told the staff member that she was physically assaulted by Resident #9. An incident report dated 6/3/25 at 3:30 a.m., read that Resident #10 reported to staff that Resident #9 grabbed her by the arm and put his hand down the back of her brief and inserted his hand into her rectum. The report read that Resident #10 reported rectal pain after the incident. On 6/3/25 at approximately 7:00 a.m., all investigations of abuse and neglect for April 2025 through June 2025 were requested; none were provided. 2. InterviewsDuring the onsite investigation on 6/3/25, Confidential Staff #1 stated that Resident #10 was not currently at the residence because she went to the emergency department (ED). Confidential Staff #1 stated that none of the staff were aware of the reason for her transport to the ED. At a subsequent interview, the confidential staff stated that Resident #10 was at the ED because she was sexually assaulted the night before the onsite investigation. Confidential Staff #1 stated she did not know who the alleged assailant was and was unable to find out because the other staff did not have that information. On 6/3/25 at approximately 11:00 a.m., Staff #4 stated that Resident #10 returned from the hospital. On 6/3/25 at approximately 11:30 a.m., Resident #10 stated that Resident #9 was controlling and that she told Resident #9 that she no longer wanted to see him. She stated that she just returned from the hospital and that she had suicidal ideations. On 6/3/25 at approximately 4:00 p.m., the administrator informed surveyors that local law enforcement arrived to the residence in order to follow up about the sexual abuse that Resident #10 reported at 2:00 a.m. on 6/3/25. The administrator stated that Resident #10 was sent to the hospital on 6/3/25 at 2:00 a.m. due to the sexual abuse allegation. The administrator stated that to ensure the safety of the residents she placed frequent two hour checks on Resident #10 and Resident #9, however, when asked to present the documentation of the frequent checks she was unable to provide the documentation. On 6/3/25 at 4:15 p.m., staff #6 stated that she was not informed of any frequent checks for Resident #10 or Resident #9. On 6/3/25 at approximately 4:30 p.m., staff #8 stated that he was told to perform frequent checks on Resident #10 due to her suicidal ideations. On 6/3/25 at approximately 4:45 p.m., staff #9 stated that she was told that Resident #10 was still in the hospital. She was not told to keep an eye on Resident #9. She stated that Resident #10 told her that Resident #9 can be rude to her. The investigation established that the findings above placed the 53 current residents at immediate jeopardy risk for abuse. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 6/3/25 at approximately 5:30 p.m. the administrator submitted written evidence that read in pertinent part: "(The residence) created a new frequent check sheet and began education with the caregivers and (qualified medication administration personnel QMAP's on duty. Education will continue until all caregiver and QMAP staff are trained on the new form. Frequent checks will be completed by any caregiver or QMAP on duty. Frequent check form will be kept in the caregivers workroom. Each morning a new form will be created for the upcoming day. Check started on each resident, one at 3 p.m. and one at 4:00 p.m., no issues identified. One caregiver will be assigned to always have line of sight with (the) alleged victim when she is outside of her room until the investigation is completed. This will continue for longer if deemed necessary after investigation is completed. Staff currently on duty will be trained on: New resident frequent check form, completing required checks as scheduled, initialing form upon completion of checks, and notifying (the administrator) of any issues identified. All training will be completed by 6/6/2025" However, the written evidence did not indicate the risk had been removed because it did not contain an acceptable monitoring element of the alleged assailant, documentation tracking for retraining, and a timely manner for the training and timely communication to staff of the alleged abuse and training for monitoring the alleged assailant. The administrator was directed to submit additional written evidence. On 6/3/25 at approximately 6:00 p.m., the administrator submitted additional written evidence that read in pertinent part: "Frequent checks will be completed at a minimum of every two hours by any caregiver or QMAP on duty. Education will continue until all caregiver(s) and QMAP staff are trained on the new form. One caregiver will be assigned to always have line of sight with the alleged perpetrator when he is outside of his room until the investigation is completed. This will continue for longer if deemed necessary after investigation is completed. Notifying (the administrator) of any issues identified and documenting these on the frequent check form. All remaining training will be completed by 6/4/25."

Based on record review and interview the residence failed to ensure that only medication ordered by an authorized practitioner be prepared for or administered to residents affecting four of eight sample residents (#2, #6, #10, and #14). (Cross-reference T1568, T1600, T1604, and T1612)Findings Include:1. Record ReviewResident #2 was admitted to the residence on 1/13/23 with a diagnosis of hypothyroidism, anxiety, bradycardia, chronic obstructive pulmonary disorder, emotional stress, osteoporosis, and skin cancer. A medication administration record for May 2025 read that dexamethasone 0.5 mg, omeprazole 20 mg, and lorazepam 0.5 mg were given between 5/22-5/31. Review of Resident #2's medical records on 6/3/25 at approximately 12:00 p.m., revealed no medication orders for dexamethasone 0.5 mg, omeprazole 20 mg, or lorazepam 0.5 mg. 2. InterviewsOn 6/3/25 at approximately 12:30 p.m., Staff #4 stated that she was unable to locate missing practitioner's orders for Resident #2. On 6/3/25 at approximately 2:30 p.m., the administrator stated that if the medication order was not in the resident record then they did not have it. She stated that she expected all medications that were administered to residents to have a practitioner's order. Similar deficient practice was discovered for Residents #6, #10, and #14.

Based on record review and interview, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting six of eight sample residents (#2, #10, #11, #12, #13, #15). (Cross-reference T1530, T1600, T1604, and T1612)Findings include:Resident #13 was admitted to the residence on 1/25/21 with diagnoses including congestive heart failure (CHF). A written practitioner's order, dated 3/20/25, directed the residence to administer the following medications: Calcium 600 D3 800 tab once daily Metoprolol 75 mg once dailyFurosemide 30 mg once dailyAspirin 81mg once dailyMyrbetriq 50 mg once daily Glucosamine Complex once daily Senna Plus 50 mg twice daily Acetaminophen 650 mg twice dailyPravastatin 20 mg once dailyTrelegy Ellipta inhale one buff 25 mg dailyHowever, the May and June 2025 medication administration records (MARs) for Resident #13 read the following medications had blank entries on the MAR:Calcium 600 D3 800 tab once daily 5/14, 5/19, 5/31, 6/1Metoprolol 75 mg once daily 5/14, 5/19, 5/31, 6/1 Furosemide 30 mg once daily 5/14, 5/19, 5/31, 6/1 Aspirin 81mg once daily 5/14, 5/19, 5/31, 6/1 Myrbetriq 50 mg once daily 5/14, 5/19, 5/31, 6/1 Glucosamine Complex once daily 5/14, 5/19, 5/31, 6/1 Senna Plus 50 mg twice daily 5/16pm, 5/17pm, 5/19am, 5/23pm, 5/24pm, 5/28pm, 5/29pm, 5/31am, 5/31pm, 6/1 Acetaminophen 650 mg twice daily 5/14am, 5/16pm, 5/17pm, 5/19am, 5/23pm, 5/24pm, 5/28pm, 5/29pm, 5/31am, 5/31pm, 6/1 Pravastatin 20 mg once daily 5/4, 5/5, 5/11, 5/12, 5/16, 5/17, 5/23, 5/24, 5/28, 5/29, 5/31, 6/1 Trelegy Ellipta inhale one buff 25 mg daily 5/13, 5/14, 5/15, 5/16, 5/18, 5/19, 5/21, 5/22, 5/23, 5/31, 6/1 On 6/3/25 at approximately 2:30 p.m., the administrator stated blank spaces on the MAR indicated that the medication was not administered. She also acknowledged Resident #13 not receiving cardiac medications could potentially cause problems to Resident #13's health. Similar deficient practice was found for Residents #2, #10, #11, #12, #15.

