GRACE POINTE CONTINUING CARE SENIOR CAMPUS ASSISTED LIVING

A revisit survey was completed on 12/15/25 for all previous deficiencies cited on 8/12/25. The facility is in compliance with all deficiencies that were cited.

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

A relicensure survey with complaint #CO40673 was completed on 8/12/25. Deficiencies were cited.

Based on observation, interview, and record review, the residence failed to ensure each staff member receivedtraining prior to working independently with a resident for two of three sample staff (#1), (#3) affecting 67 currentresidents. Findings include:1. Observations On 8/12/25 at 8:00 a.m., Staff #3 was observed providing care and services to residents. 2. Record reviewThe personnel file for Staff #3 read was hired 7/28/25 and had no record of specific hands-on training prior toproviding care to residents. 3. Interview On 8/12/2025 at 8:40 a.m., Staff #3 stated she was hired on 7/28/25 as a qualified medication administrationperson (QMAP). She stated she received one day of training as a QMAP and had been working as a direct carestaff to residents ever since, with no specific or hands-on training to the current residents. On 8/12/2025 at 3:52 p.m., the director of nursing stated staff #3 has worked in a secured environment in the pastand should have known what to do. On 8/12/2025 at 4:53 p.m., the administrator stated she expected the staff to be fully trained in specific care for itscurrent residents. Similar deficient practice was identified for Staff #1

Based on record review and interview, the residence failed to have an involuntary discharge grievance policy thatincluded all required elements, affecting 67 current residents. Findings include:A review of the residence's discharge and grievance policies and the termination section of the resident agreement revealed that the residence did not include the following required parts of the involuntary discharge grievance policy: (1) The ability for any of the persons the assisted living residence must notify under Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), within 14 calendar days after the assisted living residence provides written notice of the involuntary discharge. (2) 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. (3) A requirement that no later than 5 business days after the submission of a grievance under subpart (D), the individual designated by the assisted living residence to receive involuntary discharge grievances must respond to the grievance as follows: (a) An oral explanation of the written response must be provided to the resident and/or person filing the grievance, as appropriate.(b) The written response must 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."(4) 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 under Section 24-4-105, C.R.S.(5) A requirement that the assisted living residence must not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal under this Part.(6) A requirement that the resident must be allowed to return to the assisted living residence if all of the following apply:(a) The stated reason for the involuntary discharge in the notice of involuntary discharge provided under Part 11.17 is nonpayment of monthly services or room and board.(b) 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(c) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. On 8/12/25 at 3:00 p.m., the administrator stated the residence's current policy did not meet the generalrequirements for involuntary discharge and the residence was currently working on adding them to the policy.

Based on record review and interview, the residence failed to establish a policy for when a practitioner's assessment is appropriate, and contact a resident's primary practitioner when the resident experiences a significant change in their baseline status, affecting six of eight sample residents (#1, #4 - #8 ). Findings include:1. Residence PolicyOn 8/12/25 at 9:46 a.m., the residence's policy for practitioner assessment was requested; and read the residence would contact the residents practitioner when the following occurs, a significant change in the resident ' s baseline status, evidence of possible infection (open sores, etc.); injury or accident sustained by the resident, known exposure of the resident to a communicable disease; and development of any condition which would have initially precluded admission to the facility. However, the policies provided did not include the circumstances for when a practitioner's assessment was appropriate. 2. Resident #1 was admitted to the residence on 5/18/23. An assessment dated 2/3/25 read in part, Resident #1 was able to attend to self care with no assistance. No practitioner assessment had been completed. A practitioner's order dated 6/25/25, read residence staff were to continue applying pressure socks and lymph pump. The July 2025 electronic medication administration record (eMAR) had not included compression socks. On 8/16/25 at approximately 2:40 p.m., Resident #1's practitioner stated the residence asked his opinion of what to do about Resident #1 ' s lymphedema, the residence voiced no concern regarding the inability to apply the compression socks. On 8/16/25 at 4:53 p.m., the executive director (ED), stated the residence policies were outdated and was updating the policy manual. She was unaware the residence policies did not include the circumstances for when a practitioner's assessment was appropriate, and the requirement to contact a resident's practitioner for a change in baseline; however, expected the requirements to have been included in policy. The ED further stated she would have expected the director of nursing (DON) and staff, to have notified her and contacted the practitioner for Resident #1 ' s lymphedema progression. Similar deficient practice was identified for Residents #4-#8.

Based on record review and interview the residence failed to update each resident's comprehensive assessment at least annually and whenever the resident's condition changes from baseline status, affecting seven of eight sample residents (#1, #2, #4 - #8). Findings Include:1. Residence PolicyThe residence ' s undated change of condition policy read in part, staff will assess residents prior to admission as well as at least annually and with change of condition. 2. Record Review Resident #1 was admitted to the residence on 5/18/23 with the diagnosis of heart failure and lymphedema. An admissions assessment dated 5/18/23 was completed, and a change of condition assessment was completed on 8/24/23. There had been no reassessment until 2/3/25. A practitioner's note dated 7/21/25 read in part, Resident #1 ' s lost her local lymphedema clinic as it closed down. Now weeping from her right lower outer leg. Severe bilateral elephantiasis with broken skin surface right lower leg and weeping of clear fluid. Transfer to Skilled Nursing Facility for daily tight wraps and close care. No further documentation from the residence for the care and changes in Resident #1's conditions was available for department review. Resident #2 was readmitted on 6/14/25 with the diagnosis of spondylolisthesis, progressive neuropathy. An assessment dated 6/16/25 read in part, Resident #2 had no skin integrity concerns. A progress note dated 8/5/25 read in part, Resident #2 went to the primary care provider PCP and received an order for wound care through an outside provider. A nurse from Banner was at the residence on 8/4/25 and dressed the wound. No reassessment or skin assessment had been completed regarding the change of condition. 3. Interview On 8/16/25 at 11:52 p.m., the Director of Nursing (DON) stated she expected assessments to be completed annually or after a resident's change of condition. The DON acknowledged assessments had not been completed per the expectation. On 8/16/25 at 4:53 p.m., the Executive Director stated she expects assessments to be completed annually or after the residents' change of condition and she was unaware the residents' assessments were not being updated. Similar deficient practice was investigated for residents #4- #8.

