CROSSROADS AT LAKEWOOD

A revisit survey was completed on 2/3/25 for all previous deficiencies cited on 6/3/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 2/3/25 for all previous deficiencies cited on 6/3/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO37027, was completed on 8/13/24. No deficiencies were cited.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.

A COVID-19 Infection Control focused revisit was completed on 6/3/24 for all previous deficiencies cited on 2/24/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 6/14/23 and the Chapter VII regulations were implemented on 11/15/23.

A licensure complaint revisit was completed on 6/3/24 for all previous deficiencies cited on 2/14/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 6/14/23 and the Chapter VII regulations were implemented on 11/15/23.

Based on observation, interview, and record review, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting four of six sample residents (#2, #22, #45, #48). This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence Policy and Referencea. The residence's, undated, medication administration policy read in part: If medication errors or discrepancies occur, the error or discrepancy must be described in detail in the resident record and on an incident report. Appropriate action must be taken to correct the error and this action would have been recorded on the incident report. Medication errors would immediately be brought to the administrator's attention. 2. Resident #48 was admitted to the residence on 1/22/24 with no related diagnoses.a. On 5/30/24 at 7:51 a.m., Staff #29 prepared medications for Resident #48. She stated the resident required her medications to be crushed for administration. Staff #29 subsequently removed the resident's olanzapine from the medication cup and stated that the medication was not crushable and stated the rest of the medications were okay to crush. Staff #29 subsequently crushed the medications and administered them to Resident #48. A written practitioner's order, dated 1/22/24, directed the residence to administer atorvastatin 80 once daily, furosemide 20 mg once daily, and multivitamin once daily. However, the written practitioner's order did not instruct the residence to crush the medications and the May 2024 medication administration record (MAR) did not reveal directions for staff to crush the medication. A written practitioner's order, dated 1/23/24, directed the residence to administer lisinopril 2.5 mg once daily, metoprolol succinate extended-release 25 mg once daily, and vitamin D3 2,000 units once daily. However, the written practitioner's order did not instruct the residence to crush the medications and the May 2024 MAR did not reveal directions for staff to crush the medication. The record for Resident #48 revealed no evidence of an order to crush medications. b. A written practitioner's order, dated 1/23/24, directed the residence to administer vitamin D3 2,000 units once daily. However, the April 2024 MAR read vitamin D3 1000 units one tablet was administered daily from 4/1-4/29/24. On 5/30/24 at 3:53 p.m., the responsible party for Resident #48 stated the resident did not have any swallowing issues or concerns about taking whole medications. She stated Resident #48 was not supposed to have her medications crushed. The responsible party further stated metoprolol succinate extended-release was not a crushable medication. On 5/30/24 at 4:34 p.m., the resident care coordinator stated that over-the-counter medications were brought into the residence by the family. She stated the residence conducted cart audits twice weekly to ensure medications did not run out. On 5/30/24 at 5:42 p.m., the administrator stated staff should have checked orders and ensured medications were administered correctly. There was similar deficient practice found for Residents #2, #22 and #45.

A licensure complaint revisit was completed on 6/3/24 for all previous deficiencies cited on 2/14/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 6/14/23 and the Chapter VII regulations were implemented on 11/15/23.

Based on observation, interview, and record review, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting four of six sample residents (#2, #22, #45, #48). This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence Policy and Referencea. The residence's, undated, medication administration policy read in part: If medication errors or discrepancies occur, the error or discrepancy must be described in detail in the resident record and on an incident report. Appropriate action must be taken to correct the error and this action would have been recorded on the incident report. Medication errors would immediately be brought to the administrator's attention. 2. Resident #48 was admitted to the residence on 1/22/24 with no related diagnoses.a. On 5/30/24 at 7:51 a.m., Staff #29 prepared medications for Resident #48. She stated the resident required her medications to be crushed for administration. Staff #29 subsequently removed the resident's olanzapine from the medication cup and stated that the medication was not crushable and stated the rest of the medications were okay to crush. Staff #29 subsequently crushed the medications and administered them to Resident #48. A written practitioner's order, dated 1/22/24, directed the residence to administer atorvastatin 80 once daily, furosemide 20 mg once daily, and multivitamin once daily. However, the written practitioner's order did not instruct the residence to crush the medications and the May 2024 medication administration record (MAR) did not reveal directions for staff to crush the medication. A written practitioner's order, dated 1/23/24, directed the residence to administer lisinopril 2.5 mg once daily, metoprolol succinate extended-release 25 mg once daily, and vitamin D3 2,000 units once daily. However, the written practitioner's order did not instruct the residence to crush the medications and the May 2024 MAR did not reveal directions for staff to crush the medication. The record for Resident #48 revealed no evidence of an order to crush medications. b. A written practitioner's order, dated 1/23/24, directed the residence to administer vitamin D3 2,000 units once daily. However, the April 2024 MAR read vitamin D3 1000 units one tablet was administered daily from 4/1-4/29/24. On 5/30/24 at 3:53 p.m., the responsible party for Resident #48 stated the resident did not have any swallowing issues or concerns about taking whole medications. She stated Resident #48 was not supposed to have her medications crushed. The responsible party further stated metoprolol succinate extended-release was not a crushable medication. On 5/30/24 at 4:34 p.m., the resident care coordinator stated that over-the-counter medications were brought into the residence by the family. She stated the residence conducted cart audits twice weekly to ensure medications did not run out. On 5/30/24 at 5:42 p.m., the administrator stated staff should have checked orders and ensured medications were administered correctly. There was similar deficient practice found for Residents #2, #22 and #45.

A licensure complaint revisit was completed on 6/3/24 for all previous deficiencies cited on 2/14/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 6/14/23 and the Chapter VII regulations were implemented on 11/15/23.

Based on interview, and record review, the residence failed to have at least one staff member onsite who has certification in first aid from a nationally recognized organization, affecting 28 current residents. This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:A review of staff first aid certifications on 5/30/24 revealed that Staff #23, #25, #45, and #46 did not have first aid certifications from a nationally recognized organization. The staff schedule from 5/18-5/31/24 revealed there were no staff with certification from a nationally recognized organization for the first shift on 5/18, 5/19, 5/23, 5/25, 5/30, and the third shift on 5/26/24. On 5/30/24 at 5:41 p.m., the administrator stated staff had first aid certifications; however, the card they were printed on were through a different organization than the cardiopulmonary resuscitation. She stated she thought the certifications would have been acceptable and thought the deficiency had been corrected. On 6/3/24 at 10:23 a.m., the administrator confirmed the residence had no record of first aid evidence from a nationally recognized organization.

Based on interview, and record review, the residence failed to implement a fall management program, affecting four of six sample residents #2, #45, #46 and #47. This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence Policya. The residence's Fall Management policy, dated February 2022, read in part: "the community has developed policies and procedures to establish a fall management program. The program includes the following: Providing fall management education and a (sic) materials to residents and family members. 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."2. Resident #45 was admitted to the residence on 2/29/24, with diagnoses including cerebrovascular accident (CVA), coronary artery disease (CAD), constipation, and non-Alzheimer's dementia. An incident report, dated 5/7/24 at 6:43 p.m., read on 5/7/24 at 3:49 p.m., Resident #45 was found lying on the floor next to his room without his walker and wheelchair. An incident report, dated 5/15/24 at 8:43 p.m. read on 5/15/24 at 7:36 p.m., the resident was found sitting on the floor by his recliner. The incident report read the resident was now required to have hourly checks. An incident report, dated 5/17/24 at 8:48 p.m., read on 5/17/24 at 2:33 p.m., Resident #45 was found on the floor in his room. The report stated the resident required monitoring for 72 hours. An incident report, dated 5/17/24 at 9:47 p.m., read on 5/17/24 at 7:40 p.m., Resident #45 was sitting in his wheelchair and would not move from leaning on his right side, had a very strong grip on his chair, slurred/gargle speech and the left side of his face was droopy. Resident #45 was sent to the emergency department. Resident #45 was admitted and discharged from the hospital on 5/20/24. Resident #45 was sent to the emergency department. Resident #45 was admitted and discharged from the hospital on 5/20/24. Documentation that Resident #45 provided upon discharge from the emergency department, read the resident was ordered a new medication; however the discharge paperwork did not include an admitting diagnosis. An incident report, dated 5/20/24 at 9:05 p.m., read on 5/20/24 at 7:00 p.m., Resident #45 was found on the floor in his room. The report stated the resident required monitoring every 30 minutes. A fall risk assessment, dated 5/24/24, read Resident #45 was at higher risk for falls, however, did not contain any interventions or approaches for staff to mitigate future falls. An undated significant change service plan stated Resident #45 required two person staff assistance with transfers. He used a regular wheelchair daily with foot pedals. The undated significant change service plan did not contain any interventions or approaches for staff to mitigate future falls other than frequent checks every shift. There no other assessments were in the record for Resident #45. Additionally, similar findings were identified for Residents #2, #46 and #47.3. InterviewsOn 5/30/24 at 5:14 p.m. the resident care coordinator (RCC) stated that all care plans should have been updated when there was a change in the resident such as a fall and it should have included interventions. Further, the RCC stated that the registered nurse, the administrator or the RCC were responsible for updating care plans. On 5/30/24 at 5:46 p.m. the administrator stated that care plans were completed before admission, on admission, and every 6 months unless there was a significant change in condition. She stated after a hospitalization the care plans should have been updated to reflect the changes and interventions. The administrator further stated specifically that a fall would require the care plan to be updated.