Based on record review and interview, the residence failed to ensure that each qualified medication administration person (QMAP) documented accurate information on the medication administration record (MAR) including any medication omissions, affecting three of eight sample residents (#6, #11, #14). (Cross-reference T1530, T1568, T1604, T1612, and T2230)Findings include:The May 2025 MAR for Resident #6 had a hand-written line drawn through each medication administration on dates 5/7/25 through 5/18/25. The QMAPs failed to document the medication omissions, along with the reasons for the omissions, on the MAR as required. On 6/3/25 at 12:55 p.m., Resident #16 (who shared a double-occupancy room with Resident #6) stated that Resident #6 was admitted at the hospital for the above time frame. On 6/3/25 at 2:30 p.m., the administrator stated that Resident #6 had herself admitted for a hospital stay during the above time frame. She acknowledged that the QMAPs drew the line to document that they did not administer the medications, but they did not document the reason on the back of the MAR. The administrator stated that she expected the QMAPs to have done so. Evidence revealed the residence additionally failed to accurately document medication administration in the MAR for Residents #11 and #14.

Based on interview and record review, the administrator and the qualified medication administration personnel (QMAP) supervisor failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting 53 current residents (Cross-reference T1530, T1568, T1600, and T1612)Findings include:On 6/3/25, documents provided by the administrator, each dated between 1/23/25 and 3/11/25, and signed by the former resident care coordinator (RCC) revealed that the administrator did not participate in a quarterly medication audit. Each of the documents had a name printed at the top and a checklist of items, next to which was handwritten: "yes," "no," or "N/A." Twenty-two documents were provided; the residence had 53 current residents. On 6/3/25 at approximately 2:30 p.m., the administrator stated that she was not a qualified QMAP and therefore did not participate in medication audits. She stated that the former RCC was responsible for completing quarterly audits, and she acknowledged the audits did not meet the requirements.

Based on interview and record review the residence failed to ensure the resident ' s authorized practitioner and resident's legal representative was notified of medication errors that affect the resident, affecting one of eight sample residents (#13). (Cross-reference T1530, T1568, T1600, T1604, and T2230)Findings include: Resident #13 was admitted to the residence on 1/25/21 with diagnoses including congestive heart failure (CHF). A written practitioner's order, dated 3/20/25, directed the residence to administer metoprolol 75 mg once daily along with furosemide 30 mg once daily. However, the May and June 2025 medication administration record (MAR) read blank spaces in the MAR on 5/14, 5/19, 5/31, 6/1 for a total of four missed doses each. The May and June 2025 progress notes revealed no documentation that staff had any communication with the practitioner or legal representative about Resident #13's missed medications. On 6/3/25 at approximately 1:30 p.m., the legal representative for Resident #13 stated they were not made aware of the medication errors by the residence. The legal representative also stated they do not have much contact with the staff at the residence. On 6/3/25 at approximately 1:45 p.m., the practitioner's office for resident #13 stated they were not informed of any medications errors or missed dosages for Resident #13 during the months of May and June 2025. On 6/3/25 at approximately 2:30 p.m., the administrator stated blank spaces on the MAR indicated that the medication was not administered. She also acknowledged Resident #13 not receiving cardiac medications could potentially cause problems to Resident #13's health. On 6/3/25 at approximately 3:00 p.m., the administrator provided a letter dated 5/30/25 that was sent out to the legal representative of all residents. The letter was to schedule a care conference but not specifics on notifying the representative of the medication errors for Resident #13.

Based on record review and interview, the residence failed to complete progress notes at the end of each shift, which included documentation regarding any out-of-the-ordinary event or issue that affected the resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address that resident's changing needs, affecting seven of nine sample residents (#2, #6, #9, #10, #12,#13, #15). Findings include:Resident #13 was admitted to the residence on 1/25/21 with diagnoses including congestive heart failure (CHF). On 6/3/25 at approximately 8:00 a.m., Staff #5 was observed attempting to pass medication to Resident #13. Resident #13 was confused and scared and could not understand why the Staff #5 was attempting to do so. On 6/3/25 at approximately 8:45 a.m., Staff #4 stated Resident #13 had been more confused lately and her dementia seems to be increasing. On 6/3/25 at approximately 10:00 a.m., resident records were requested and reviewed for Resident #13. After review, the records revealed no progress notes for the resident. On 6/3/25 at 12:30 p.m., Staff #4 stated that the residence staff were not documenting progress notes in the provided binders and that there would not be any updates in the binders. On 6/3/25 at approximately 2:30 p.m., the administrator stated she expected the staff to be documenting out of the ordinary events in the residents progress notes. Similar deficient practice was found for Residents #2, #6, #9, #10, #12, #15.

A certification complaint, prompted by #CO38769 and #CO38863, was completed on 3/26/25. A deficiency was cited.

Based on interview and record review, the facility failed to ensure each qualified medication administration person (QMAP) accurately recorded all medication administered, to include, the date, amount, and time of each members medication, affecting five (#1, #4, #8, #9 and #10) out of five sample members whose medication administration was observed. Findings include:The facility ' s undated medication administration policy read, in part: "The residence shall administer medications on an individual basis, the QMAP administering the medications must immediately initial the MAR and note any discrepancies."On 3/26/25 from 7:45 a.m. to 8:45 a.m., Staff #1 administered the medications to Member #4, but she did not fill out her signature on the medication administration record (MAR). Staff #1 stated that she does not fill out the MAR until 2:00 p.m. On 3/26/25 at approximately 11:30 a.m., record reviews revealed Member #4 MARs were not signed. On 3/26/25 at approximately 1:00 p.m., the administrator stated that she expected the qualified medication administration personnel (QMAP) to record the MAR after medication administration. Similar deficient practice was observed for Members #1, #8, #9 and #10.

A complaint revisit was completed on 3/26/25 for the previous deficiencies cited on 11/20/24. The residence is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO38767 and #CO38862, was completed on 3/26/25. Deficiency was cited.

Based on observations and interviews, the residence failed to ensure that each resident received proper monitoring of medications, affecting five (#1, #4, #8, #9 and #10) out of five sample residents whose medication administration was observed. (Cross-reference S1600) 1. Residence PolicyThe residence's undated medication administration policy read, in part: "The residence will ensure that each resident receives proper administration and/or monitoring of medications."2. ObservationOn 3/26/25 from 7:45 a.m. to 8:45 a.m., Staff #1 was observed preparing medication for Resident #4. Staff #1 placed the medications in a plastic container on the table, walked away, and did not monitor Resident #4 to ensure his medications were properly administered. 3. InterviewsOn 3/26/25 at approximately 1:00 p.m., the administrator stated that she expected a qualified medication administration personnel to pass medication to a resident and observe that all medications were taken and staff cannot leave the medication with the resident for them to take on their own. 4. Similar deficient practice was observed for Residents #1, #8, #9 and #10.

Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting five (#1, #4, #8, #9, #10) out of five sample residents whose medication administration was observed. (Cross-reference S1522)Findings include:The residence ' s undated medication administration policy read, in part: "The residence shall administer medications on an individual basis, the QMAP administering the medications must immediately initial the MAR and note any discrepancies."On 3/26/25 from 7:45 a.m. to 8:45 a.m., Staff #1 administered the medications to Resident #4, but she did not fill out her signature on the medication administration record (MAR). Staff #1 stated that she did not fill out the MAR until 2:00 p.m. On 3/26/25 at approximately 11:30 a.m., record reviews revealed Resident #4 MARs were not signed. On 3/26/25 at approximately 1:00 p.m., the administrator stated that she expected the qualified medication administration personnel to record the MAR after medication administration. Similar deficient practice was observed for Residents #1, #8, #9 and #10.

A complaint revisit was completed on 3/26/25 for the previous deficiencies cited on 11/20/24. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 3/18/25 for previous deficiencies cited on 1/30/25. The agency is in compliance with all regulations surveyed.

An involuntary discharge appeal survey, prompted by #CO38818, was completed on 1/30/25. A deficiency was cited.

Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy affecting 52 current residents. Findings include:Record ReviewOn 1/23/25 at approximately 8:08 a.m., the involuntary discharge policy was requested by email. On 1/24/25 at approximately 3:32 p.m., the involuntary discharge policy was requested for a second time by email. On 1/27/25 at approximately 7:46 a.m., the involuntary discharge policy was requested for a third time by email. On 1/27/25 at approximately 2:36 p.m., the involuntary discharge policy was requested via a telephone call. On 1/27/25 at approximately 3:28 p.m., the residence receptionist emailed the surveyor stating she would be emailing the requested documents. On 1/28/25 at approximately 8:59 a.m., the involuntary discharge policy was requested for a fourth time by email. On 1/28/25 at approximately 1:29 p.m., the residential agreement was received by email. On 1/28/25 at approximately 4:27 p.m., the involuntary discharge policy was requested for a fifth time by email. On 1/29/25 at approximately 11:55 a.m. the involuntary discharge policy was requested for a sixth time by email. On 1/29/25 the residential agreement; specifically the section titled "Termination of Lease Agreement" was reviewed. The section titled "Termination of Lease Agreement" failed to include the following elements: (A) The individual designated by the assisted living residence to receive involuntary discharge grievances.(B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence.(C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence.(D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows:(1) In writing, or(2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence.(a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness's name and contact information, and shall keep that information as part of the grievance documentation.(E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows:(1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman.(2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate.(3) The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation."(F)Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S.(G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part.(H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending.(I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply:(1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board,(2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and(3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. InterviewOn 1/29/25 at approximately 2:34 p.m., the residential agreement was provided by email and a telephone call to the executive director where she stated that the residential agreement had a section titled "Termination of Lease Agreement," where the process for involuntary discharge is documented for the residents to review and sign. On 1/30/25 at approximately 11:00 a.m., the executive director stated the residence does not have a separate involuntary discharge policy as the residence has a section in their residential agreement titled "Termination of Lease Agreement" where the residence involuntary discharge process is documented for the residence. The executive director additionally stated that the residence's residential lease agreement has not been updated to meet the regulations and the residence does follow the eviction process as the regulations state, however, the residence does not have a separate involuntary discharge policy.

A certification complaint, prompted by #CO38221, was completed on 11/20/24. Deficiencies were cited.

Based on record review and interview, the facility (residence) failed to conduct fire drills at least quarterly, affecting 54 current members (residents). Findings include:The residence's Training and Drills policy, dated January 2023, read in part that the residence conducted fire drills with each shift under the supervision of the maintenance supervisor on a quarterly basis. On 11/20/24, during the onsite investigation, the residence provided documentation that they conducted a fire drill on 6/12/24 between 10:00 p.m. and 6:00 a.m.; the staff members who participated in the fire drill no longer worked at the residence and residents were not evacuated during the drill. The residence did not provide documented drills for any potential risk requiring evacuation, including fire, flood, earthquake, tornado, or power outage. On 11/20/24 at 10:00 a.m., Staff #1, #3, and #5 stated that the residence had not conducted any emergency drills for at least five months before the on site investigation. On 11/20/24 at 12:55 p.m., the administrator acknowledged they had not conducted a fire drill during each shift at least quarterly.

Based on record review and interview, the facility (residence) failed to have policies and procedures to ensure the continuation of care to all members (residents) for 72 hours following an emergency, affecting 54 current residents. Findings include On 11/20/24 at 8:30 a.m. a 72 hour continuation of care policy and procedure was provided but was not complete or specific to the resident population and residence. On 11/20/24 at 10:35 a.m., the administrator confirmed the document was a 72 hour continuation of care policy and procedure. The administrator stated she was unaware of the requirement to have a written policy and procedure for the 72 hours following an emergency and acknowledged the policy she provided did not meet regulatory requirements.

A licensure complaint, prompted by #CO38220, was completed on 11/20/24. Deficiencies were cited.

Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following an emergency including, but not limited to, a long-term power failure, affecting 54 current residents. Findings include On 11/20/24 at 8:30 a.m., a 72 hour continuation of care policy and procedure was provided but was not complete or specific to the resident population and residence. On 11/20/24 at 10:35 a.m., the administrator confirmed the document was a 72 hour continuation of care policy and procedure. The administrator stated she was unaware of the requirement to have a written policy and procedure for the 72 hours following an emergency and acknowledged the policy she provided did not meet regulatory requirements.

Based on record review and interview, the residence failed to identify the highest potential risk as well as hold and document routine drills to facilitate staff and resident response to that risk, affecting 54 current residents. Findings include:The residence's Training and Drills policy, dated January 2023, read in part that the residence conducted fire drills with each shift under the supervision of the maintenance supervisor on a quarterly basis. On 11/20/24, during the onsite investigation, the residence provided documentation that they conducted a fire drill on 6/12/24 between 10:00 p.m. and 6:00 a.m.; the staff members who participated in the fire drill no longer worked at the residence and residents were not evacuated during the drill. The residence did not provide documented drills for any potential risk requiring evacuation, including fire, flood, earthquake, tornado, or power outage. On 11/20/24 at 10:00 a.m., Staff #1, #3, and #5 stated that the residence had not conducted any emergency drills for at least five months before the on site investigation. On 11/20/24 at 12:55 p.m., the administrator acknowledged they had not conducted a fire drill during each shift at least quarterly.