Based on record review and interview, the residence failed to ensure each care plan had details specific to personal service needs and preferences, along with the staff tasks necessary to meet those needs, affecting six of eight sample residents (#1, #4 - #8). Findings include:Resident #8 was admitted to the residence on 5/1/24 with diagnosis of Alzheimer's disease. On 8/12/25 at approximately 9:00 a.m., resident records were reviewed for Resident #8. After review, the records revealed an assessment dated 5/1/25 read in part, Resident #8 paces and wanders. A care plan for Resident #8 last updated 2/7/24 revealed no mention of pacing or wandering patterns. On 8/12/25 at approximately 8:30 a.m., Staff #3 and Staff #4 stated Resident #8 is exit seeking and constantly paces and wanders the halls and needed to be redirected from the exit doors. On 8/12/25 at approximately 11:15 a.m, the memory care charge nurse stated Resident #8 needs to be constantly redirected by staff from attempting to exit the secured environment. She also stated she was not aware the care plan had no mention of wandering patterns and or why no interventions had been put in place. On 8/12/25 at 4:45 p.m, the director of nursing stated she was in charge of making sure care plans are being kept up to date with the most current assessment information and interventions being in place. Similar deficient practice was identified for Resident #1, #4 and #7.

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 eight of eight sample residents (#1-#8). Findings include:Resident #4 was admitted to the residence on 6/9/23 with pain in hip. A nurses note dated 7/14/25 read in part, Resident #4 Wounds still open but healing. No slough noted. Healthy pink skin. No inflammation. The resident denies pain. On 8/12/25 at approximately 8:30 a.m., Staff #1 stated that Resident #4 often had a yellow pus oozing from the surgical incision and wound. Staff #1 stated Qualified Medication Administration Personnel (QMAP) did not have access to create a progress note in the chart, staff would take their concerns to their lead or manager and no progress note had been submitted. On 8/12/25 at 4:38 p.m., the Director of Nursing (DON) stated she expected the nurse to place a progress note if staff contacted the responsible party, practitioner and when a reassessment had been completed. The DON further stated QMAP ' s and caregivers do not have access to progress notes and do not document prior to the end of their shift, staff often relayed information verbally and the DON expected the nurse to add a progress note. Since the former nurse had stepped down, it was the DON ' s responsibility to ensure progress notes were submitted. The DON stated she reviewed the 24 hour report however was unaware that progress notes were not submitted although she expected one. On 8/12/25 at 4:56 p.m., the Executive Director stated she was unaware of the regulation for staff to document in the progress notes any out of the ordinary events. The DON further stated the DON was responsible for ensuring documentation had been submitted and was not aware that progress notes had not been completed.

Based on observation and interview the residence failed to keep grounds maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction in the secure environment outdoor courtyard, affecting 44 residents in the assisted living residence. Findings include:During an environmental tour on 8/12/25 in the outdoor courtyard of the assisted living residence there was a a five and a half inch drop along the paved sidewalk, spanning approximately 17 feet. The courtyard was located in the central part of the building and was accessible to all residents. At approximately 9:50 a.m., an unknown male resident was seen walking and gardening in the area of the tripping hazard. On 8/12/25, at approximately 11:35 a.m., the plant manager acknowledged the drop-off on the walkway and agreed that it could pose a potential hazard to the residents. On 8/12/25 at approximately 4:53 p.m., the administrator stated she expected the courtyard to be free of trip and fall hazards.

Based on record review and interview, the residence failed to reassess residents every six months for the need of a secure environment, affecting three of three sample residents in the secure environment (#7, #8, #9). Findings include: Resident #7 was admitted to the residence on 7/15/22 with a diagnosis of Alzheimer's disease. The record for Resident #7 contained an evaluation for the secure environment, dated 7/12/22. However, the record contained no further evidence that the residence re-assessed the resident every six months for the need of a secure environment. On 10/15/24 at approximately 11:50 a.m., the director of nursing stated the residence had not been consulting with the resident ' s attending practitioner, family, and/or the resident ' s representative for the continued need for the secured environment every six months. She stated she was not aware of the requirement. Similar deficient practice was found for Residents #8 and #9.

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 existingprogram regulations found at 6 CCR 1011-1, Chapter 7.12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: (B) Detailing in each resident ' s care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment; 14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications.

A licensure complaint, prompted by #CO36283, was completed on 3/18/25. No deficiencies were cited.

A revisit survey was completed on 3/5/24 for all previous deficiencies cited on 10/12/23. The facility is in compliance with all deficiencies that were cited.

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

A relicensure survey with complaints #CO33783 and #CO28666 was completed on 10/11/23. Deficiencies were cited.

Based on interview and record review, the residence failed to only allow a personal care worker to perform tasks that have a chronic, stable, predictable outcome and do not require routine nurse assessment, affecting one former resident (#7). (Cross-reference Q1110)Findings Include:1. ReferenceChapter VII regulations governing assisted living residences, part 2.33, Personal Care Worker, means an individual who provides personal services for any resident. 2. Former Resident #7 was admitted to the residence on 8/18/23 with diagnoses including paraplegia. A family member of Former Resident #7 provided a photo of Former Resident #7's wound taken on 9/25/23. There was a four by four gauze bandage removed from Former Resident #7's bottom. On the coccyx area there were approximately one to two layers of skin gone and the area was the size of a silver dollar. There was white puss present with black and purple spots in and around the wound. There were approximately four additional dark purple bruises adjacent and below the open wound. A progress note in Former Resident #7's record, dated 9/20/23, read there was a new open area observed on Former Resident #7's coccyx area. "Open wound measures 2.7 cm by 2.3 cm by 0.4 cm wound bed contains 40% slough but no drainage noted."The September 2023 medication administration record (MAR) for Former Resident #7 read, "Cleanse open area to coccyx with wound cleanser, pat dry and apply medihoney to wound. Cover with gauze and secure with tape of choice. In the evening every Mon, Wed, Fri, Sun nurse to change Tues, Thurs and Sat. QMAPs (qualified medication administration persons) to change the remainder of days of the week."The September 2023 MAR read that Staff #5 provided the wound care to Former Resident #7 on 9/22/23. The September 2023 staff schedule confirmed Staff #5 worked at the residence on 9/22/23 from 6:00 a.m. to 6:00 p.m. On 10/11/23 at approximately 2:15 p.m., the director of nursing confirmed that an unlicensed staff member cleansed the wound and applied medihoney to Former Resident #7 on 9/22/23. She added she was not aware unlicensed staff were not allowed to perform tasks that were not chronic or stable. On 10/11/23 at approximately 3:00 p.m., the administrator said she was unaware QMAPs were not allowed to cleanse, apply cream and dress a residents open wound.