Based on observation, interview, and record review, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting four of six sample residents (#2, #22, #45, #48). This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence Policy and Referencea. The residence's, undated, medication administration policy read in part: If medication errors or discrepancies occur, the error or discrepancy must be described in detail in the resident record and on an incident report. Appropriate action must be taken to correct the error and this action would have been recorded on the incident report. Medication errors would immediately be brought to the administrator's attention. 2. Resident #48 was admitted to the residence on 1/22/24 with no related diagnoses.a. On 5/30/24 at 7:51 a.m., Staff #29 prepared medications for Resident #48. She stated the resident required her medications to be crushed for administration. Staff #29 subsequently removed the resident's olanzapine from the medication cup and stated that the medication was not crushable and stated the rest of the medications were okay to crush. Staff #29 subsequently crushed the medications and administered them to Resident #48. A written practitioner's order, dated 1/22/24, directed the residence to administer atorvastatin 80 once daily, furosemide 20 mg once daily, and multivitamin once daily. However, the written practitioner's order did not instruct the residence to crush the medications and the May 2024 medication administration record (MAR) did not reveal directions for staff to crush the medication. A written practitioner's order, dated 1/23/24, directed the residence to administer lisinopril 2.5 mg once daily, metoprolol succinate extended-release 25 mg once daily, and vitamin D3 2,000 units once daily. However, the written practitioner's order did not instruct the residence to crush the medications and the May 2024 MAR did not reveal directions for staff to crush the medication. The record for Resident #48 revealed no evidence of an order to crush medications. b. A written practitioner's order, dated 1/23/24, directed the residence to administer vitamin D3 2,000 units once daily. However, the April 2024 MAR read vitamin D3 1000 units one tablet was administered daily from 4/1-4/29/24. On 5/30/24 at 3:53 p.m., the responsible party for Resident #48 stated the resident did not have any swallowing issues or concerns about taking whole medications. She stated Resident #48 was not supposed to have her medications crushed. The responsible party further stated metoprolol succinate extended-release was not a crushable medication. On 5/30/24 at 4:34 p.m., the resident care coordinator stated that over-the-counter medications were brought into the residence by the family. She stated the residence conducted cart audits twice weekly to ensure medications did not run out. On 5/30/24 at 5:42 p.m., the administrator stated staff should have checked orders and ensured medications were administered correctly. There was similar deficient practice found for Residents #2, #22 and #45.

Based on observations, interviews, and record review, the residence failed to ensure the residence grounds were maintained to protect residents from hazards, affecting 28 current residents. This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence PolicyThe residence Exterior Environment policy, dated February 2022, read in part, "The community grounds are kept free of high weeks, garbage and rubbish. The grounds are maintained to protect residents from slopes, holes, or other hazards and must be consistent with any landscape plan approved by the local jurisdiction."2. Observations On 5/30/24 at 9:30 a.m., an environmental tour was conducted of the west secure outdoor courtyard area which revealed un-repaired hazardous safety on the west side as follows: The sidewalk had a drop-off that measured one and a half inches deep on one side of the sidewalk, and two and a half inches deep on the other side of the sidewalk. There were plants that needed to be trimmed as they had multiple stems that posed a risk of injury as they could potentially stab or injure someone if not addressed. There were two large upholstered chairs positioned on concrete with the front two legs on the concrete and the back two legs on the rocks, creating a risk of tipping backward. There was a large shepherd hook lying on the ground with stakes not embedded in the rocks, which posed a risk of injury as it could potentially stab or injure someone if not addressed. 3. InterviewOn 5/30/24 at 5:59 p.m. the administrator stated that the residence currently did not have a maintenance director that was responsible for ensuring the residence was free from hazards. She stated she was responsible for the courtyard and had it in good repair before winter.

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

A licensure complaint revisit was completed on 6/3/24 for all previous deficiencies cited on 2/14/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 6/14/23 and the Chapter VII regulations were implemented on 11/15/23.

Based on interview, and record review, the residence failed to have at least one staff member onsite who has certification in first aid from a nationally recognized organization, affecting 28 current residents. This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:A review of staff first aid certifications on 5/30/24 revealed that Staff #23, #25, #45, and #46 did not have first aid certifications from a nationally recognized organization. The staff schedule from 5/18-5/31/24 revealed there were no staff with certification from a nationally recognized organization for the first shift on 5/18, 5/19, 5/23, 5/25, 5/30, and the third shift on 5/26/24. On 5/30/24 at 5:41 p.m., the administrator stated staff had first aid certifications; however, the card they were printed on were through a different organization than the cardiopulmonary resuscitation. She stated she thought the certifications would have been acceptable and thought the deficiency had been corrected. On 6/3/24 at 10:23 a.m., the administrator confirmed the residence had no record of first aid evidence from a nationally recognized organization.

Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated for residents whenever residents' conditions changed from baseline status, affecting five of six sample residents (#2, #22, #45-#47) who experienced a change in condition. This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence Policya. The residence's Comprehensive Resident Assessment policy, dated 2/22, read in part: "the comprehensive assessment shall be updated for each resident at least annually and whenever a resident's condition changes from baseline status ... The (residence) administrator or wellness coordinator and his/her designee, conducts an in-person assessment of individual residents, and all assessment information is recorded on the proper forms and is filed in the resident record."b. Chapter VII regulations governing assisted living residences, requires in part 12.7, that the comprehensive assessment shall include all the following items: (A) Information from the comprehensive pre-admission assessment described in Part 11.1; (B) Information regarding the resident ' s overall health and physical functioning ability; (E) Current diagnoses and any known or anticipated need or impact related to the diagnoses; (H) Reactions to the environment and others, including changes that may occur at certain times or in certain circumstances; (J) History and circumstances of recent falls and any known approaches to prevent future falls; (K) Safety awareness; (L) Types of physical, mental, and social support required. 2. Resident #45 was admitted to the residence on 2/29/24, with diagnoses including cerebrovascular accident (CVA), coronary artery disease (CAD), constipation, and non-Alzheimer's dementia. An incident report, dated 5/7/24 at 6:43 p.m., read on 5/7/24 at 3:49 p.m., Resident #45 was found lying on the floor next to his room without his walker and wheelchair. An incident report, dated 5/15/24 at 8:43 p.m. read on 5/15/24 at 7:36 p.m., the resident was found sitting on the floor by his recliner. The incident report read the resident was now required to have hourly checks. An incident report, dated 5/17/24 at 8:48 p.m., read on 5/17/24 at 2:33 p.m., Resident #45 was found on the floor in his room. The report stated the resident required monitoring for 72 hours. An incident report, dated 5/17/24 at 9:47 p.m., read on 5/17/24 at 7:40 p.m., Resident #45 was sitting in his wheelchair and would not move from leaning on his right side, had a very strong grip on his chair, slurred/gargle speech and the left side of his face was droopy. Resident #45 was sent to the emergency department. Resident #45 was admitted and discharged from the hospital on 5/20/24. Documentation that Resident #45 provided upon discharge from the emergency department, read the resident was ordered a new medication; however the discharge paperwork did not include an admitting diagnosis. An incident report, dated 5/20/24 at 9:05 p.m., read on 5/20/24 at 7:00 p.m., Resident #45 was found on the floor in his room. The report stated the resident required monitoring every 30 minutes. A fall risk assessment, dated 5/24/24, read Resident #45 was at higher risk for falls, however, the assessment did not contain any interventions or approaches for staff to mitigate future falls. There were no other assessments in the record for Resident #45. Additionally, similar findings were identified for Residents #2, #22,#46 and#47.3. InterviewsOn 5/30/24 at 5:14 p.m. the resident care coordinator stated that all assessments should have been updated when there was a change in the resident such as a fall and it should include interventions. On 5/30/24 at 5:46 p.m. the administrator stated that assessments were completed before admission, on admission, and every 6 months unless there was a significant change in condition. She stated after a resident's hospitalization there should have been a new assessment completed.