Based on record review and interview, the residence failed to ensure its emergency policies addressed the storage and preservation of medications, a pre-determined means of communicating with residents and families, a plan to ensure the availability of emergency power for essential functions, specific tasks, and responsibilities for staff members during emergencies, protection and transfer of health information as needed to meet the care needs of residents, and In the event relocation of residents becomes necessary, written agreements with other health facilities and community agencies, affecting 54 current residents. Specifically, the residence's emergency policies and procedures were minimal and not specific to the resident population nor the residence. The policies were specific to a residence with multiple floors and did not include specific steps for the staff in the event of an emergency. Staff were untrained in emergency preparedness and did not know how to safely assist residents, how to evacuate them from the residence, and were not given specific roles and responsibilities. This failure created an immediate jeopardy risk of neglect to all 54 current residents residing in the residence. On 11/20/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:On 11/20/24 at 8:30 a.m., the residence's emergency preparedness policies and procedures were requested and reviewed. Included was a schematic plan of the building placed visibly throughout the building and procedure for the protection and transfer of health information as needed to meet the care needs of residents. Residence Policya. The residence's Complete Evacuation policy, dated January 2023, read in part, two way radios were handed out, staff retrieved "Go-Kits" which were pre-assembled and located in the activities room. Starting at the top floor, residents evacuated through stairwells; after the floor was evacuated the next floor would begin evacuation. The policy did not address specific events as to when staff were required to evacuate the residence.b. The residence's undated Risk Assessment policy read in part that the residence identified potential emergencies that may disrupt the residence's ability to provide care. The residence analyzed the likelihood of these events occurring and its consequences. The residence addressed specific hazards in their plan. "Complete Hazard vulnerability risk assessment and paste/insert here." As of 11/20/24, the residence had not completed a risk assessment for potential hazards. ObservationOn the date of the onsite investigation (11/20/24), the residence did not have available radios for staff to use, the residence had not prepared "Go-Kits" in the event of an emergency. Additionally, the residence had only one floor. Record ReviewOn 11/20/24 at 8:30 a.m., the storage and preservation of medication policy and procedure was requested and not provided throughout the onsite visit. On 11/20/24 at 8:30 a.m., a written agreement with other health facilities was requested. A signed agreement, dated 8/23/2012, between the residence and a local church read in part that the church accepted the residence request for the use of the church as an alternate emergency evacuation site. A signed agreement, dated 9/9/2012, between the residence and another local church read in part that the church would provide space on a temporary basis for the residents in case of an emergency evacuation. The residence provided no written agreements with other health facilities and community agencies regarding emergent relocation. On 11/20/24 at 9:58 a.m., Staff #1 stated she had not been trained in emergency preparedness and did not know how to evacuate the residence or where to relocate them in the event of an emergency. On 11/20/24 at 10:10 a.m., Staff #4 stated the residence had not done emergency drills in five or six months prior to the onsite investigation. She stated she had no training in emergency preparedness and did not know what to do in the event of an emergency at the residence. On 11/20/24 at 10:25 a.m., Staff #3 stated the residence had not provided emergency preparedness training so she did not know how she would assist residents who required oxygen during an emergency. On 11/20/24 at 10:55 a.m., the activities director stated she had not participated in an evacuation drill, and she would require direction to support residents during an emergency. On 11/20/24 at 11:58 a.m., Staff #5 stated she trained new staff in their roles; however, she did not train them on emergency policies and procedures. She stated she did not know what designated facility staff were to relocate residents in the event it was required. She stated that staff did not have any means of communication during an emergency, adding that she had not participated in a fire drill in at least three months prior to the onsite investigation. On 11/20/24 at 12:42 p.m., Staff #2 stated she was the qualified medication administration personnel (QMAP) supervisor and did not know where to store medications during an emergency. She stated the residence had not performed a fire drill in seven months and she did not know what to do in the event of an emergency, adding that she would not know how to communicate with other staff. On 11/20/24 at 12:55 p.m., the administrator acknowledged the residence's lack of policy and procedures regarding emergency preparedness. She stated she expected to have the documentation and expected staff to know how to handle an emergency when it arose. The administrator acknowledged that staff had not been trained in emergency preparedness. On 11/20/24 at 4:55 p.m., Residents # 1-#3 stated the residence had not conducted any emergency drills or training for staff in two years prior to the onsite investigation. They stated they would not know what would happen if everyone needed to evacuate the residence because staff did not receive the proper training for evacuating residents with high care needs. On 11/21/24 at 9:30 a.m., The quality improvement specialist (QIS) with the residence's management company acknowledged that their emergency preparedness policies and procedures did not meet regulatory standards. He stated the residence needed to ensure they had written agreements with other facilities as well as ensure staff had consistent communication to ensure all residents were accounted for. The QIS stated that the management company had completed a risk assessment but had not given it to the administrator yet. 4. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the five current residents at immediate jeopardy risk for potential harm due to staff not trained in effectively bringing residents to safety during an emergency or evacuation. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 11/20/24 at 4:18 p.m., the administrator submitted written evidence that read in pertinent part: "We will continue to care for our residents as we have been caring for them. (We) will complete a risk assessment on any emergencies that will happen. The previous (administrator) used a template not specific to our (residence). The new (administrator) will revise a plan specific to our (residence). (We will) Have the entire emergency plan documented and implemented by (12/4/24) with signed in-service documentation for each staff member.". However, the written evidence did not indicate the risk had been removed because it did not contain an acceptable monitoring element, how all resident's care would be provided during an emergency evacuation, an investigation element, completion dates for the staff training, and how each element would be documented and implemented. The administrator was directed to submit additional written evidence. On 11/20/24 at 7:28 p.m., the administrator submitted written evidence that read in pertinent part: "The (residence) has put in place an updated Emergency Preparedness Plan specific to the (residence) to be utilized in case of an emergency. The (residence) has put in place a new Policy and procedure for Fire Plan, Evacuation, & Emergency Procedures. The (residence) has created a list of all current residents on oxygen and posted this in the medication room and the caregiver office to identify (any) resident who may need assistance transferring oxygen to an e-tank (emergency oxygen tank) in case of a (residence) emergency requiring this transfer. The (residence) has verified that all residents currently on oxygen have an available e-tank in their room in case of emergency. The (residence) has a current transfer agreement in place to transfer residents to another facility should that become necessary in the event of an emergency requiring evacuation. This will be accomplished utilizing the (residence) van of both facilities, PACE transportation, and emergency services. administrator/designee will ensure that (residence) Emergency Preparedness Plan is reviewed in QMP (quality management program) quarterly to ensure that it remains current. Any changes will be completed as necessary, and staff will be trained on these changes. administrator/designee will review all new hire orientation training sheets to ensure that above training was completed prior to working residents. Emergency/Disaster drills will be completed at least twice per year to ensure that staff are utilizing proper policies and procedures in case of a (residence) emergency. QMP committee will review any drills and will evaluate and make recommendations for further improvement, as necessary."Staff currently on duty will be trained on:Call 911 and evacuate if necessary the new Fire Plan, Evacuation, & Emergency Procedures. Where to locate the Emergency Preparedness Plan. Proper notifications to administrator and/or emergency agencies. Location of list of residents currently on oxygen. Need to assist above resident in the case of emergency."All staff employed at (the residence) will be trained prior to working their next shift related to:Call 911 and evacuate if necessary the new Fire Plan, Evacuation, & Emergency Procedures. Where to locate the Emergency Preparedness Plan. Proper notifications to administrator and/or emergency agencies. Location of list of residents currently on oxygen. Need to assist the above resident in the case of emergency. All staff will be trained by 12/4/24."However, the written evidence did not indicate the risk had been removed because it did not contain an acceptable method for evacuation of the residence to another health facility and had been titled "Plan of Correction". The written evidence did not include the procedure for residents with oxygen tanks in the event of a power outage. The administrator was directed to submit additional written evidence by 11/21/24 at 9:30 a.m. On 11/21/24 at 9:30 a.m., the administrator submitted written evidence that read in pertinent part: "The (residence) completed an observation audit and verified that all residents currently on oxygen have an available e-tank in their room in case of emergency. The (residence) has a current transfer agreement in place to transfer residents to another (residence) should that become necessary in the event of an emergency requiring evacuation. The (residence) will obtain additional transfer agreements with other facilities by 11/21/24, including the church across the street, to ensure that they have current agreements in place so that more beds will be available in case of emergency. In the event of an emergency, the (residence) will contact other facilities to determine the number of beds available to ensure that all residents can be accommodated. The (residence) will also utilize emergency services to assist in finding other accommodation, if necessary. Transportation to these other facilities will be completed utilizing the (residence)van of both facilities, PACE transportation, and emergency services."The residence corrected the circumstances that gave rise to the immediate jeopardy situation as required on their third and final attempt.

A revisit survey was completed on 8/6/24 for all previous deficiencies cited on 5/29/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 8/6/24 for all previous deficiencies cited on 5/29/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint #CO35738 was completed on 5/29/24. Deficiencies were cited.

Based on interview and record review, the residence failed to report suspected caretaker neglect to law enforcement within 24 hours of discovery, affecting one current resident (#1). (Cross-reference: S430, S1410)Findings include:1. Residence PolicyThe residence's policy for investigating allegations of abuse or neglect, dated 5/11/22, read in part that all staff reported suspected neglect of a resident to the appropriate supervisor, and the administrator contacted the appropriate state agency and state department within 24 hours. 2. Record ReviewA care plan for Resident #2 read, in part, as follows. Under the heading Allegations Physical Abuse, there was a checkmark in the box next to "Physical abuse." Underneath, it read: "(Resident #2) hit (Resident #1) with her cup on 5/20/24. See narrative of events for more details."Documentation under the heading Narrative of Events/Additional Information read in part: "(Resident #1) was bugging (Resident #2) at lunch when (Resident #2" told him to stop bugging (them). (Resident #1) continued to talk to her, and she got up and went over to (Resident #1) to hit him with her cup. This took place around 12:40 p.m. on May 20, 2024." 3. InterviewsOn 5/29/24 at approximately 10:13 a.m., the resident care coordinator (RCC) said that Resident #2 hit Resident #1 with a cup at lunchtime on 5/20/24. She said she did not report the physical abuse as an occurrence but had documented it in the care plan. She acknowledged that she did not take action when Resident #2 hit Resident #1 with a cup. Although the RCC recognized it as abuse, she failed to respond and report it to Local Law enforcement. On 5/29/24 at 12:34 p.m., the administrator said that she had contacted APS and local law enforcement on 5/29/24 during the onsite investigation to report that Resident #2 had physically hit Resident #1. On 5/29/24 at 1:25 p.m., the RCC said that she had failed to report abuse of a resident to local law enforcement. On 5/29/24 at 1:42 p.m., the administrator acknowledged that the residence failed to report physical abuse of a resident to local law enforcement.

Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one of three sample residents (#2). (Cross-reference S410, S1410)Findings include:1. References a. According to the Health Facilities and Emergency Medical Services Division Occurrence Reporting Manual (2018), "Any occurrence involving physical...abuse of a patient or resident, as described in section...18-3-402, 18-3-403, 18-3-404, or 18-3-405 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.b. The residence's policy for investigating allegations of abuse or neglect, dated 5/11/22, read in part that all staff reported suspected neglect of a resident to the appropriate supervisor, and the administrator contacted the appropriate state agency and state department within 24 hours. 2. Record Review A grievance form dated 5/20/24 read in part that Resident #2 hit Resident #1 with a cup. In the comments section, the administrator documented that "30-day notice was given to [Resident #2], and [their guardian] was notified." A review of the department's database on 5/29/24 for occurrence reports revealed that the residence did not report any occurrences of abuse in 2024. An email to Adult Protective Services (APS) dated 5/29/24 read in part that "[Resident #1] was bugging [Resident #2] at lunch when [Resident #2] told him to stop bugging me. [Resident #1] continued to talk to her, and she got up and went over to [Resident #1] to hit him with her cup. This took place around 12:40 p.m. on May 20, 2024." A care plan for Resident #2 read in part as follows:Under the heading Allegations Physical Abuse, there was a checkmark in the box next to "Physical abuse." Underneath, it read: "[Resident #2] hit [Resident #1] with her cup on 5/20/24. See narrative of events for more details."Documentation under the heading Narrative of Events/Additional Information read in part: "[Resident #1] was bugging [Resident #2] at lunch when [Resident #2]" told him to stop bugging me. [Resident #1] continued to talk to her and she got up and went over to [Resident #1] to hit him with her cup. This took place around 12:40 p.m. on May 20, 2024." 3. InterviewsOn 5/29/24, at approximately 10:13 a.m., the resident care coordinator (RCC) said that Resident #2 had physically hit Resident #1 with a cup at lunch on 5/20/24. She said she did not report the incident as an occurrence, as required. She acknowledged that she did not take action when Resident #2 hit Resident #1 with a cup. Although the RCC recognized it as abuse, she failed to respond and report it to Adult Protective Services (APS) or Local Law enforcement. On 5/29/24 at 1:25 p.m., the RCC said that she was unaware of the requirement for the residence to report abuse as an occurrence but informed the administrator that Resident #2 hit Resident #1. On 5/29/24 at 1:42 p.m., the administrator acknowledged that Resident #2 had hit Resident #1 with a cup. She acknowledged it was physical abuse and that the residence failed to report physical abuse as an occurrence to the department, as required.

Based on observation and interview, the residence failed not to use restraints of any kind and deprive a resident of their liberty for the purposes of care, affecting one current resident. (#2)Findings include:1. ObservationOn 5/29/24 at 7:53 a.m., Resident #2 was observed in her room during breakfast. 2. Record Review A grievance form dated 5/20/24 read in part that Resident #2 hit Resident #1 with a cup. In the comments section, the administrator documented that "30-day notice was given to [Resident #2], and [their guardian] was notified."A 30-day notice of Termination of the Resident Lease Agreement, dated 5/21/24, read in part that the residence could no longer meet the resident's needs due to harassment of other residents, physical altercations with other residents, and verbal abuse of staff. Further, it read in part that the residence and Resident #2's responsible party were working to find a better-fitted residence due to the behavior that included physical abuse. However, service to the resident would continue until discharge. 3. InterviewsOn 5/29/24 at 7:53 a.m., Resident #2 said the staff told her to go to her room and that she would stay in her room. On 5/29/24 at approximately 8:15 a.m., Resident #1 said that Resident #2 had a disability and struggled to understand basic instructions. He said she "would seek him out and try to cause trouble." Resident #1 added that all staff would tell her to go to her room, and she would be in "time out" or "grounded" when she tried to talk or get near him. He acknowledged that staff were restraining her when they required her to stay in her room. On 5/29/24 at 8:40 a.m., Staff #1 said that all staff, including herself, had told Resident #2 she was "grounded" to her room when she would not listen or behave in unusual ways. She said that staff informed the resident care coordinator (RCC) when the resident was agitated and was told to go to her room. Staff #1 acknowledged that the staff was restraining her when they mandated that she go to her room. She said she considered the restraint against the resident's right but did not discuss it with the RCC. On 5/29/24, at approximately 8:40 a.m., Resident #4 said that Staff #2 had told Resident #2 that she was "grounded" on multiple occasions when Resident #2 attempted verbal altercations with Resident #1. On 5/29/24, at approximately 8:40 a.m., Resident #5 said that she had heard staff tell Resident #2 to go to her room on several occasions. She said that Resident #2 followed Resident #1 around and interrupted him when talking to other residents. Resident #5 said that sending Resident #2 to her room was the only thing the staff could do that worked. However, she then acknowledged that it was against the resident's rights for staff to restrain her to her room. On 5/29/24 at approximately 8:55 a.m., Staff #2 acknowledged that other staff members "grounded" Resident #2 to her room when Resident #2 refused to comply with staff requests to not speak to Resident #2. She added that staff were required to inform the RCC when this happened. She added the resident's family member had informed her that telling Resident #2 "to go in her room and stay there" was an effective way to allow Resident #2 to "calm down." Staff #2 acknowledged that when she instructed Resident #2 to go to her room and stay, she was imposing a restraint on the resident. On 5/29/24 at 9:00 a.m., the administrator said staff were unable to effectively intervene when Resident #2 displayed aggressive behaviors that infringed on the freedoms of other residents and when she seemed to be unaware of others' personal space. She said she did not instruct staff to "ground" the resident and wondered if the guardian had instructed staff. On 5/29/24 at approximately 10:13 a.m., the RCC said that Resident #2 had physically hit Resident #1 with a cup at lunch on 5/20/24. She added that she was unaware that staff told aresident she was "grounded." The RCC said Resident #2 became agitated when Resident #1 interacted with other residents. The RCC stated that she instructed staff to direct her to engage in puzzles and watch television in her room. On 5/29/24 at 1:42 p.m., the RCC and the administrator acknowledged that staff restrained Resident #2 when they required her to go to her room and stay there.

Based on interview and record review, the residence failed to investigate an allegation of physical abuse in accordance with its written policy which included an allegation of physical abuse to adult protection services (APS) affecting one of three sample residents (#2). (Cross-reference S410, S430)Findings include:1. Residence PolicyThe residence's policy for investigating allegations of abuse or neglect, dated 5/11/22, read in part that when, during an investigation, the administrator or other manager determined abuse had occurred law enforcement was notified to file a report. In addition, the administrator contacted the appropriate state agency and state department within 24 hours. 2. Record ReviewA care plan for Resident #2 read in part as follows:Under the heading Allegations Physical Abuse there was a checkmark in the box next to "Physical abuse." Underneath, it read: "(Resident #2) hit (Resident #1) with her cup on 5/20/24. See narrative of events for more details."Documentation under the heading Narrative of Events/Additional Information read in part: "(Resident #1) was bugging (Resident #2) at lunch when (Resident #2" told him to stop bugging (them). (Resident #1) continued to talk to her and she got up and went over to (Resident #1) to hit him with her cup. This took place around 12:40 p.m. on May 20, 2024."Documentation of a formal investigation was requested On 5/29/24. However, was not provided. 3. InterviewsOn 5/29/24 at 9:00 a.m., the administrator said staff were unable to effectively intervene when Resident #2 displayed aggressive behaviors that infringed on the freedoms of other residents and when she seemed to be unaware of others' personal space. She said she did not instruct staff to "ground" the resident and wondered if the guardian had instructed staff. On 5/29/24 at approximately 10:13 a.m., the resident care coordinator (RCC) said that Resident #2 had hit Resident #1 with a cup at lunch on 5/20/24. She stated the residence did not complete or document a formal investigation into the allegations of abuse, and they failed to report the abuse allegations to adult protective services as required. On 5/29/24 at 1:25 p.m. the RCC said that she had failed to report abuse of a resident to APS, as required. On 5/29/24 at 1:42 p.m., the administrator acknowledged that the residence failed to report physical abuse of a resident to APS.