Based on interview and record review, the residence failed to provide protective oversight including, but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach, affecting one former resident (#7). (Cross-reference Q676, Q1130, Q1146, Q1468)Specifically, care staff noticed redness on Former Resident #7's coccyx on 9/4/23. The care plan update on 9/5/23 revealed a stage one pressure sore on Former Resident #7's bottom due to lack of repositioning. On 9/15/23 the resident care coordinator (RCC) who was also a licensed practical nurse noticed a stage two open wound on Former Resident #7's coccyx. As a result, on 9/15/23, the coccyx wound was a stage two and developed into a stage three on 9/20/23 when the director of nursing (DON) assessed her coccyx. On 9/25/23, Former Resident #7 was sent to the emergency department due to concern for the severity of the pressure sore on her bottom that was diagnosed as stage four, was infected and required two separate antibiotics. Findings Include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.3, defines "Activities of daily living (ADLs)" as those personal functional activities required by an individual for continued well-being, health and safety. As used in this Chapter 7, activities of daily living include, but are not limited to, accompaniment, eating, dressing, grooming, bathing, personal hygiene (hair care, nail care, mouth care, positioning, shaving, skin care), mobility (ambulation, positioning, transfer), elimination (using the toilet) and respiratory care.b. Chapter VII regulations governing assisted living residences, part 2.9, defines "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual ' s need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual's needs. In order to deliver person-centered care, the care plan shall take into account the resident's preferences and desired outcomes. "Care plan" may also mean a service plan for those facilities which are licensed to provide services specifically for the mentally ill.c. Chapter VII regulations governing assisted living residences, part 2.38, defines "protective oversight" as guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following:(B) Monitoring the activities of the resident while on the premises to ensure the resident's health, safety and well-being, including monitoring the resident's needs and ensuring that the resident receives the services and care necessary to protect the resident's health, safety, and well-being.d. "Pressure injuries have been given various names over the last several years, including pressure ulcers, pressure ulcers, or bed sores. Pressure injuries are defined as the breakdown of skin integrity due to pressure. This can occur when a bony prominence is under persistent contact with an external surface. The most common site for pressure injuries is the sacrum ... Wound pressure injuries have been given various names over the last several years. In the past, they were referred to as pressure ulcers, decubitus ulcers, or bed sores; and now they are most commonly termed "pressure injuries." Pressure injuries are defined as the breakdown of skin integrity due to some types of unrelieved pressure. This can be from a bony area on the body coming into contact with an external surface which leads to pressure injury ... Pressure ulcers result from long periods of repeated pressure applied to the skin, soft tissue, muscle, and bone ... It is very important to avoid friction and shear force injuries. These injuries may occur when the patient is sliding down in the bed. For example, when the coccyx bone is moving upwards and the skin is moving downward (i.e., the two forces move in opposite direction), the middle layer which supplies and perfuses the dermis and epidermis may tear, leading to decreased perfusion and eventually resulting in a pressure injury. There are various stages of pressure injury, all of which classify the injury based on the depth of skin injury. Pressure ulcers are categorized into four stages: Stage 1: just erythema of the skin. Stage 2: erythema with the loss of partial thickness of the skin including epidermis and part of the superficial dermis. Stage 3: full thickness ulcer that might involve the subcutaneous fat. Stage 4: full thickness ulcer with the involvement of the muscle or bone ...Proper repositioning is essential in maintaining skin integrity and is needed in patients who are unable to do this for themselves. Pressure, friction, and shear forces should be avoided during positioning. The most effective way of repositioning is to move the patient every 2 hours so that the ischemic areas can recover. This can be done with the use of pillows or wedges to keep the patient on their side and placing pillows between their legs and under their calves helps take pressure off their back, buttocks, medial aspect of the knees, and heels." National Library of Medicine (2023), Wound Pressure Injury Management. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK532897/#:~:text=Stage%201%3A%20just%20erythema%20of,of%20the%20muscle%20or%20bone e. The residence's updated Resident Agreement, read in part, "The care points may be changed immediately by the provider upon assessment. Assessments include, but are not limited to, a change of condition, decline in physical and medical condition of resident, and an increased need of care services for resident ... The following services are provided by (Residence) and are included in the monthly rate ... 24 hour protective oversight ... Person-centered care plan and assistance with activities of daily living such as dressing, bathing, shaving, oral hygiene, hair care, etc., standby assist with transfers ... health assessment services and safety checks."f. The residence's undated Care Plan policy, read in part, "The facility shall develop and implement a written person-centered care plan for each resident, and consistent with resident rights, shall be developed with the resident/resident representative to include goals for admission and discharge and desired outcomes. The care plan will promote choice, mobility, independence, safety, personal service needs and preferences. THe care plan is used to monitor and oversee each resident's care needs ... The care plan shall be revised to reflect the results of the reassessment."2. Former Resident #7 was admitted to the residence on 8/18/23 and discharged from the residence on 9/25/23. A preadmission practitioner's assessment, dated 7/25/23, read in part, "Monitor for pressure wounds."An undated pre-admission assessment completed by the residence, read that Former Resident #7 required moderate assistance with bathing, minimal assistance with dressing, assistance of one person when pulling up pants. Former Resident #7 was wheelchair bound and required the use of a slide board for transfers. An assessment in Former Resident #7's record, dated 8/18/23 and signed 8/24/23, read that Former Resident #7 required assistance with bathing twice weekly, dressing, toileting, transfers and mobility. She required the use of a slide board and had skin integrity concerns; however, the specific skin integrity concerns were not listed. A care plan in Former Resident #7's record, dated 8/18/23 and revised on 9/5/23, read that Former Resident #7 required maximum assistance with bathing, required assistance with dressing/undressing and assistance with toileting. Former Resident #7 had limited physical mobility and required maximum staff assistance with transfers and required an assistive device. Additionally it read, "The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury though the next review date 8/17/24 ... The resident has potential/actual impairment to skin integrity of the buttocks, back and back of legs (due to) pressure and lack of repositioning. Resident refuses to sleep in hospital bed. Resident spends most of her days in a electric wc (wheelchair) ...The resident's skin injury stage I (one) to buttocks will be healed by review date." The care plan read Former Resident #7 required pressure relieving/reducing mattress, pillows, sheepskin padding to protect the skin while in bed. Progress notes for Former Resident #7 for August and September 2023 revealed the following:On 8/21/23, staff reported Former Resident #7 required three to four staff members to assist her with transfers. Additionally, Former Resident #7 preferred to stay in her wheelchair to sleep and was uncomfortable in the respite bed provided. On 8/22/23, it took three staff to take Former Resident #7 to the bathroom. The wheelchair did not fit well in the bathroom and the transfer was difficult. Former Resident #7 was weak and unable to use her upper body to assist. On 8/23/23, a communication was had with the Former Resident #7's family member concerned about the increased staff ratio assistance required. Specifically, Former Resident #7 "was one person assist at previous rehab and has been struggling with transfer once admitting that is not resolving after allowing adjustment period to community ... Did mention to son that it may be needed for resident to go to (rehab) to build up strength again to where she is able to assist with transfer board and transfers again."On 8/24/23, Former Resident #7 refused to sleep in her bed and slept in her wheelchair. On 8/28/23, Former Resident #7 required a two person transfer assist on 8/26/23 and one person assist on 8/27. On 9/5/23, the DON spoke with Former Resident #7's family member on 8/25/23 about her increased level of care. Former Resident #7 required max assistance with activities of daily living, transfers and grooming. "Resident is at risk for skin breakdown d/t (due to) refusing to sleep in her hospital bed."On 9/5/23, staff reported Former Resident #7 had redness on her buttocks. The RCC wrote, "At assessment, resident had pink discoloration to both buttocks and sacral areas ... Resident did (complain of) pressure and discomfort to touch. Skin is intact."On 9/6/23, a daily schedule, titled up/down schedule was created by an external hospice representative to help prevent further skin damage. On 9/14/23, staff reported Former Resident #7 had redness on her bottom. On 9/15/23, staff reported a red spot on Former Resident #7's bottom was beginning to open. On 9/20/23, the RCC observed a new open area to Former Resident #7's coccyx area. "Open wound measures 2.7 cm by 2.3 cm by 0.4 cm wound bed contains 40% slough but no drainage noted."A written practitioner's order, dated 9/21/23 read, "Please get her on her feet for five minutes every hour until coccyx ulcer heals."On 9/25/23, Former Resident #7 was transported to the emergency department to have the coccyx wound further evaluated. External therapy representative notes for August and September 2023 revealed the following:On 8/25/23, Former Resident #7 required assistance from two staff