Based on interview, and record review, the residence failed to implement a fall management program, affecting four of six sample residents #2, #45, #46 and #47. This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence Policya. The residence's Fall Management policy, dated February 2022, read in part: "the community has developed policies and procedures to establish a fall management program. The program includes the following: Providing fall management education and a (sic) materials to residents and family members. 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."2. Resident #45 was admitted to the residence on 2/29/24, with diagnoses including cerebrovascular accident (CVA), coronary artery disease (CAD), constipation, and non-Alzheimer's dementia. An incident report, dated 5/7/24 at 6:43 p.m., read on 5/7/24 at 3:49 p.m., Resident #45 was found lying on the floor next to his room without his walker and wheelchair. An incident report, dated 5/15/24 at 8:43 p.m. read on 5/15/24 at 7:36 p.m., the resident was found sitting on the floor by his recliner. The incident report read the resident was now required to have hourly checks. An incident report, dated 5/17/24 at 8:48 p.m., read on 5/17/24 at 2:33 p.m., Resident #45 was found on the floor in his room. The report stated the resident required monitoring for 72 hours. An incident report, dated 5/17/24 at 9:47 p.m., read on 5/17/24 at 7:40 p.m., Resident #45 was sitting in his wheelchair and would not move from leaning on his right side, had a very strong grip on his chair, slurred/gargle speech and the left side of his face was droopy. Resident #45 was sent to the emergency department. Resident #45 was admitted and discharged from the hospital on 5/20/24. Resident #45 was sent to the emergency department. Resident #45 was admitted and discharged from the hospital on 5/20/24. Documentation that Resident #45 provided upon discharge from the emergency department, read the resident was ordered a new medication; however the discharge paperwork did not include an admitting diagnosis. An incident report, dated 5/20/24 at 9:05 p.m., read on 5/20/24 at 7:00 p.m., Resident #45 was found on the floor in his room. The report stated the resident required monitoring every 30 minutes. A fall risk assessment, dated 5/24/24, read Resident #45 was at higher risk for falls, however, did not contain any interventions or approaches for staff to mitigate future falls. An undated significant change service plan stated Resident #45 required two person staff assistance with transfers. He used a regular wheelchair daily with foot pedals. The undated significant change service plan did not contain any interventions or approaches for staff to mitigate future falls other than frequent checks every shift. There no other assessments were in the record for Resident #45. Additionally, similar findings were identified for Residents #2, #46 and #47.3. InterviewsOn 5/30/24 at 5:14 p.m. the resident care coordinator (RCC) stated that all care plans should have been updated when there was a change in the resident such as a fall and it should have included interventions. Further, the RCC stated that the registered nurse, the administrator or the RCC were responsible for updating care plans. On 5/30/24 at 5:46 p.m. the administrator stated that care plans were completed before admission, on admission, and every 6 months unless there was a significant change in condition. She stated after a hospitalization the care plans should have been updated to reflect the changes and interventions. The administrator further stated specifically that a fall would require the care plan to be updated.

Based on observation, interview, and record review, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting four of six sample residents (#2, #22, #45, #48). This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence Policy and Referencea. The residence's, undated, medication administration policy read in part: If medication errors or discrepancies occur, the error or discrepancy must be described in detail in the resident record and on an incident report. Appropriate action must be taken to correct the error and this action would have been recorded on the incident report. Medication errors would immediately be brought to the administrator's attention. 2. Resident #48 was admitted to the residence on 1/22/24 with no related diagnoses.a. On 5/30/24 at 7:51 a.m., Staff #29 prepared medications for Resident #48. She stated the resident required her medications to be crushed for administration. Staff #29 subsequently removed the resident's olanzapine from the medication cup and stated that the medication was not crushable and stated the rest of the medications were okay to crush. Staff #29 subsequently crushed the medications and administered them to Resident #48. A written practitioner's order, dated 1/22/24, directed the residence to administer atorvastatin 80 once daily, furosemide 20 mg once daily, and multivitamin once daily. However, the written practitioner's order did not instruct the residence to crush the medications and the May 2024 medication administration record (MAR) did not reveal directions for staff to crush the medication. A written practitioner's order, dated 1/23/24, directed the residence to administer lisinopril 2.5 mg once daily, metoprolol succinate extended-release 25 mg once daily, and vitamin D3 2,000 units once daily. However, the written practitioner's order did not instruct the residence to crush the medications and the May 2024 MAR did not reveal directions for staff to crush the medication. The record for Resident #48 revealed no evidence of an order to crush medications. b. A written practitioner's order, dated 1/23/24, directed the residence to administer vitamin D3 2,000 units once daily. However, the April 2024 MAR read vitamin D3 1000 units one tablet was administered daily from 4/1-4/29/24. On 5/30/24 at 3:53 p.m., the responsible party for Resident #48 stated the resident did not have any swallowing issues or concerns about taking whole medications. She stated Resident #48 was not supposed to have her medications crushed. The responsible party further stated metoprolol succinate extended-release was not a crushable medication. On 5/30/24 at 4:34 p.m., the resident care coordinator stated that over-the-counter medications were brought into the residence by the family. She stated the residence conducted cart audits twice weekly to ensure medications did not run out. On 5/30/24 at 5:42 p.m., the administrator stated staff should have checked orders and ensured medications were administered correctly. There was similar deficient practice found for Residents #2, #22 and #45.

Based on observations, interviews, and record review, the residence failed to ensure the residence grounds were maintained to protect residents from hazards, affecting 28 current residents. This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence PolicyThe residence Exterior Environment policy, dated February 2022, read in part, "The community grounds are kept free of high weeks, garbage and rubbish. The grounds are maintained to protect residents from slopes, holes, or other hazards and must be consistent with any landscape plan approved by the local jurisdiction."2. Observations On 5/30/24 at 9:30 a.m., an environmental tour was conducted of the west secure outdoor courtyard area which revealed un-repaired hazardous safety on the west side as follows: The sidewalk had a drop-off that measured one and a half inches deep on one side of the sidewalk, and two and a half inches deep on the other side of the sidewalk. There were plants that needed to be trimmed as they had multiple stems that posed a risk of injury as they could potentially stab or injure someone if not addressed. There were two large upholstered chairs positioned on concrete with the front two legs on the concrete and the back two legs on the rocks, creating a risk of tipping backward. There was a large shepherd hook lying on the ground with stakes not embedded in the rocks, which posed a risk of injury as it could potentially stab or injure someone if not addressed. 3. InterviewOn 5/30/24 at 5:59 p.m. the administrator stated that the residence currently did not have a maintenance director that was responsible for ensuring the residence was free from hazards. She stated she was responsible for the courtyard and had it in good repair before winter.

A licensure complaint revisit was completed on 6/3/24 for all previous deficiencies cited on 2/14/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 6/14/23 and the Chapter VII regulations were implemented on 11/15/23.

Based on interview, and record review, the residence failed to have at least one staff member onsite who has certification in first aid from a nationally recognized organization, affecting 28 current residents. This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:A review of staff first aid certifications on 5/30/24 revealed that Staff #23, #25, #45, and #46 did not have first aid certifications from a nationally recognized organization. The staff schedule from 5/18-5/31/24 revealed there were no staff with certification from a nationally recognized organization for the first shift on 5/18, 5/19, 5/23, 5/25, 5/30, and the third shift on 5/26/24. On 5/30/24 at 5:41 p.m., the administrator stated staff had first aid certifications; however, the card they were printed on were through a different organization than the cardiopulmonary resuscitation. She stated she thought the certifications would have been acceptable and thought the deficiency had been corrected. On 6/3/24 at 10:23 a.m., the administrator confirmed the residence had no record of first aid evidence from a nationally recognized organization.

Based on interview, and record review, the residence failed to implement a fall management program, affecting four of six sample residents #2, #45, #46 and #47. This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence Policya. The residence's Fall Management policy, dated February 2022, read in part: "the community has developed policies and procedures to establish a fall management program. The program includes the following: Providing fall management education and a (sic) materials to residents and family members. 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."2. Resident #45 was admitted to the residence on 2/29/24, with diagnoses including cerebrovascular accident (CVA), coronary artery disease (CAD), constipation, and non-Alzheimer's dementia. An incident report, dated 5/7/24 at 6:43 p.m., read on 5/7/24 at 3:49 p.m., Resident #45 was found lying on the floor next to his room without his walker and wheelchair. An incident report, dated 5/15/24 at 8:43 p.m. read on 5/15/24 at 7:36 p.m., the resident was found sitting on the floor by his recliner. The incident report read the resident was now required to have hourly checks. An incident report, dated 5/17/24 at 8:48 p.m., read on 5/17/24 at 2:33 p.m., Resident #45 was found on the floor in his room. The report stated the resident required monitoring for 72 hours. An incident report, dated 5/17/24 at 9:47 p.m., read on 5/17/24 at 7:40 p.m., Resident #45 was sitting in his wheelchair and would not move from leaning on his right side, had a very strong grip on his chair, slurred/gargle speech and the left side of his face was droopy. Resident #45 was sent to the emergency department. Resident #45 was admitted and discharged from the hospital on 5/20/24. Resident #45 was sent to the emergency department. Resident #45 was admitted and discharged from the hospital on 5/20/24. Documentation that Resident #45 provided upon discharge from the emergency department, read the resident was ordered a new medication; however the discharge paperwork did not include an admitting diagnosis. An incident report, dated 5/20/24 at 9:05 p.m., read on 5/20/24 at 7:00 p.m., Resident #45 was found on the floor in his room. The report stated the resident required monitoring every 30 minutes. A fall risk assessment, dated 5/24/24, read Resident #45 was at higher risk for falls, however, did not contain any interventions or approaches for staff to mitigate future falls. An undated significant change service plan stated Resident #45 required two person staff assistance with transfers. He used a regular wheelchair daily with foot pedals. The undated significant change service plan did not contain any interventions or approaches for staff to mitigate future falls other than frequent checks every shift. There no other assessments were in the record for Resident #45. Additionally, similar findings were identified for Residents #2, #46 and #47.3. InterviewsOn 5/30/24 at 5:14 p.m. the resident care coordinator (RCC) stated that all care plans should have been updated when there was a change in the resident such as a fall and it should have included interventions. Further, the RCC stated that the registered nurse, the administrator or the RCC were responsible for updating care plans. On 5/30/24 at 5:46 p.m. the administrator stated that care plans were completed before admission, on admission, and every 6 months unless there was a significant change in condition. She stated after a hospitalization the care plans should have been updated to reflect the changes and interventions. The administrator further stated specifically that a fall would require the care plan to be updated.