A certification complaint, prompted by #CO35739, was completed on 5/29/24. Deficiencies were cited.

Based on observation, interview, and record review, the facility (residence) failed to observe a participant's (residents') right to independence and was restrained to her room when her behaviors were negatively impacting the facility, affecting one current participant (resident). (#2) 1. Resident #2 was admitted to the residence on 2/16/18 with diagnoses including mild cognitive impairment. Resident #2's record contained no informed consent (IC) documentation to remove the resident's rights. On 5/29/24 at 9:00 a.m., the administrator said that Resident #2 had behaviors not controlled by the residence. She stated she issued a 30-day discharge notification to the resident on 5/21/24 after Resident #2 had initiated a physical altercation with Resident #1. On 5/29/24 at 10:13 a.m., the resident care coordinator (RCC) said that Resident #2 had aggressive behaviors toward Resident #2 and that on 5/20/24 Resident #2 hit Resident #1. She said the best way for the resident to calm down was to be in her room. The RCC added that the guardian told her that intervention was effective when Resident #2 was a child. The RCC acknowledged she was unaware the residence was required to document an IC or rights modification when staff restrained her to her room. She acknowledged that she was unaware an IC was required when staff told Resident #2 to go to her room and stay there. On 5/29/24 at 12:33 p.m., the administrator acknowledged she was unaware that the facility was required to document a rights modification when staff restrained Resident #2 by telling her to go to her room.

Based on observation, interview, and record review, the facility (residence) failed to ensure participants (residents) had the right to: leave their quarters and to have access to the entire facility, affecting one current resident. (#2)Findings include: 1. Resident #2 was admitted to the residence on 2/16/18 with diagnoses including mild cognitive impairment. Resident #2's record contained no informed consent (IC) documentation to remove the resident's rights. On 5/29/24 at 9:00 a.m., the administrator said that Resident #2 had behaviors that were not controlled by the residence. She stated she issued a 30-day discharge notification to the resident on 5/21/24 after Resident #2 had initiated a physical altercation with Resident #1. On 5/29/24 at 10:13 a.m., the resident care coordinator (RCC) said that Resident #2 had aggressive behaviors toward Resident #2 and that on 5/20/24 Resident #2 hit Resident #1. She said the best way for the resident to calm down was to be in her room. The RCC added that the guardian told her that intervention was effective when Resident #2 was a child. The RCC acknowledged she was unaware the facility was required to document an IC or rights modification when staff restrained her to her room. She acknowledged that she was unaware an IC was required when staff told Participant #2 to go to her room and stay there. On 5/29/24 at 12:33 p.m., the administrator acknowledged she was unaware that the residence was required to document a rights modification when staff restrained Resident #2 by telling her to go to her room.

Based on record review and interview, the residence failed to ensure an informed consent for rights modification, was documented in resident records, affecting one of five sample participants (residents) (#1). Findings include 1. Record Review Resident #2 was admitted to the residence on 2/16/18 with diagnoses including mild cognitive impairment. Resident #2's record contained no informed consent (IC) documentation to remove the resident's rights. 2. InterviewOn 5/29/24 at 9:00 a.m., the administrator said that Resident #2 had behaviors that were not controlled by the residence. She stated she issued a 30-day discharge notification to the resident on 5/21/24 after Resident #2 had initiated a physical altercation with Resident #1. On 5/29/24 at 10:13 a.m., the resident care coordinator (RCC) said that Resident #2 had aggressive behaviors toward Resident #2 and that on 5/20/24 Resident #2 hit Resident #1. She said the best way for the resident to calm down was to be in her room. The RCC added that the guardian told her that intervention was effective when Resident #2 was a child. The RCC acknowledged she was unaware the residence was required to document an IC or rights modification when staff restrained her to her room. She acknowledged that she was unaware an IC was required when staff told Resident #2 to go to her room and stay there. On 5/29/24 at 12:33 p.m., the administrator acknowledged she was unaware that the residence was required to document a rights modification when staff restrained Resident #2 by telling her to go to her room.

Based on interview and record review, the facility (residence) failed to ensure a Critical Incident report involving abuse was submitted to the participant's case manager within 24 hours of discovery of the actual or alleged incident, affecting one current resident. (#1)Findings include:1. A care plan for Resident #2 read, in part, as follows. Under the heading Allegations Physical Abuse, there was a checkmark in the box next to "Physical abuse." Underneath, it read: "(Resident #2) hit (Resident #1) with her cup on 5/20/24. See narrative of events for more details."Documentation under the heading Narrative of Events/Additional Information read in part: "(Resident #1) was bugging (Resident #2) at lunch when (Resident #2" told him to stop bugging (them). (Resident #1) continued to talk to her and she got up and went over to (Resident #1) to hit him with her cup. This took place around 12:40 p.m. on May 20, 2024." On 5/29/24 at approximately 10:13 a.m., the resident care coordinator (RCC) said that Resident #2 hit Participant #1 with a cup at lunchtime on 5/20/24. She said she did not report the physical abuse as an occurrence but had documented it in the care plan. She acknowledged that she did not take action when Resident #2 hit Resident #1 with a cup. Although the RCC recognized it as abuse, she failed to respond and report it to Local Law enforcement. On 5/29/24 at 12:34 p.m., the administrator said that she had contacted APS and local law enforcement on 5/29/24 during the onsite investigation to report that Resident #2 had physically hit Resident #1. On 5/29/24 at 1:25 p.m. the RCC said that she had failed to report abuse of a resident to local law enforcement. On 5/29/24 at 1:42 p.m., the administrator acknowledged that the residence failed to report physical abuse of a resident to local law enforcement.

A revisit survey was completed on 12/7/23 for all previous deficiencies cited on 10/12/23. No deficiencies 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 revisit survey was completed on 12/7/23 for all previous deficiencies cited on 6/27/23. No deficiencies 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 recertification survey with complaint #CO33856 was completed on 10/12/23. No deficiencies were cited.

A relicensure survey with complaint #CO33855 was completed on 10/12/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure applicants complied with Colorado Adult Protective Service Data Systems (CAPS) requirements prior to hiring staff who provided care to the residents, for three of four sample staff (#1-#3), affecting 51 current residents. Findings include:1. References and Residence Policya. According to Colorado Revised Statutes (2020) Title 26 Human Services Code," ... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult.b. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado adult protective services data system pursuant to section 26-3.1-111.c. Chapter VII regulations governing assisted living residences, part 2.7, defines an "At-risk person" as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (D) Is a person with an intellectual and developmental disability as defined in Section 25.5-10-202, C.R.S.; (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.2. Record ReviewPersonnel files for Staff #1-#3 revealed no documentation of CAPS requests:Staff #1 had a hire date of 8/1/23. Staff #2 had a hire date of 9/7/23. Staff #3 had a hire date of 9/9/23September and October 2023 schedules revealed the following:Staff #1 worked on 9/18-9/30/23 and 10/1-10/4/23Staff #2 worked on 9/17, 9/21-9/24/23, and 9/28-9/30/23Staff #3 worked on 10/11-10/12/233. ObservationDuring the on site visit on 10/11/23 and 10/12/23, Staff #1 and #2 were observed providing care and services to residents. 4. InterviewOn 10/12/2023 at 11:47 a.m., the administrator confirmed that none of the sample staff files had CAPS documentation. She further stated that the business manager forgot to request CAPS checks for Staff #1-#3.