members for slide board transfer. Daily skin checks needed. On 8/31/23, it was recommended to residence staff that Former Resident #7 required two staff members for all transfers. On 9/4/23, bilateral buttocks redness was noted. Former Resident #7 was educated that staff at the residence do not have rehabilitation training to provide assistance at the assisted living residence that she required and was at risk for skin breakdown. On 9/15/23, "It was later discovered that pt (Former Resident #7) has what appears to be a stage 2 wound on her coccyx/buttocks area, which was reported to pt from aides when they were helping her undress and complete hygiene last night. DON was obtained and assessed the wound ... Family educated that nursing oversight of this type of wound is critical to preventing further problems ..."On 9/18/23, there was slight improvement to the coccyx pressure sore. On 9/20/23, a second coccyx pressure sore was noted and was opened, at a stage three with fatty tissue present. Former Resident #7 was in bed for 12 plus hours during the night. On 9/21/23, an external hospice nurse assisted the DON with wound care and a bandage change. The DON stated that Former Resident #7's coccyx wound was a stage three. DON applied wound dressing. Former Resident #7 had not been transferred to the shower chair since 9/15/23 to sit over the commode. Former Resident #7 still required two staff when transferring. An additional external therapy representative note, dated 9/25/23 read in part, "Upon arrival in room it was also noted that pt (patient) was not positioned in side-lying nor was the wound off-loaded at all ... PA (practitioner assistant) guided this clinician that if this clinician had concerns about the health and safety of the pt, then calling 911 was always advised for the safety of the pt. Pt at this time was in agreement to call 911, but wanted to see what her wound actually looked like, since she had never seen a picture of it. Pt required total A (assist) for changing brief, and wound dressing was partially attached to wound area. Pt stated that it had been changed by QMAP/aide Sunday morning (9/24/23) but that no one else had looked at it. Pt provided this clinician her phone, and clinician took two photos of wound on pt ' s phone for pt to see. Pt became upset, and set (sic) pictures to her son. Pt required total A to dress LE (lower extremity), and min a for UE (upper extremity) drsg (sic). Pt called her son, and discussed PA recommendation for 911 call if pt felt her health and safety were at risk."An undated document in Former Resident #7's record read in part, "Up/down schedule for (Former Resident #7): 7:00-8:00 a.m. patient should be awakened, dressed in brief, bowel program initiated. 8:45-10:00 Therapy/nursing to assist out of bed -2 person- participating in therapy-toileting program, secured in wheelchair- lunch and on own in wheelchair doing pressure reduction tilting in chair every 10 min. 3:00-5 pm down time - nursing - 2 person slide board to bed, positioning in bed for down time 2 hours, checking skin- butt paste at this time. 5:00 pm - nursing to get patient up into wheelchair slide board - 2 person. Patient down to dinner, weight shifting/tilting in chair and own personal activity time. 7:00 pm-8:00 - Nursing to assist - 2 person with slide board recliner to bed, undressed and secure on side. Skin check, boots placed on. An external ambulance report, dated 9/25/23, read in part, "Patient states she had suffered a spinal stroke prior to being admitted into the facility. Patient states after the stroke she has become paraplegic and has no feeling or sensation from the waste down. Patient states she developed the bed sore/ open wound while in the facility. Patient states when the wound was discovered it was already in the 2nd stage. Patient states she received an inadequate amount of care to prevent it to the 3rd stage. Patient's wound was in the 3rd stage upon EMS arrival. Patient states she was unaware of the wound or what it looked like because she could not see or feel it until the day the ambulance was called when a picture was taken. Patient states the staff has not been cleaning or changing bandages appropriately. Patient states they changed the bandaging approximately every other day. Patient states there has not been a nurse there to look or care for the wound. Patient states the facility has been having qmaps change the bandages."External emergency department admission paperwork for Former Resident #7, dated 9/25/23 to 10/3/23 read that Former Resident #7 had a stage four infected pressure wound on her coccyx. Former Resident #7 was started on antibiotics. A family member of Former Resident #7 provided a photo of Former Resident #7's wound taken on 9/25/23. There was a four by four gauze bandage removed from Former Resident #7's bottom. On the coccyx area there were approximately one to two layers of skin gone and the area was the size of a silver dollar. There was white puss present with black and purple spots in and around the wound. There were approximately four additional dark purple bruises adjacent and below the open wound. The care plan in Former Resident #7's record, dated 8/18/23 and revised on 9/5/23, did not reflect the most current assessment information. The care plan did not detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs after coccyx wounds developed on 9/14/23 and subsequently worsened to a stage three on 9/20/23 and a stage four wound upon Former Resident #7's arrival at the emergency department on 9/25/23. 3. InterviewsOn 10/10/23 at approximately 12:00 p.m., an external therapy representative (ETR) said the assisted living residence was not the right level of care for Former Resident #7. She added, on 9/15/23 there was a stage two wound found on Former Resident #7's buttocks by the QMAPS that were helping her. She added on 9/18/23 the wound was still present and on 9/20/23 there was another wound found on her buttocks. On 9/21/23 the DON confirmed one of the wounds on her buttocks was a stage three. The ETR said a nurse had not looked at the wound over the weekend on 9/23 and 9/24/23 and that the care staff changed the bandages. The ETR said Former Resident #7 remained in bed during the night into the morning for approximately 12-13 hours and said Former Resident #7 told her staff did not rotate her from side to side when she was in bed. The ETR said Former Resident #7's skin on her buttocks was unopened and intact when she moved into the residence. The ETR said there were discussions with management about Former Resident #7 possibly being transferred to another residence so that a higher level of care could be received. On 10/11/23 at 10:12 a.m., the practitioner for Former Resident #7 said the pressure wounds on Former Resident #7 began on 9/4/23, when redness was noted, through 9/25/23. He added he wrote an order for staff to stand up Former Resident #7 for five minutes every hour. He added, staff could apply any ointment to the wound, however, staff needed to reposition the resident to avoid the worsening of the wound. On 10/11/23 at 10:54 a.m., Former Resident #7 said she did not have the wounds on her buttocks when she moved into the residence in August 2023. Former Resident #7 said the staff did not consistently bandage the wounds on her buttocks. She added, she was numb from the waist down and unable to see the wound on the bottom. Therefore, she stated she had to take the staff's word for what the wound looked like. She also stated when she saw the picture the ETR took, she felt sick due to the severity of the wound. She added that staff were supposed to take care of her by applying bandages and medicine, however, staff were not doing so consistently. Further, Former Resident #7 stated staff was supposed to reposition her every two hours and they failed to do so. She stated when she asked staff if the wound was "okay", they would tell her it was okay. She added by the time she was admitted to the hospital on 9/25/23, the wound developed into a stage four wound. Former Resident #7 said at one point she was going to be transferred to a place that could provide a higher level of care, however, she was never discharged from the residence. Former Resident #7 stated she followed the recommendations of the therapists. She added, "If they would have caught it right away and took care of it right away it wouldn't have gotten as bad. The doctor said the same thing...that it was a stage four. It was scary ... I was there, but not there. When you need the help and you can't get it...I am helpless. I could have gotten a lot better care. This is what I am paying these people for. A lot of money. You call somebody and ask for a bandage change...they don't come back for two hours. I sat for two and a half hours...it was 11pm at night. I kept calling saying they'd be back. Seemed to be like that all the time."On 10/11/23 at approximately 12:30 p.m., Confidential Staff #1 said Former Resident #7 was not independent with slide board transfers when she arrived to the residence in August 2023. S/he added Former Resident #7 required two staff for transfer assistance. S/he added it was discussed around 9/5/23 to transfer Former Resident #7 to a residence with a higher level/skilled nursing care but because of a medication error involving coumadin that happened with Former Resident #7, she would be transferred to a higher level of care and would remain at the assisted living residence. Confidential Staff #1 said the care provided to Former Resident #7 was inconsistent and she was not getting the care she needed. On 10/11/23 at 2:18 p.m., the DON said Former Resident #7 was paraplegic from a recent spinal stroke and she required standby assistance from staff for transfers with the use of a slide board. The DON said Former Resident #7 was progressing well as of 9/18/23 and on 9/20/23 there was a moisture related spot on Former Resident #7's right buttocks. She added the spot was a stage three and the residence initiated a daily schedule called up/down where staff were to get her up and out of bed throughout the day and wound care. The DON said there were plans to move Former Resident #7 to a higher level of care but she was sent to the emergency department by a former external therapy representative and did not return to the residence. On 10/11/23 at 3:15 p.m., the RCC, said the care staff were expected to encourage Former Resident #7 to adhere to the up/down schedule created and to reposition her from side to side as needed. She added, Former Resident #7 rotated herself in bed. On 10/11/23 at approximately 3:30 p.m., the administrator said she thought Former Resident #7 remained independent with transfers throughout her time at the residence. She added she was not aware Former Resident #7 required maximum assistance with transfers.