Based on observation, interview, and record review, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting four of six sample residents (#2, #22, #45, #48). This deficiency was cited previously during a licensure complaint survey conducted on 2/14/23. Findings include:1. Residence Policy and Referencea. The residence's, undated, medication administration policy read in part: If medication errors or discrepancies occur, the error or discrepancy must be described in detail in the resident record and on an incident report. Appropriate action must be taken to correct the error and this action would have been recorded on the incident report. Medication errors would immediately be brought to the administrator's attention. 2. Resident #48 was admitted to the residence on 1/22/24 with no related diagnoses.a. On 5/30/24 at 7:51 a.m., Staff #29 prepared medications for Resident #48. She stated the resident required her medications to be crushed for administration. Staff #29 subsequently removed the resident's olanzapine from the medication cup and stated that the medication was not crushable and stated the rest of the medications were okay to crush. Staff #29 subsequently crushed the medications and administered them to Resident #48. A written practitioner's order, dated 1/22/24, directed the residence to administer atorvastatin 80 once daily, furosemide 20 mg once daily, and multivitamin once daily. However, the written practitioner's order did not instruct the residence to crush the medications and the May 2024 medication administration record (MAR) did not reveal directions for staff to crush the medication. A written practitioner's order, dated 1/23/24, directed the residence to administer lisinopril 2.5 mg once daily, metoprolol succinate extended-release 25 mg once daily, and vitamin D3 2,000 units once daily. However, the written practitioner's order did not instruct the residence to crush the medications and the May 2024 MAR did not reveal directions for staff to crush the medication. The record for Resident #48 revealed no evidence of an order to crush medications. b. A written practitioner's order, dated 1/23/24, directed the residence to administer vitamin D3 2,000 units once daily. However, the April 2024 MAR read vitamin D3 1000 units one tablet was administered daily from 4/1-4/29/24. On 5/30/24 at 3:53 p.m., the responsible party for Resident #48 stated the resident did not have any swallowing issues or concerns about taking whole medications. She stated Resident #48 was not supposed to have her medications crushed. The responsible party further stated metoprolol succinate extended-release was not a crushable medication. On 5/30/24 at 4:34 p.m., the resident care coordinator stated that over-the-counter medications were brought into the residence by the family. She stated the residence conducted cart audits twice weekly to ensure medications did not run out. On 5/30/24 at 5:42 p.m., the administrator stated staff should have checked orders and ensured medications were administered correctly. There was similar deficient practice found for Residents #2, #22 and #45.

A licensure revisit was completed on 2/14/23 for all previous deficiencies cited on 8/31/22. Deficiencies were cited.

Based upon observation, record review and interview, the residence failed to comply with conditions imposed by the department, affecting 26 current residents. Findings include: On 5/10/22 the department issued a Conditional License to the residence. The Conditional License read that the residence was required to maintain operational conditions during the term of the Conditional License. Following the completion of Event ZH3B12 on 12/8/21, a complaint investigation, the department imposed a consultant for 11 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The Conditional License required the residence to comply and maintain the following:Commencing the first week of the first full month, the licensee shall submit a written monthly report to the department that addresses each of the following areas of concern. The licensee shall include written monthly reports to the department information from audits performed during the previous month regarding how the licensee was ensuring compliance. Within the first 30 days of the Consultant's term, the Consultant shall review each of the cited deficiencies identified in the opportunities to present written data, views, and arguments dated January 26, 2022, with the administrator, and evaluate the facility's (residence's) current compliance with the corresponding regulations, as outlined in 6 C.C.R. 1011-1 Chapters 2, 7, and 24, where applicable. Within the first 45 days of the Consultant's term, the Consultant shall evaluate the Facility's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Facility on any additional areas of noncompliance. The Consultant shall also implement a monitoring program, to be completed at least monthly, to ensure the Facility remains in compliance with previously cited deficiencies. The monitoring program shall be incorporated into the Facility's ongoing quality management program (QMP), in accordance with 6 C.C.R. 1011-1 Chapter 2, Section 4. The Consultant shall make certain that the QMP is designed to improve resident safety and well-being, and promotes continued quality improvement to enhance service delivery. The Consultant shall make certain that the Administrator has a process in place to correct the identified deficiency, which includes utilizing the above-referenced monitoring program to ensure the deficient practice does not reoccur. The Consultant shall make certain that the monitoring identifies the scope of review, how a sample is identified for monitoring purposes, the total length of time the monitoring will continue, which will be no less than six months, and how the monitoring will be documented. During the final 60 days of the Consultant's term, the Consultant shall prepare the Administrator to independently manage the Facility to ensure compliance with all applicable regulations governing assisted living residences. The Consultant shall make certain that the Administrator has tools and resources in place to maintain compliance. The Conditional license also read that examples of a material breach of the conditional license included, but was not limited to, the following:Failure of the Licensee to comply with all applicable state rules, regulations, and standards, including without limitation, Chapter 2, 7, and 24 of the Department's regulations at 6 CCR 1011-1, and the provisions of Articles 3 and 27 of Title 25, C.R.S. or a sustained finding of immediate jeopardy at any time. Department records read the residence had chosen the consultant on 5/31/22 and the contract for the consultant was received on 6/1/22. Therefore, on the day of the completion of the complaint investigation, 2/14/23, the consultant was in the beginning of her eighth month as consultant for the residence. During the 2/14/23 revisit, the revisit established there was current deficient practice, despite having a consultant in place. Six deficiencies were cited, including Tags 540, 732, 734, 1180, 1468, 2412 (Cross-reference Q540, Q732, Q734, Q1180, Q1468, Q2412). On 2/14/23 at approximately 3:29 p.m., the administrator designee stated she was aware of the requirements of the conditional license. On 2/14/22 at approximately 12:36 p.m., the consultant stated the following:In regards to Tag 540, the consultant stated that she had done several reviews of COVID and the COVID vaccination plan. The consultant stated that she was aware that EMResource had not been updated. In regards to Tag 732, the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have first aid certification from a nationally recognized organization. In regards to Tag 734, the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have CPR certification from a nationally recognized organization. In regards to Tag 1180, the consultant stated she was aware that contracted staff were not provided fall related training. She stated she brought it to the residence's attention in January 2023, however, training still had not been implemented. She also stated the resident began using contracted staff on 1/4/23. In regards to Tag 1468, the consultant confirmed there were still medications that were not administered as required. However, she stated she was working with the residence to ensure medications were being audited and ordered every week to avoid medications being unavailable. In regards to Tag 2412, the consultant stated that the residence had a bid to have the work outside in the courtyards completed, however, snow had been a problem and outdoor contractors would not come until the spring of 2023. The consultant stated there was no date assigned they would come. The consultant stated one side of the courtyard had been fixed, she thought the east, and thought it was corrected, however could be wrong. The consultant stated the residence was aware of this safety issue.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 26 current residents. This deficiency was cited previously during a state licensure survey 8/31/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. References and Residence Policya. The Ninth Amended State Public Health Order 20-20 (PHO) Requirements for Colorado Skilled Nursing Facilities, Assisted Living Residences, Intermediate Care Facilities and Group Homes for COVID-19 Prevention and Response, dated 10/11/22, required residences to:- Report to CDPHE information pertaining to their available resources to respond to the COVID-19 pandemic. The department will provide the reporting platforms and the form and format for submission of the required information. The residence must adhere to reporting requirements as specified in RCF Comprehensive Mitigation Guidance. b. The COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/7/23, required residences to: - Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month and period two, defined as days 15 to 31 of each month). 2. Record ReviewOn 2/13/23 at 9:57 a.m., a review of EMResource revealed that the residence's most current reporting occurred on 11/10/22, resulting in six missed periods during which the residence was required to report. EMResource read that there were still 30 residents, however, the day of the onsite survey the resident roster read there were only 26 current residents. 3. InterviewsOn 2/14/23 at approximately 12:36 p.m., the consultant stated that she had done several reviews of COVID and the COVID vaccination plan. The consultant stated that she was aware that EMResource had not been updated. On 2/14/23 at approximately 1:36 p.m., the resident services director stated that she did not know why the administrator had not updated EMResource since 11/10/22. The resident services director stated that she was aware of the requirement and thought that the administrator had updated EMResource.