Based on record review and interview, the residence failed to have a nurse or qualified skilled professional provide the training and competency evaluations for staff providing specialized services affecting six of six sample residents that were diabetic (#4, #7-#11). 1. Residence PolicyThe residence ' s undated diabetic management policy, read in part the residence required all residents to self manage blood glucose readings and insulin injections. Staff cued and reminded residents to take a blood glucose reading. Staff participated in a limited manner to assist with both procedures. The residents placed equipment on their skin and obtained enough blood for a reading independently. Staff did not dial up insulin. 2. Record ReviewOn 10/12/23, a review of personnel files for Staff #1, #2 and #4 revealed no documentation of required training and competency evaluations completed by a nurse or qualified skilled professional. 3. InterviewOn 10/11/23 at 1:34 p.m., Staff #5 stated she assisted Residents #3, #4, #10, and #11 with poking their finger for blood glucose testing and dialing their insulin pens. She stated the resident care coordinator (RCC) had trained her on how to properly do both of these procedures. On 10/12/23 at 7:40 a.m., Staff #6 confirmed that she also received diabetes management training from the RCC.On 10/12/23 at approximately 7:40 a.m., Staff #1 stated her family member trained her how to test for glucose levels and dial insulin pens at another health facility in 2012, confirming that the residence had not provided any training by an appropriately skilled professional to perform these specialized techniques. On 10/12/23 at 8:45 a.m., Resident #7 stated that the qualified medication administration persons (QMAPs) at the residence "poked his finger" to check his blood glucose daily. On 10/12/23 at 8:56, Resident #4 stated two to three times daily, the QMAPs at the residence poked his finger for blood glucose testing. He stated the QMAPs also dialed his insulin pen for him prior to him injecting the insulin himself. He stated he could do it all by himself, adding, "They probably don't trust me."On 10/12/23 at 9:47 a.m., the administrator stated the RCC was a QMAP but was not an appropriately skilled professional qualified to train QMAPs at the residence on specialized techniques beyond general personal care and assistance. She stated that the residence had not provided any training by an appropriately skilled professional for staff to provide assistance with blood glucose testing and dialing insulin pens. Additionally, the administrator stated that an appropriately skilled professional had not completed competency evaluations with the QMAPs to ensure that they understand and can effectively perform these specialized techniques.

Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization such as the American Red Cross, the American Heart Association, the National Safety Council or the American Safety and Health Institute, affecting 51 current residents. Findings include:1. Referencea. According to VeryWell Health, "First aid is the emergency care a sick or injured person gets. In some cases, it may be the only care someone needs, while in others, it may help them until paramedics arrive or they are taken to the hospital. The best way to prepare for these events is to get official first aid training." VeryWell Health (6/23/23) First Aid Instructions for 10 Medical Emergencies, retrieved from: https://www.verywellhealth.com/basic-first-aid-procedures-1298578 2. Record reviewOn 10/12/23, a review of staff first aid certifications revealed Staff #4 had first aid certification from an organization that was not nationally recognized. The staff schedule, dated 9/17/23 to 10/10/23, revealed the following 10 shifts for which Staff #4 worked as the only staff member with certification in first aid. 9/19-9/21/23 2:00 p.m. to 10:00 p.m. 9/27/23 2:00 p.m. to 10:00 p.m. 10/1/23 2:00 p.m. to 10:00 p.m. 10/3-10/5/23 2:00 p.m. to 10:00 p.m. 10/8/23 2:00 p.m. to 10:00 p.m. 10/9/23 6:00 p.m. to 10:00 p.m. The residence's October 2023 staff schedule revealed that there was no staff onsite who had certification in first aid at all on 10/6/23 from 2:00 p.m. to 10:00 p.m. 3. InterviewOn 10/12/23 at 11:47 a.m., the administrator stated the resident care coordinator (RCC) was responsible for ensuring that the staff schedule reflected there was at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization. She stated that the RCC referred to a list of staff who had current certifications in first aid when creating the staff schedule; however, she added, the list was not updated with current information.

Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization such as the American Red Cross, the American Heart Association, the National Safety Council or the American Safety and Health Institute, affecting 51 current residents. Findings include:1. Referencesa. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that's useful in many emergencies, such as a heart attack or near drowning, in which someone's breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to both untrained bystanders and first responders." Mayo Clinic (7/27/23) Cardiopulmonary Resuscitation, retrieved from: https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 b. According to the American Red Cross: "Obstructed Airway Care for Adults ... If the patient is able to speak to you or is coughing forcefully: Encourage the patient to keep coughing but be prepared to clear the airway if the patient's condition changes ... Obtain consent ... Perform abdominal thrusts ... Perform alternate techniques-back blows, chest thrusts, or airway management ... Continue to clear the airway ... If the patient becomes unresponsive, carefully lower them to a firm, flat surface, while protecting their head. Immediately begin CPR, starting with chest compressions. After each set of compressions and before ventilation, open the patient's mouth and look for the object-if seen, remove it using a finger sweep." American Red Cross (2019) Skill Sheet: Obstructed Airway Care for Adults and Children, retrieved from: https://www.redcrosslearning.com/course-bin/bls-healthcare-resuscitation/app/content/a/en-US/resources/SS-Obstructed-Airway-Care-for-Adults-and-Children.pdf 2. Record ReviewOn 10/12/23, a review of staff first aid certifications revealed Staff #4 had CPR certification from an organization that was not nationally recognized. The staff schedule, dated 9/17/23 to 10/10/23, revealed the following eight shifts for which Staff #4 worked as the only staff member with CPR certification:9/19-9/21/23 2:00 p.m. to 10:00 p.m. 9/27/23 2:00 p.m. to 10:00 p.m. 10/1/23 2:00 p.m. to 10:00 p.m. 10/3-10/5/23 2:00 p.m. to 10:00 p.m. 3. InterviewOn 10/12/23 at 11:47 a.m., the administrator stated the resident care coordinator (RCC) was responsible for ensuring that the staff schedule reflected there was at least one staff member onsite at all times who had current certification in CPR from a nationally recognized organization. She stated that the RCC referred to a list of staff who had current certifications in CPR when creating the staff schedule; however, she added, the list was not updated with current 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 7.7.12 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(A) A description of the employee or volunteer duties;(B) Date of hire or acceptance of volunteer service and date duties commenced;(C) Orientation and training, including first aid and CPR certification, if applicable;(D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable;(E) Results of background checks and follow up, as applicable; and(F) Tuberculin test results, if applicable. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner.(A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication. 22.27 The assisted living residence shall prohibit the use of portable heaters in resident rooms. The use of fireplaces, space heaters, and like units that generate heat shall be prohibited in the common areas of the assisted living residence unless the ALR is able to ensure that such devices have a UL (Underwriters Laboratory) or similar certification label, do not present a resident burn risk, and are used in accordance with manufacturer instructions.

A certification complaint, prompted by #CO32581, was completed on 6/27/23. No deficiences were cited.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.400.8.495.6.(G) 1. The Alternative Care Facility is an environment that supports individual comfort, independence and preference, maintains a home-like quality and feel for participants at all times, and provides participants with unrestricted access to the facility in accordance with the residency agreement or modifications as agreed to and documented in the participant's care plan.

A licensure complaint, prompted by #CO30364 and #CO32580 , was completed on 6/27/23. Deficiencies were cited.