Based on interview and record review the residence failed to contact the resident's practitioner when the resident has physical signs of possible infection (open sores, etc.) and/or develops any condition which would have initially precluded admission to the facility, affecting one former resident (#7). (Cross-reference Q1110)Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.37, defines a "Pressure sore" (also called pressure ulcer, decubitus ulcer, bed-sore or skin breakdown) as an area of the skin or underlying tissue (muscle, bone) that is damaged due to loss of blood flow to the area. Symptoms and medical treatment of pressure sores are based upon the level of severity or "stage" of the pressure sore.(A) Stage 1 affects only the upper layer of skin. Symptoms include pain, burning, or itching and the affected area may look or feel different from the surrounding skin.(B) Stage 2 goes below the upper surface of the skin. Symptoms include pain, broken skin, or open wound that is swollen, warm, and/or red, and may be oozing fluid or pus.(C) Stage 3 involves a sore that looks like a crater and may have a bad odor. It may show signs of infection such as red edges, pus, odor, heat, and/or drainage.(D) Stage 4 is a deep, large sore. The skin may have turned black and show signs of infection such as red edges, pus, odor, heat and/or drainage. Tendons, muscles, and bone may be visible.b. The residence's undated Physician Assessment Policy, read in part, "The facility will contact the resident's primary practitioner when any of the following circumstances occur and follow the practitioner's recommendation regarding further action ... evidence of possible infection (open sores, etc.)."2. Former Resident #7 was admitted to the residence on 8/18/23 with diagnoses including paraplegia. Progress notes for Former Resident #7 for September 2023 revealed the following:On 9/5/23 staff reported Former Resident #7 had redness on her buttocks. The resident care coordinator (RCC) wrote, "At assessment, resident had pink discoloration to both buttocks and sacral areas ... Resident did (complain of) pressure and discomfort to touch. Skin is intact."On 9/6/23 an up/down schedule was created by an external hospice representative to prevent further skin damage. On 9/14/23 staff reported Former Resident #7 had redness on bottom. On 9/15/23 staff reported a red spot on Former Resident #7's bottom was beginning to open. On 9/15/23 the RCC observed a new open area to Former Resident #7's coccyx area. "Open wound measures 2.7 cm by 2.3 cm by 0.4 cm wound bed contains 40% slough but no drainage noted."On 10/11/23 at 10:12 a.m., the practitioner for Former Resident #7 said he was not notified on 9/14 or 9/15/23 about Former Resident #7's coccyx redness and subsequently open sore. He added the first time he was informed was on 9/20/23 by the nursing staff. On 10/11/23 at approximately 3:30 p.m., the administrator said she expected the residence to notify the practitioner when the residence staff first noticed the open sore.