Based on interviews and record review, the residence failed to have at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization, affecting 26 current residents. (Cross-reference Q734). This deficiency was cited previously during a state licensure survey on 8/31/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence policya. The residence's First Aid policy, dated February 2022, read in part: "There is at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization."b. According to the National CPR Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own (teacher). Our services are designed with OSHA, the ECC (Emergency Cardiovascular Care)/ILCOR (The International Liaison Committee on Resuscitation) and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2022) Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/2. Record ReviewOn 2/13/23, review of staff first aid certifications provided by the resident services director revealed that Staff #33, #38 and #42 did not have first aid certifications from a nationally recognized organization. Additionally, staff first aid certifications revealed only one staff (#34) had certification from a nationally recognized organization. The staff schedule from 1/30-2/13/23 revealed there were no staff with certification on: 1/30 from 6:00 a.m. to 2:00 p.m. and 10:00 p.m. to 6:00 a.m., 1/31-2/2 all shifts, 2/3 and 2/4 on 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m., on 2/6 from 6:00 a.m. to 2:00 p.m. and 10:00 p.m. to 6:00 a.m., all shifts on 2/7, 2/8 from 6:00 a.m. and 2:00 p.m. to 10:00 p.m., 2/9 and 2/10 for all shifts, on 2/11 from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., on 2/12 all shifts, 2/13/23 from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. for a total of 34 shifts. Additionally, the schedule revealed that staff with certification from a not nationally recognized organization worked on 1/30 from 2:00 p.m. to 10:00 p.m., 2/3 from 10:00 p.m. to 6:00 a.m., 2/4 from 10:00 to 6:00 a.m., on 2/5 from 2:00 p.m. to 6:00 a.m., 2/8 from 6:00 a.m. to 2:00 p.m. and 2/13/23 from 6:00 a.m. to 2:00 p.m., for an additional seven shifts. 3. InterviewsOn 2/14/23 at approximately 12:35 p.m., the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have first aid certification from a nationally recognized organization. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated she was aware the residence was required to have first aid certified staff scheduled at all times. She stated the resident services director was responsible for the staff schedule. She added she was aware that some contracted staff had first aid certification from an organization that was not nationally recognized. The administrator designee stated this was not corrected because the residence had not audited contracted staff certifications. On 2/14/23 at 1:33 p.m., the resident services director stated she was responsible for creating the staff schedule. She added she was not aware that the residence did not have one staff on at all times with first aid certification.

Based on interviews and record review, the residence failed to 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, affecting 26 current residents who required assistance in the event of an obstructed airway. (Cross-reference Q732). This deficiency was cited previously during a state licensure survey 8/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence policya. The residence's CPR policy, dated February 2022, read in part: "There is at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation and obstructed airway techniques from a national recognized organization."b. According to the National CPR Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own (teacher). Our services are designed with OSHA, the ECC (Emergency Cardiovascular Care)/ILCOR (The International Liaison Committee on Resuscitation) and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2022) Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/c. According to Nolo Legal Encyclopedia, "A MOST (Medical Orders for Scope of Treatment) form is a doctor's order that helps you keep control over medical care at the end of life. Like a Colorado CPR Directive, the form tells emergency medical personnel and other health care providers whether or not to administer cardiopulmonary resuscitation (CPR) in the event of a medical emergency. A MOST form may be used in addition to -- or instead of -- a CPR Directive. The MOST form may also provide other information about your wishes for end-of-life health care." Irving, S., J.D., Colorado's Medical Orders for Scope of Treatment (MOST) Form, retrieved from: https://www.nolo.com/legal-encyclopedia/colorados-medical-orders-scope-treatment-most-form.html 2. Code status and schedulesRecords for Residents #35 and #37 contained medical orders for scope of treatment that directed the residence to perform CPR in the event of an emergency. On 2/13/23, review of staff CPR certifications provided by the resident services director revealed that Staff #32, #33, #38, #40 and #42 did not have CPR certifications from a nationally recognized organization. The staff schedule revealed the residence did not have a staff member who was CPR certified from a nationally recognized organization on 1/30 from 2:00 p.m. to 10:00 p.m., 2/5 from 2:00 p.m. to 10:00 p.m., 10:00 p.m. to 6:00 a.m., 2/9 through 2/11 from 10:00 p.m. to 6:00 a.m., 2/12 from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., for a total of eight shifts in two weeks. 3. InterviewsOn 2/14/23 at approximately 12:35 p.m., the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have CPR certification from a nationally recognized organization. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated she was aware the residence was required to have CPR certified staff scheduled at all times. She stated the resident services director was responsible for the staff schedule. She added she was aware that some contracted staff had CPR certification from an organization that was not nationally recognized. The administrator designee stated this was not corrected because the residence had not audited contracted staff certifications. On 2/14/23 at 1:33 p.m., the resident services director stated she was responsible for creating the staff schedule. She added she was not aware that the CPR certifications for Contracted Staff #32, #33, and #40 were not from a nationally recognized organization.

7. Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and osteoporosis. An incident report, dated 10/2/22, read that Former Resident #18 had a fall with minor injury, that included a red bump on the side of her forehead. A progress note, dated 10/6/22, read that Former Resident #18 had a fall. An incident report, dated 10/24/22, read that Former Resident #18 had a fall with minor injury, that included a cut on the right side of former Resident #18's eye. A progress note, dated 10/28/22, read that Former Resident #18 had a fall and was found sitting on the floor. A hospital discharge summary, dated 11/5/22, read that Former Resident #18 received five staples due to injury to the right side of her head from tripping over a television cord. No other injuries. A progress note, dated 11/28/22, read that on 11/5/22, Former Resident #18 tripped over television cords, fell and hit her head, and required five staples. A progress note, dated 12/5/22 at 8:13 p.m., read that Former Resident #18 walked into a chair and fell. A progress note, dated 12/5/22 at 8:17 p.m., read that Former Resident #18 fell a second time from having walked too fast around the residence. A progress note, dated 12/21/22 at 12:58 p.m., read that Former Resident #18 had a fall. A comprehensive change in condition assessment dated 12/26/22, read that Former Resident #18 was a frequent fall risk and required redirection, assistance with ambulation, and reminders to use the walker. Former Resident #18 experienced frequent gait elevation and best practice is for staff to encourage the resident to sit down and rest. A progress note, dated 1/3/23, read that the administrator was made aware of an unreported fall with injury on 1/1/23 for Former Resident #18. The incident report further read that Former Resident #18 fell on her face which caused a nose bleed. The care plan for Former Resident #18, dated 1/6/23, read that Former Resident #18 was a high fall risk, and required redirection, an environment free of obstacles and assistance with ambulation. However, the care plan for Former Resident #18 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after each fall, on 10/2/22, 10/6/22, 10/24/22, and 10/28/22. On 2/13/23 at 11:23 a.m., Former Resident #18's family member stated that the former resident would often fall and she would not be informed of the fall. Former Resident #18's family member stated that the most recent fall on 1/1/23 Former Resident #18 was injured and Former Staff #26 did nothing and did not even report it. Former Resident #18's family member stated that staff did not know how to respond appropriately to Former Resident #18's falls. 8. Resident #22 was admitted to the residence on 8/5/21 with diagnoses including Alzheimer's disease. An incident report, dated 12/20/23, read the resident had a fall. A fall assessment, dated 1/12/23 read that Resident #22 was a fall risk. An incident report, dated 1/17/23, read the resident had a fall. A care plan, dated 1/19/23, read the resident's last fall was on 1/19/23. However, the care plan did not include detailed individualized approaches necessary to address the resident's fall risk. Additionally, contracted staff were not aware of the individualized approaches necessary to address fall risk. On 2/13/23 at approximately 12:40 p.m., Staff #29 stated that Resident #22 was a fall risk. However, she was unablt to recall any individualized approaches necessary to address the resident's fall risk. On 2/14/23 at 8:26 a.m., the responsible party for Resident #22 stated the resident was a fall risk. She stated she was unsure of individualized approaches the residence had to address the resident's fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware that Resident #22 was at risk for falls or the individualized approaches necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware that Resident #22 was at risk for falls or the individualized approaches necessary to address fall risk. 9. Staff trainingOn 2/13 and 2/14/23, personnel files for Contracted Staff #31-#33 revealed no evidence of training related to fall prevention. On 2/13/23 at 3:11 p.m., fall training for all contracted staff was requested. However, the residence was unable to provide the requested training documentation. The staff schedule revealed approximately six shifts worked in the previous two weeks with only contracted staff on shift and no residence staff. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/13/23 at 3:02 p.m., Contracted Staff #32 stated that she had picked up shifts at the residence for about three weeks. Contracted Staff #32 stated that the residence did not provide her with fall management training or education, and was only provided an online fall management training with her contracted agency, where she learned she was supposed to follow individual residence protocols for falls. Contracted Staff #32 stated that she was not sure what the residence's fall protocol was, or how to respond to a fall, since the residence had not taught her. On 2/14/23 at 8:33 a.m., Contracted Staff #40 stated she worked at the residence approximately eight times in the prior month. She stated she was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/14/23 at 9:00 a.m., Contracted Staff #41 stated he worked at the residence three times in the prior few weeks. He also stated he was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/14/23 at 11:04 a.m., the resident services director (RSD) stated the residence had not provided fall related training to contracted staff. On 2/14/23 at 11:04 a.m., the administrator designee acknowledged the residence had not provided fall related training to contracted staff. On 2/14/23 at 12:36 p.m., the consultant stated she was aware that contracted staff were not provided fall related training. She stated she brought it to the residence's attention in January 2023, however, training still had not been implemented. She also stated the resident began using contracted staff on 1/4/23. On 2/14/23 at 1:47 p.m., The RSD stated that she was responsible for updating care plans with the administrator. The resident services director stated that she had updated some of the care plans the week prior to the onsite survey. However she stated she had not had not gotten around to updating all of them, or had time to learn about what all needed to be included, since the administrator was still teaching her. The resident services director stated that she was aware that fall interventions needed to be updated after each fall. The resident services director stated that she provided staff with fall management orientation and training, however, did not provide training to contracted staff. The resident services director stated that she would make sure to train contracted staff moving forward. 10. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed 26 current residents at immediate jeopardy risk for falls with injury. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 2/14/23 at 12:45 p.m., the administrator designee submitted written evidence that read in pertinent part, "All (residence) and Agency (contracted) care staff on day, evening and overnight shift will be trained by RSD on fall intervention/fall management and residents who are high fall risk beginning today, 2/14/2023. Training / In-Service and discussion to continue at mandatory All-Staff meeting tomorrow, 2/15/2023.a. 2/14/2023 day staff to be trained before their shift ends today.b. 2/14/2023 evening staff to be trained at shift change / before their shift begins tonight.c. 2/14/2023 overnight staff to be trained at shift change / before their shift begins tonight.d. All staff required to attend monthly All-Staff meeting at 2:15 p.m. on Wed(nesday). 2/15/2023 to continue with this training and reiterate the importance of updated fall management.e. Continued training to be provided by RSDf. Training will be documented on In-Service sheets to be located/stored in In-Service binder in Administrator ' s office. 2. Fall Management Binder to be compiled immediately by Resident Services Director, and to include:a. Identify residents who are a high fall risk, including their photob. Inform of resident-specific interventions in placec. Identify recent fallsd. Binder to be located on bookshelf in Clock-in/Copier Room for all staff to access at any time and will be taken to each shift report, daily.e. RSD responsible for daily updates 3. Monitoring:a. Will be monitored daily by RSD for 90 days with any discrepancies discussed at weekly QMP (quality management program) meetings and additional training needs followed-upat that time. 4. Staff File Audits:a. BOM (business office manager)/RCC (resident care coordinator)/RSD to audit five staff files per month and discrepancies corrected immediately and discussed during weekly QMP meetings."However, the written evidence did not indicate the risk had been removed because it did not indicate who the scheduler would be aware of which staff were provided the required training. On 2/14/23 at 1:28 p.m., the administrator designee submitted additional written evidence that read in pertinent part, "Follow-up Question: how will scheduler know who from Agency has already had training and who is new and needs training?a. RSD and RCC shall create and utilize Audit sheet to verify Agency staff members have been trained prior to shift to identify residents who are at risk for falls and identify interventions."However, the written evidence did not indicate the risk had been removed because it did not indicate when the audit sheet would be created and a date as to when it would be implemented. On 2/14/24 at 2:14 p.m. the administrator designee submitted additional written evidence that read in pertinent part, "The audit form will be created and implemented today, 2/14/23."Based on observation, interview, and record review, the residence failed to implement a fall manangement program affecting 26 current residents. (Cross-reference Q1146). This deficiency was cited previously during a state licensure survey 8/31/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #43 was admitted to the residence on 12/13/22. Resident #43 sustained 12 falls in 44 days (12/16, 12/20, 12/21, 12/23, 12/24, 12/28/22, 1/1, 1/2, 1/5, 1/10, 1/12, and 1/30/23). Five of the falls resulted in injuries. On 12/16/22, the resident sustained an abrasion on his left leg. On 12/21/22, the resident had shoulder pain. On 12/23/22, the resident had knee pain. On 12/28/22, the resident reopened a scab on his leg. On 1/10/23, the resident had a skin tear on his left knee. A care plan, dated 1/12/23, read in part, the residence implemented several fall precautions such as external hospice services, a fall mat, and frequent safety checks. However, contracted staff were not aware of the individualized approach necessary to address the resident's fall risk. Specifically, Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease and Parkinson's Disease. A care plan, dated 1/5/23, read in part, the residence had implemented several fall precautions such as external hospice services, a fall mat, reminders to use a call pendant, changing his bed to a hospital bed, and frequent safety checks. However, contracted staff were not aware of the individualized approach necessary to address fall risk. Further, the resident had four falls from 1/10-2/7/23 with two injuries. Specifically, Resident #38 was admitted to the residence on 8/15/22 with diagnoses including Alzhemier's disease. The resident had a fall on 1/8 and 2/10/23 which resulted in bruises to his right shoulder. A care plan, dated 1/9 and 1/19/23, read the resident required two hour safety checks, however, it did not include that the resident was at risk for falls. Additionally, contracted staff were not aware the resident was at risk for falls or the individualized approach necessary to address fall risk. Specifically, Resident #42 was admitted to the residence on 1/11/23, with diagnoses including long term use of anticoagulants, lumbar vertebral osteoporotic fracture, and vascular dementia. The resident had a fall on 2/6/23 and had bruising to her hip. The resident fell again and hit her nose and hit her left elbow 2/8/23 and was hospitalized 2/9/23 due to pain and swelling of her elbow. A care plan, dated 1/26/23, read that Resident #42 used a walker, however did not did not include that the resident was at risk for falls. Additionally, contracted staff were not aware of the resident was a fall risk or of any approaches necessary to address falls due to the care plan that was not updated after Resident #42 had her first fall on 2/6/23. Specifically, Resident #19 was admitted to the residence on 10/29/21, with diagnoses including Alzheimer's disease, localized osteoporosis and abnormalities of gait and mobility. The resident fell out of bed at 5:30 a.m., on 2/10/23, and fell again in the dining room and hit her head and sustained a bruise on her right temple, at 10:10 a.m. on 2/10/23. A care plan, dated 1/5/23, read that Resident #19 had a history of falls, used a wheelchair, and had a fall mat and non-slip socks. However contracted staff were not aware of the individualized approach necessary to address fall risk. Specifically, Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and osteoporosis. The resident had sustained nine falls in the past two months on 10/2, 10/6, 10/24, 10/28, 11/5, 12/5 twice, 12/21/22 and 1/1/23. During the fall on 10/2/22, the resident sustained a red bump on the side of her forehead. On 10/24/22, the resident sustained a cut on the right side of her eye. On 11/5/22, the resident hit her head and received stitches from a major fall. On 1/1/23 the resident had a nose bleed from a major unreported fall with injury. The care plan for former Resident #18, updated on 12/27/22 and 1/6/23, read that former Resident #18 was a high fall risk, and required redirection, an environment free of obstacles and assistance with ambulation. However, the care plan for former Resident #18 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after each fall, on 10/2/22, 10/6/22, 10/24/22, and 10/28/22. Additionally, contracted staff were not aware of the individualized approach necessary to address fall risk. These failures created an immediate jeopardy risk of falls with injury to six sample residents residing in the residence. On 2/14/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Residence policyThe residence's Fall Management Program, dated February 2022, read in part, the residence would detail in each resident's care plan the individualized approach necessary to address fall risk and provide staff training related to fall prevention. 2. Resident #42 was admitted to the residence on 1/11/23, with diagnoses including long term use of anticoagulants, lumbar vertebral osteoporotic fracture, and vascular dementia. On 2/13/23 at 8:51 a.m., Resident #42 was lying on an elevated double mattress bed, and there were no assistive devices or other approaches observed to remove fall risk. An incident report, dated 2/6/23, read that Resident #42 had sustained a fall in the dining area, and hurt her hip. An incident report, dated 2/8/23, read that Resident #42 had sustained a fall, and staff found her laying on her back next to the east medication cart. Resident #42 had a bruise on her nose and was not in pain. A progress note, dated 2/10/23 at 5:01 p.m., read that Resident #42 had a swollen left elbow and complained of pain during the 2:00-10:00 p.m., shift on 2/9/23 and was sent out to the hospital. A hospital discharge summary, dated 2/9/23, read that Resident #42 had a fall with altered mental status. Labs and imaging showed no signs of intracranial hemorrhage or fractures. An incident report dated 2/13/23, read that Resident #42 had swelling in her left hand and discoloration on parts of her body and complained of pain. Resident was subsequently sent out to the hospital. A hospital discharge summary, dated 2/13/23, read that Resident #42 had multiple contusions and x-rays of the hands and hips were normal. Ice was recommended for the swelling and ibuprofen every four hours. The most current care plan for Resident #42, dated 1/26/23, read that Resident #42 used a walker and had no reported falls at home or a history of falls. Moreover, the care plan for Resident #42 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after she fell on 2/6, or 2/8/23. On 2/14/23 at 10:06 a.m., Resident #42's friend, stated that Resident #42 had no falls prior to moving into the residence, and since moving it she had sustained two falls and two fall-related emergency department visits. Resident #42's friend stated that Resident #42 had a walker when she was moved in, but was not aware of any fall interventions that were put in place since Resident #42 had her first fall at the residence on 2/6/23. On 2/14/23 at 11:12 p.m., the resident services director stated that Resident #42 was sent out 2/13/23 due to swelling and bruising that she suspected from the previous fall on 2/8/23 that had worsened. On 2/14/23 at 1:06 p.m., Staff #29 stated that she had found Resident #42 when she came on shift on 2/9/23, and night shift had never reported to her Resident #42 fell during the evening shift. Staff #29 stated that Resident #42 complained of pain when she dressed her in the morning of 2/9/23, and it was not until later that evening when they found out about Resident #42's fall, that she was finally taken to the hospital. Staff #29 stated that the night staff member who was either Staff #27 or #20, did not respond and report the fall appropriately, which was why there was a delayed action. On 2/14/23 at 1:44 p.m., the resident services director stated that she was aware that Resident #42 had no falls prior to admission to the residence and was aware she had not updated the care plan since she had her first fall. The resident services director acknowledged that the care plan should have been updated to include fall interventions after Resident #42 first fell on 2/6/23. 3. Resident #43 was admitted to the residence on 12/13/22 with diagnoses including dementia. A fall risk assessment, dated 1/10/23 read the resident was a high fall risk. A care plan, updated 1/12/23, read the resident had had 11 falls at the residence. The care plan detailed interventions including safety checks, non-slip socks, hospice, a new wheelchair, fall mat, and use of a hospital bed. However, the care plan was not updated to include an additional individualized approach necessary to address fall risk after the resident's fall on 1/30/23. Additionally, contracted staff were not aware of the individualized approach necessary to address fall risk. Incident reports revealed the following:12/16/22: Resident found on the floor with an abrasion to his left leg that looked like an old wound that was reopened. 12/20/22: Resident found on the floor. 12/21/22: Resident was found on the floor and stated his right shoulder was hurting. 12/23/22: The resident fell and stated he had pain in his knee. 12/24/22: The resident fell. 12/28/22: The resident fell and reopened a scab on his leg. 1/1/23: Resident found on the floor and is on two hour checks. 1/2/23: The resident fell. 1/5/23: Resident found on the floor. 1/10/23: Resident found on the floor with a skin tear on his left knee. 1/12/23: Resident found on the floor. 1/30/23: Resident found on the floor. On 2/13/23 at 12:40 p.m., Staff #29 stated that Resident #43 was a high fall risk and had several falls since he moved in. She added the resident had a new wheelchair and she was unsure of any additional individualized approaches necessary to prevent fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware that Resident #43 was at risk for falls or the individualized approaches necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware that Resident #43 was at risk for falls or the individualized approaches necessary to address fall risk. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated the resident was a fall risk and had fallen at the residence, which resulted in bruises, cuts, and scrapes. He added he was not sure of interventions the residence had in place to prevent future falls. On 2/14/23 at 10:22 a.m., an external hospice provider stated that Resident #43 was a fall risk. 4. Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease and Parkinson's Disease. A care plan, dated 1/5/23, read in part, the residence had implemented several fall preventions such as external hospice services, a fall mat, reminders to use a call pendant, changing his bed to a hospital bed, and frequent safety checks. However, contracted staff were not aware of the individualized approach necessary to address fall risk. A progress note, dated 1/10/23, read in part, the resident fell next to his night stand and wheelchair. The resident sustained redness to his forehead due to the fall. A care plan, dated 1/12/23, read in part, the residence placed signs in his room to remind him to use his call pendant for staff assistance with transfers. An incident report, dated 1/16/23, read in part, the resident was found on the floor next to his bed after a fall. The resident sustained a scratch above his eye. A care plan, dated 1/19/23, read in part, the residence increased external hospice visits to three times a week. An incident report, dated 1/23/23, read in part, the resident was found on the floor because he fell to the floor. An incident report, dated 2/7/23, read in part, the resident fell. Another care plan, dated 2/8/23, read in part, the residence implemented hourly checks and encouraged the resident to remain in common areas for supervision. On 2/13/23 at 1:06 p.m., the legal representative for Resident #2 stated the resident fell often because of poor safety awareness. He confirmed the residence implemented individualized approaches necessary to address fall risk, however, he stated the contracted staff were not trained or aware of the approaches necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 8:14 a.m., the external hospice nurse stated the resident was at risk for falls and was required to be provided with hourly safety checks. She stated she did notthink contracted staff implemented the individualized approaches necessary to address fall risk because they were not aware that Resident #2 was at risk for falls. On 2/14/23 at 8:33 a.m., Contracted Staff #40 stated she worked at the residence approximately eight times in the prior month. She stated she was unaware that Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 9:00 a.m., Contracted Staff #41 stated he worked at the residence three times in the prior few weeks. He also stated he was not aware that Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. 5. Resident #19 was admitted to the residence on 10/29/21, with diagnoses including Alzheimer's disease, localized osteoporosis and abnormalities of gait and mobility. An incident report, dated 2/10/23 at 5:30 a.m., written by a contracted staff member, read that Resident #19 was found on the floor next to her bed, and family and hospice was notified. A progress note, dated 2/10/23 at 10:10 a.m., read that Resident #19 slid from her wheelchair in the dining room and hit the right side of her temple on another resident's wheelchair. A comprehensive assessment, dated 9/13/22, read that Resident #19 was at a high risk for falls and required staff assistance with wheelchair transfers and ambulation. The most current care plan for Resident #19, dated 1/5/23, read that Resident #19 had a history of falls, used a wheelchair, and had a fall mat and non-slip socks. However, the care plan for Resident #19 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after either of Resident #19's falls on 2/10/23. On 2/13/23 at 2:37 p.m., Resident #19's family member stated that Resident #19 had a history of falls, however, she had a reduced number of falls since Resident #19 had gotten a new mattress in October 2022. Resident #19's family member stated that he was aware of Resident #19's fall where she hit her head against another resident's wheelchair, however, he stated that he was not aware that Resident #19 had also fallen out of bed earlier that same morning on 2/10/23. 6. Resident #38 was admitted to the residence on 8/15/22 with diagnoses including Alzhemier's disease. A progress note, dated 1/8/23, read in part, the resident fell. The resident required two hour safety checks. A care plan, dated 1/9/23, read in part, the resident required two hour safety checks and a two hour toileting schedule. A care plan, dated 1/19/23, read in part, the resident required two hour safety checks. However, the care plan did not include that the resident was at risk for falls. A progress note, dated 2/10/23, read in part, the resident had two bruises on the right shoulder due to a fall. Staff were required to provide the resident with hourly safety checks. On 2/13/23 at 12:47 p.m., the legal representative for Resident #38 stated the resident was at risk for falls because he would forget to use his walker which resulted in falls. She also stated the resident fell on 2/10/23 which resulted in bruises. Further the legal representative stated contracted staff worked at the residence often and were not aware of the resident's fall prevention plan. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware Resident #38 was at risk for falls or the individualized approach necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware Resident #38 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 8:33 a.m., Contracted Staff #40 stated she worked at the residence approximately eight times in the prior month. She stated she was unaware that Resident #38 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 9:00 a.m., Contracted Staff #41 stated he worked at the residence three times in the prior few weeks. He also stated he was not aware that Resident #38 was at risk for falls or the individualized approach necessary to address fall risk.

Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of five sample residents (#2, #32, #38, #43) and two former residents (#18, #44). This deficiency was cited previously during a state licensure survey 8/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Medication Administration policy, dated February 2022, read in part: "The community (residence) is responsible for complying with practitioner orders, associated with the administration of medication or treatment."2. Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease, major depressive disorder, and Parkinson's disease.a. OmeprazoleA written practitioner's order, dated 2/23/21, directed the residence to administer omeprazole 20 mg twice daily. However, the January 2023 medication administration record (MAR) read the medication was not administered in the morning on 1/14, 1/15, and 1/26 and in the evening on 1/1/23, for a total of four missed doses due to the medication being unavailable.b. LorazepamA written practitioner's order, dated 12/12/22, directed the residence to administer lorazepam 2 mg/mL oral concentrate 0.5 mg twice daily. However, the January 2023 MAR read the medication was not administered twice on 1/14 and in the evening on 1/31/23, for a total of three missed doses due to the medication being unavailable.c. QuetiapineA written practitioner's order, dated 2/23/21, directed the residence to administer quetiapine 100 mg twice daily. However, the January 2023 MAR read the residence did not administer the medication in the morning on 1/28 and 1/29 and in the evening on 1/28/23, for a total of three missed doses due to the medication being unavailable.d. DuloxetineA written practitioner's order, dated 4/19/22, directed the residence to administer duloxetine 40 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/7/23, for a total of one missed dose due to the medication being unavailable.e. TamsulosinA written practitioner's order, dated 2/23/21, directed the residence to administer tamsulosin 0.4 mg daily. However, the January 2023 MAR read the medication was not administered on 1/7/23, for a total of one missed dose due to the medication being unavailable. On 2/13/23 at 1:06 p.m., the legal representative for Resident #2 stated he was not aware of any medications being unavailable. 3. Resident #32 was admitted to the residence on 8/3/22. a. AmlodipineA written practitioner's order, dated 8/3/22, directed the residence to administer amlodipine 5 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/16, 1/18, and 1/19/23 for a total of three missed doses due to the medication being out of stock.b. RivastigmineA written practitioner's order, dated 8/3/22, directed the residence to administer a rivastigmine patch 4.6 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/3-1/6/23 for a total of four missed doses due to the medication being out of stock. 4. Resident #43 was admitted to the residence on 12/13/22.a. DivalproexA written practitioner's order, dated 11/22/22, directed the residence to administer divalproex 250 mg twice daily. However, the January 2023 MAR read the medication was not administered on 1/14/23 due to the medication being out of stock. b. HaloperidolA written practitioner's order, dated 11/22/22, directed the residence to administer haloperidol 5 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/17 and 1/18/23 for a total of two missed doses due to the medication being out of stock. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated he was not aware of medications being out of stock. 5. Former Resident #44 was admitted to the residence on 11/14/22. A written practitioner's order, dated 11/14/22, directed the residence to administer Xarelto 10 mg once daily. However, the November 2022 MAR read the medication was not administered on 11/27/22 for a total of one missed dose due to the medication being out of stock. On 2/13/23 at approximately 1:00 p.m., an anonymous staff member stated she remembered an issue with Former Resident #44's Xarelto, however, she could not recall what happened exactly. On 2/13/23 at 2:20 p.m., the responsible party for Former Resident #44 stated the resident's Xarelto went missing at the end of November and the resident missed at least one dose. 6. Resident #38 was admitted to the residence on 8/15/22. A written practitioner's order dated, 12/6/22, directed the residence to administer lidocaine cream 4% twice daily to the left side of his face. However, the January 2023 MAR read the medication was not administered in the evening on 1/4-1/6 and 1/10 and once in the morning on 1/10/23, for a total of five missed doses due to the medication being out of stock. On 2/13/23 at 12:47 p.m., the legal representative for Resident #38 stated she was not aware of the lidocaine ever being out of stock. 7. Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and major depressive disorder.a. Quetiapine 50 mgA written practitioner's order, dated 3/18/21, directed the residence to administer quetiapine 50 mg three times daily until discontinued on 9/2/22. A written practitioner's order dated 9/2/22, directed the residence to administer quetiapine 50 mg once at bedtime. However, quetiapine 50 mg was not administered on 9/2/22 in the evening, and was administered 9/2/22 in the morning instead, and was not administered 9/3-9/5/22, due to being inactive in the MAR, for a total of three missed doses. In addition, on 9/6 and 9/7/22, quetiapine 50 mg was administered in the afternoon instead of at bedtime as ordered. On 2/14/23 at 7:18 a.m., Staff #29 stated that former Staff #18 had messed up the charting and acknowledged that former Resident #18 was not given her quetiapine 50 mg at bedtime on 9/6/22 and instead was given it in the afternoon. Staff #29 stated that quetiapine was inactive in the MAR on 9/3-9/5/22, which was why it was not administered. On 2/14/23 at 1:33 p.m., the resident services director stated that medications that were inactive were not given at all. The resident services director acknowledged that former Resident #18's quetiapine 50 mg was not being administered as ordered and stated that as a result, evening doses were missed. b. Quetiapine 25 mgA written practitioner's order, dated 9/2/22, directed the residence to administer quetiapine 25 mg once every morning. A practitioner's order, dated 9/19/22, directed the residence to discontinue the current 25 mg once in the morning dose of quetiapine, and administer 25 mg three times daily. However, on 9/3/22 and 9/20/22, Quetiapine was not administered in the morning due to the medication being inactive in the MAR, for a total of two missed doses. On 2/14/23 at 7:18 a.m., Staff #29 stated that quetiapine was inactive on the MARs with the new orders and order changes, which was why it was marked as inactive. On 2/14/23 at 12:26 p.m., the consultant confirmed there were still medications that were not administered as required. However, she stated she was working with the residence to ensure medications were being audited and ordered every week to avoid medications being unavailable. On 2/14/23 at 1:30 p.m., the administrator designee stated she expected the residence to administer all prescribed doses of medication to residents as ordered. She stated that qualified administration persons reordered medications when they ran low. She added she was not aware that medication compliance was still an issue and was unsure why it had not been corrected. On 2/14/23 at approximately 1:33 p.m., the residence services director stated she was aware that some resident medications were out of stock.