Based on interviews and record review, the residence failed to have readily available a roster of current residents, their room assignments and emergency contact information, along with a residence diagram showing room locations, affecting 47 current residents. Findings Include:On 6/27/23 at approximately 7:45 a.m., a resident roster was requested from Staff #5. She stated she did not know the current number of residents or how to obtain a roster. She further stated she would need to ask one of the qualified medication administration person(s) (QMAP) if they knew how. On 6/27/23 at approximately 8:20 a.m., a resident roster was requested from Staff #2. She stated there were forty seven current residents and did not know how to obtain a roster. On 6/27/23 at 8:22 a.m., a resident roster was requested from Staff #3. She stated she was agency staff and did not know the current number of residents or how to obtain a roster. On 6/27/23 at approximately 8:30 a.m., a resident roster was requested from the Activity Director. She stated she was unsure of the exact number of residents. She provided an undated roster list. However, the resident list did not include emergency contact information or a residence diagram that showed room locations. Additionally, the provided resident list contained 48 current residents instead of 47. On 6/27/23 at 8:37 a.m., a request was made for review of the provided roster list with Staff #2. Upon review the roster revealed it had not been updated and several residents that were indicated on the roster as 'active' no longer resided in the residence. On 6/27/23 at 8:48 a.m., a resident roster was requested from the concierge. She stated did not know the current number of residents or how to obtain a roster. On 6/27/23 at approximately 9:15 a.m., a resident roster was requested from the business manager. She stated there were 44 current residents and provided the most accurate roster list. However, the undated resident roster did not include emergency contact information or a residence diagram that showed room locations. Additionally, the provided resident roster contained 51 current residents and labeled "occupancy report for the month of June". On 6/27/23 at 9:23 a.m., request made for review of the provided roster list with the resident care coordinator. She stated there were 48 current residents. She further stated the roster provided was the most up to date and considered to be their resident roster. Upon review the roster revealed it had not been updated, did not include emergency contact information or a residence diagram that showed room locations. On 6/27/23 at 1:54 p.m., the executive director stated the resident roster was located in the residence's emergency preparedness binder located at the concierge desk. She further stated she educated all staff as to the location of the binder and the information contained within. The binder was provided by the executive director. She acknowledged the resident roster did not include emergency contact information therefore, did not meet the requirements.

Based on record review and interviews, the residence failed to ensure comprehensive assessments for residents contained physical, mental, and social support affecting one of four sample residents (#1). Findings Include:Resident #1 was admitted to the residence on 10/28/22 with diagnoses including orofacial dyskinesia, urinary incontinence and bipolar. A progress note dated 4/2/23 read, "While in the dining room after breakfast, (Resident #1) approached me, she was upset she rudely asked me where her laundry was. I replied, I didn't know. As she became increasingly upset she asked me if I could get her laundry. I informed her I didn't know where it was. She exploded and I couldn't really say much more. Shen then went to another caregiver. I told her that she was an agency caregiver and had no idea about her laundry. A kitchen staff member then intervened and advised me to remove myself, which I then did."A progress note dated 6/8/23 read, "I went to administer medication to (Resident #1). I have to be in and out every 15 minutes. I asked (Resident #1) if I could leave the door unlocked since I had to be in and out every 15 minutes for the next hour. (Resident #1) started screaming saying, 'no you may not you may not leave my door open for them to come steal my stuff out of my apartment no you may no, no you may not... I am going to let (staff) know that will not happen.' While she's getting upset, frustrated, screaming crying and rushing down the hallway. I did not say anything more to her because I was in shock due to her explosive behavior."On 6/27/23 at approximately 1:50 p.m. the administrator stated Resident #1 had self reports of self neglect and suicidal ideation. She additionally confirmed Resident #1 had behaviors with staff and she was considering issuing a 30 day notice of discharge because of the behaviors. Review of the residence's comprehensive assessment, dated 11/7/22, revealed independence with mobility, bathing, dressing and incontinence care. The care plan did not reflect the resident's reported behaviors, bipolar disorder, history of suicidal ideations, or the staff tasks necessary to meet those needs. On 6/27/23 at 1:54 p.m., the resident care coordinator stated the residence's assessments were being completed; however, acknowledged the residence's assessments were not updated to reflect the most current information.

Based on interviews and record review, the residence failed to investigate allegations of abuse of residents in accordance with Part 5.3 and its written policy, affecting one of four sample residents (#1). Findings Include: 1. Residence Policies and Referencesa. Chapter II regulations governing assisted living residences defines, in part 1.1, "Abuse" as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish.b. Chapter VII regulations governing assisted living residences part 5.3 reads, "An assisted living residence shall comply with all occurrence reporting required by state law and shall follow the reporting procedures set forth in 6 CCR 1011-1, Chapter 2, Part 4.2. (A) An assisted living residence shall investigate an occurrence to determine the circumstances of the event and institute appropriate measures to prevent similar future situations. (1) Documentation regarding the investigation, including the appropriate measures to be instituted, shall be made available to the Department, upon request. (B) An assisted living residence shall submit its final investigation report to the Department within five business days after the initial report of the occurrence."2. Allegations of abuse and Investigations of allegations The residence's email correspondence, undated, between the executive director and the business manager read the following: The business manager reported to the executive director that Resident #1 claimed she had a heart attack and came back with Takotsubo Cardiomyopathy which she stated is extreme anxiety and caused a heart arrhythmia. The business manager further stated that Resident #1 had no restrictions and called her outside provider to complain and told her outside provider service coordinator that she was being abused at the residence. The outside provider service coordinator contacted the residence to discuss Resident #1's voiced concerns and the needed follow up into the alleged abuse. The email further read, she stated to staff if the residence did not, she would call the department for abuse. The residence's email correspondence, dated 6/13-6/14/23, between the executive director the outside provider service coordinator, the business manager and the resident care coordinator read the following: The outside provider service coordinator reported to the executive director the incident that had occurred with Resident #1 and stated could have serious consequences if not addressed. She further stated she was required to submit an incident report which had already been submitted to the department. The executive director responded and stated she was made aware of the incident. She stated the resident care coordinator could address further, but she would try to assist since at the time of the reported incident she was working from home. The executive director notified the business manager and resident care coordinator in regards to the email received from the outside provider service coordinator. She further stated an incident report submitted by the outside provider service coordinator was filed with the department and she was concerned the residence could get in serious trouble for verbal abuse. The residence's written correspondence, dated 6/24/23, provided to the executive director by the business manager read the following:The business manager reported that Resident #1 came to her and stated the caregivers degraded her and made 'mean' comments to her when she asked for assistance. Resident #1 further stated she felt they were also condescending and made fun of her. The business manager stated she had talked with staff and got a 'whole other story' into what had happened between staff and Resident #1. She stated she spoke with staff on duty and they gave assistance to Resident #1 when asked; however, when assisted Resident #1 became rude to them and staff told the resident they would step out of room if contiued to speak to them in that manner and asked if there was anything else they could assist with. The correspondonce further read, Resident #1 just wanted to let the business office manager know about the staff. The residence failed to provide documentation that an investigation of the allegations of abuse had been initiated or reported prior to the onsite visit. Additionally, there was no occurrence report submitted to the Department. 3. InterviewsOn 6/27/23 at 1:54 p.m., the administrator acknowledged the residence's failure in not documenting the allegations of abuse for Resident #1.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.13.10 Each assisted living residence shall develop and implement an internal process to ensure the routine and prompt handling of grievances or complaints brought by residents, family members, or advocates. The process for raising and addressing grievances and complaints shall be placed in a visible on-site location along with full contact information for the following agencies: (A) The state and local long-term care ombudsman; (B) The Adult Protection Services of the appropriate county Department of Social Services; (C) The advocacy services of the area's agency on aging; (D) The Colorado Department of Public Health and Environment; and (E) The Colorado Department of Health Care Policy and Financing, in those cases where the assisted living residence is licensed to provide services specifically for persons with intellectual and developmental disabilities.