Based on interview and record review, the residence failed to update the comprehensive assessment whenever the resident's condition changed from baseline status, affecting one former resident (#7). (Cross-reference Q1110)Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(B) Information regarding the resident's overall health and physical functioning ability.b. The residence's undated resident agreement read, in part, "Assessments include, but are not limited to, a change of condition, decline in physical and medical condition of resident, and an increased need of care services for resident."2. Former Resident #7 was admitted to the residence on 8/18/23 with diagnoses including paraplegia. An undated pre-admission assessment completed by the residence, read that Former Resident #7 required moderate assistance with bathing, minimal assistance with dressing, assistance of one person when pulling up pants. Former Resident #7 was wheelchair bound and required the use of a slide board for transfers. An assessment in Former Resident #7's record, dated 8/18/23 and signed 8/24/23, read that Former Resident #7 required assistance with bathing twice weekly, dressing, toileting, transfers and mobility. She required the use of a slide board with one staff. External therapy representative notes for August and September 2023 revealed the following:On 8/25/23, Former Resident #7 required assistance from two staff members for slide board transfers. Daily skin checks needed. On 8/31/23, it was recommended to residence staff that Former Resident #7 required two staff members for all transfers. On 9/4/23, bilateral buttocks redness noted. Former Resident #7 was educated that staff at the residence do not have rehabilitation training to provide assistance at the assisted living residence that she required and was at risk for skin breakdown. On 9/15/23, "It was later discovered that pt (Former Resident #7) has what appears to be a stage 2 wound on her coccyx/buttocks area, which was reported to pt from aides when they were helping her undress and complete hygiene last night. DON was obtained and assessed the wound ... Family educated that nursing oversight of this type of wound is critical to preventing further problems ..."On 9/20/23, a second coccyx wound was noted and was opened, at a stage three with fatty tissue present. Former Resident #7 was in bed for 12 plus hours during the night. Progress notes for Former Resident #7 for August and September 2023 revealed the following:On 8/21/23 staff reported Former Resident #7 required three to four staff members to assist her with transfers. Additionally, Former Resident #7 preferred to stay in her wheelchair to sleep and was uncomfortable in the respite hospital bed provided. On 8/22/23, it took three staff to take Former Resident #7 to the bathroom. The wheelchair did not fit well in the bathroom and the transfer was difficult. Former Resident #7 was weak and unable to use her upper body to assist. On 8/23/23 a communication was had with the Former Resident #7's family member concerned about the increased staff ratio assistance required. Specifically, Former Resident #7 "was one person assist at previous rehab and has been struggling with transfer once admitting that is not resolving after allowing adjustment period to community ... Did mention to son that it may be needed for resident to go to (rehab) to build up strength again to where she is able to assist with transfer board and transfers again."On 8/24/23 Former Resident #7 refused to sleep in her bed and slept in her wheelchair. On 8/28/23 Former Resident #7 was a two person assistance on 8/26/23 and one person assist on 8/27/23. On 9/5/23 the director of nursing (DON) spoke with Former Resident #7's family member on 8/25/23 about her level of care. Former Resident #7 required maximum staff assistance with activities of daily living, transfers and grooming. "Resident is at risk for skin breakdown d/t (due to) refusing to sleep in her hospital bed."On 9/5/23 staff reported Former Resident #7 had redness on her buttocks. The resident care coordinator (RCC) wrote, "At assessment, resident had pink discoloration to both buttocks and sacral areas ... Resident did (complain of) pressure and discomfort to touch. Skin is intact. On 9/6/23 an up/down schedule was created by an external hospice representative to prevent further skin damage. On 9/14/23 staff reported Former Resident #7 had redness on her bottom. On 9/15/23 staff reported a red spot on Former Resident #7's bottom was beginning to open. On 9/15/23 the RCC observed a new open area to Former Resident #7's coccyx area. "Open wound measures 2.7 cm by 2.3 cm by 0.4 cm wound bed contains 40% slough but no drainage noted."The service plan for Former Resident #7, dated 8/18/23 and revised on 9/5/23, read Former Resident #7 had a stage one pressure sore on her bottom from lack of repositioning. There was no evidence that the comprehensive assessment for Former Resident #7 was updated to reflect the change in baseline status after Former Resident #7 had an open coccyx wound on her bottom on 9/15/23 and an additional open wound on her coccyx on 9/20/23. On 10/10/23 at 7:26 a.m., Staff #7 said Former Resident #7 started declining when she moved in and required more assistance from staff. On 10/10/23 at 7:44 a.m., Staff #6 said when Former Resident #7 moved into the residence she needed help from two staff to transfer in and out of the bed and after a while she was a one person transfer. She added staff applied cream to the wound on her bottom that developed a couple days after she was admitted to the residence. On 10/10/23 at 8:50 a.m., Staff #1 said when Former Resident #7 moved in she required two to three staff to transfer her in and out of bed. She added Former Resident #7 had open sores on her bottom but did not know when they first started and staff were required to put lotion on her bottom. On 10/11/23 at approximately 4:00 p.m., the administrator said she expected the comprehensive assessments for residents to be updated when residents experienced a change in condition and every six months. The administrator said a new wound on a resident (including the former resident) was considered a change from baseline.

Based on record review and interview, the residence failed to be responsible for complying with authorized practitioners orders associated with medication administration, affecting one of five sample residents (#3) and one former resident (#7). (Cross-reference Q1110, Q1514, Q1522) Findings Include:1. References and Residence Policya. "Coumadin is an anticoagulant (blood thinner). Warfarin reduces the formation of blood clots. Coumadin is used to treat or prevent blood clots in veins or arteries, which can reduce the risk of stroke, heart attack, or other serious conditions ... Take Coumadin exactly as prescribed by your doctor. Follow all directions on your prescription label ... Do not take warfarin in larger or smaller amounts or for longer than your doctor tells you to ... An overdose can cause excessive bleeding." Drugs.com (2023), coumadin. Retrieved from: https://www.drugs.com/coumadin.html b. "A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results. Prothrombin is a protein made by the liver. It is one of several substances known as clotting (coagulation) factors. When you get a cut or other injury that causes bleeding, your clotting factors work together to form a blood clot. How fast your blood clots depends on the amount of clotting factors in your blood and whether they're working correctly. If your blood clots too slowly, you may bleed too much after an injury. If your blood clots too fast, dangerous clots may form in your arteries or veins. A PT/INR test helps diagnose the cause of bleeding or clotting disorders. It also checks to see if a medicine that prevents blood clots is working the way it should." National Library of Medicine (2022), Prothrombin Time Test and INR (PT/INR). Retrieved from: https://medlineplus.gov/lab-tests/prothrombin-time-test-and-inr-ptinr/ c. "For patients who are on anticoagulant therapy, the therapeutic INR ranges between 2.0 to 3.0. INR levels above 4.9 are considered critical values and increase the risk of bleeding ... INR above the therapeutic range is associated with increased risk of bleeding among which the most concerning condition is an intracranial hemorrhage. Patients can also present with gastrointestinal bleeding, hematuria or bleeding from any other site." National Library of Medicine (2023) International Normalized Ratio (INR), retrieved from: https://docs.google.com/document/d/1q2gLbv8dExBfOeTXqHru0O9PBLJhzHnI_Sh4EVwM1oI/edit d. "Atrial fibrillation, often called AFib or AF, is the most common type of treated heart arrhythmia. An arrhythmia is when the heart beats too slowly, too fast, or in an irregular way ... Treatment for AFib can include ... Blood-thinning medicine to prevent blood clots from forming and reduce stroke risk." Centers for Disease Control and Prevention (2022), Atrial Fibrillation. Retrieved from: https://www.cdc.gov/heartdisease/atrial_fibrillation.htm e. The residence's Medication Administration policy, dated January 2019, read in part, "The facility shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers."2. Former Resident #7 was admitted to the residence on 8/18/23, with diagnoses including atrial fibrillation.a. Coumadin (Warfarin)A written practitioner's order, dated 8/18/23, directed the residence to administer Warfarin 2.5 mg at bedtime. However, the August 2023 MAR for Former Resident #7 read to administer Warfarin 2.5 mg every morning and at bedtime; twice daily instead of once daily. The residence administered an additional dose of Warfarin on 8/19- 8/29/23 for a total of eleven extra doses administered. A preadmission progress note, dated 8/14/23, written by Former Resident #7's external therapy provider, read her INR results were 2.2 on 7/27/23. An external service provider note, dated 8/30/23 read that the Former Resident #7 was not taking warfarin as ordered and Former Resident #7's INR results were 6.23 on 8/28/23 and 5.6 on 8/30/23. On 10/10/23 at 11:30 a.m., a family member of Former Resident #7 said the residence administered the incorrect dose of Warfarin and as a result Former Resident #7's INR results increased. On 10/11/23 at 10:12 a.m., the practitioner for Former Resident #7 said, "A high increase in INR is attributed to the double dose."On 10/11/23 at 10:54 a.m., Former Resident #7 said a normal INR result for her was around 2.2. She added she had received double doses of Warfarin in August and her INR results increased to 6.2. On 10/11/23 at 2:18 p.m., the DON said the previous resident care coordinator entered Warfarin into the medication administration system to be administered twice daily instead of once daily. The DON stated she noticed the error on 8/30/23. On 10/11/23 at approximately 4:00 p.m., the administrator stated she was informed about the medication error for Former Resident #7. She added she expected resident medications to be administered as ordered. 2. Resident #3 was admitted on 7/5/23 to a secure environment portion of the residence with diagnoses including dementia. Record review, and interview revealed similar deficient practice for Resident #3.

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor conducted quarterly audits of medication administration records, controlled substance lists, medication error reports, and medication disposal records for completeness and accuracy, affecting five residents (#1, #2, #3, #4, #5) whose medications were administered by the residence. Findings Include:1. Record ReviewOn 10/10/23 at 8:25 a.m. medication audits were requested. Upon review of medication audit records, revealed the administrator did not perform audits in tandem with the QMAP supervisor per regulations. 2. InterviewsOn 10/11/23 at approximately 2:45 p.m. the director of nursing (DON) stated she was responsible for performing the medication audits with the resident care coordinator (RCC). The DON confirmed she was unaware that medicine audits were to be performed in tandem with the administrator per regulations. On 10/11/23 at 3:10 p.m. the RCC confirmed that she did not complete medication audits with the administrator as required.

Based on record review and interview, the residence failed to ensure the resident's authorized practitioner was notified of a medication error that affected a resident, affecting one Former Resident (#7). (Cross-reference Q1468)Findings include:1. References and Residence Policya. "Coumadin is an anticoagulant (blood thinner). Warfarin reduces the formation of blood clots. Coumadin is used to treat or prevent blood clots in veins or arteries, which can reduce the risk of stroke, heart attack, or other serious conditions ... Take Coumadin exactly as prescribed by your doctor. Follow all directions on your prescription label ... Do not take warfarin in larger or smaller amounts or for longer than your doctor tells you to ... An overdose can cause excessive bleeding." Drugs.com (2023), coumadin. Retrieved from: https://www.drugs.com/coumadin.html b. "A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results. Prothrombin is a protein made by the liver. It is one of several substances known as clotting (coagulation) factors. When you get a cut or other injury that causes bleeding, your clotting factors work together to form a blood clot. How fast your blood clots depends on the amount of clotting factors in your blood and whether they're working correctly. If your blood clots too slowly, you may bleed too much after an injury. If your blood clots too fast, dangerous clots may form in your arteries or veins. A PT/INR test helps diagnose the cause of bleeding or clotting disorders. It also checks to see if a medicine that prevents blood clots is working the way it should." National Library of Medicine (2022), Prothrombin Time Test and INR (PT/INR). Retrieved from: https://medlineplus.gov/lab-tests/prothrombin-time-test-and-inr-ptinr/ c. "Atrial fibrillation, often called AFib or AF, is the most common type of treated heart arrhythmia. An arrhythmia is when the heart beats too slowly, too fast, or in an irregular way ... Treatment for AFib can include ... Blood-thinning medicine to prevent blood clots from forming and reduce stroke risk." Centers for Disease Control and Prevention (2022), Atrial Fibrillation. Retrieved from: https://www.cdc.gov/heartdisease/atrial_fibrillation.htm d. The residence's Medication Administration policy, dated January 2019, read in part, "The facility shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers."2. Former Resident #7 was admitted to the residence on 8/18/23, with diagnoses including atrial fibrillation.a. Coumadin (Warfarin)A written practitioner's order, dated 8/18/23, directed the residence to administer Warfarin 2.5 mg at bedtime. However, the August 2023 medication administration record (MAR) for Former Resident #7 read Warfarin 2.5 mg was administered every morning and at bedtime; twice daily instead of once daily. The residence administered an additional dose of Warfarin on 8/19- 8/29/23 for a total of eleven extra doses administered. A preadmission progress note, dated 8/14/23, written by Former Resident #7's external therapy provider, read her INR results were 2.2 on 7/27/23. An external service provider note, dated 8/30/23 read that Former Resident #7 was not taking warfarin as ordered and caused Former Resident #7's INR results were 6.23 on 8/28/23 and 5.6 on 8/30/23. On 10/10/23 at 11:30 a.m., a family member of Former Resident #7 said the residence administered the incorrect dose of Warfarin and as a result Former Resident #7's INR results increased. On 10/11/23 at 10:12 a.m., the practitioner for Former Resident #7 said he was not notified of the medication error until 9/25/23. On 10/11/23 at 10:54 a.m., Former Resident #7 said a normal INR result for her was around 2.2. She added she had received double doses of Warfarin in August and her INR results increased to 6.2. On 10/11/23 at 2:18 p.m., the DON said she did not notify Former Resident #7's practitioner of the medication error and had only notified the external coumadin clinic representative. On 10/11/23 at approximately 4:00 p.m., the administrator stated the external coumadin clinic representative was responsible for notifying the practitioner if there was a medication error. She added she was unaware the external coumadin clinic representative had not notified Former Resident #7's practitioner of the medication error.

Based on interview and record review, the residence failed to hold quarterly meetings to allow residents, their family members, friends and representatives to provide mutual support and share concerns about the care and services with the secure environment, affecting 21 current residents who resided in the secure environment. Findings Include:On 10/10/23 at 8:35 a.m., the last family council quarterly meetings were requested. However, no such meeting documents were provided. On 10/10/23 at approximately 9:00 a.m., the administrator confirmed quarterly family meetings for the secured environment were not happening, as required.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.400.8.7 Each assisted living residence shall have at least one staff member onsite at all times who has 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. The certification shall either be in Adult CPR or include Adult CPR.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. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications. 14.33 The assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of:(B) A resident's pattern of refusal14.44 The assisted living residence shall have policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and/or expired medications which are not returned to the resident or legal representative. At a minimum, the policies and procedures shall include the following requirements: (A) Outdated, discontinued, and/or expired medications shall be destroyed in accordance with federal, state, and local regulations within thirty (30) days. 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident's condition changes from baseline status.(A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident's attending practitioner, family, and/or resident's representative and review service documentation dating back to the most recent comprehensive assessment.