Based on observations, interviews, and record review, the residence failed to ensure the residence grounds were maintained to protect residents from hazards, affecting 26 current residents. This deficiency was cited previously during a state licensure survey 8/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include: 1. ObservationsOn 2/13/23 at 7:30 a.m., an outside environmental tour was conducted of the east and west secure courtyard area which revealed un-repaired hazardous safety on the east and west sides. The following was observed:An area of the sidewalk on the east side of the secure outdoor courtyard had a drop off that measured 2.5 inches deep. An area of the sidewalk on the west side of the secure outdoor courtyard had a drop off that measured 3 inches deep on one side, and 2.5 inches deep on the other side of the sidewalk. 2. InterviewsOn 2/14/23 at 12:36 p.m., the consultant stated that the residence had a bid to have the work outside in the courtyards completed. However, she stated the snow had been a problem and outdoor contractors would not come until the spring of 2023. The consultant stated there was no date assigned they would come. The consultant further stated one side of the courtyard had been fixed, she thought the east, and thought it was corrected. The consultant stated the residence was aware of this safety issue. On 2/14/23 at 2:02 p.m., the resident services director stated that Resident #32 and Resident #42 went out into the courtyards, however, had not lately since it was winter. The resident services director stated that she was aware that the concrete had been an issue, however, was unable to get it fixed because of the weather.

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

A licensure revisit was completed on 2/14/23 for all previous deficiencies cited on 8/31/22. Deficiencies were cited.

Based upon observation, record review and interview, the residence failed to comply with conditions imposed by the department, affecting 26 current residents. Findings include: On 5/10/22 the department issued a Conditional License to the residence. The Conditional License read that the residence was required to maintain operational conditions during the term of the Conditional License. Following the completion of Event ZH3B12 on 12/8/21, a complaint investigation, the department imposed a consultant for 11 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The Conditional License required the residence to comply and maintain the following:Commencing the first week of the first full month, the licensee shall submit a written monthly report to the department that addresses each of the following areas of concern. The licensee shall include written monthly reports to the department information from audits performed during the previous month regarding how the licensee was ensuring compliance. Within the first 30 days of the Consultant's term, the Consultant shall review each of the cited deficiencies identified in the opportunities to present written data, views, and arguments dated January 26, 2022, with the administrator, and evaluate the facility's (residence's) current compliance with the corresponding regulations, as outlined in 6 C.C.R. 1011-1 Chapters 2, 7, and 24, where applicable. Within the first 45 days of the Consultant's term, the Consultant shall evaluate the Facility's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Facility on any additional areas of noncompliance. The Consultant shall also implement a monitoring program, to be completed at least monthly, to ensure the Facility remains in compliance with previously cited deficiencies. The monitoring program shall be incorporated into the Facility's ongoing quality management program (QMP), in accordance with 6 C.C.R. 1011-1 Chapter 2, Section 4. The Consultant shall make certain that the QMP is designed to improve resident safety and well-being, and promotes continued quality improvement to enhance service delivery. The Consultant shall make certain that the Administrator has a process in place to correct the identified deficiency, which includes utilizing the above-referenced monitoring program to ensure the deficient practice does not reoccur. The Consultant shall make certain that the monitoring identifies the scope of review, how a sample is identified for monitoring purposes, the total length of time the monitoring will continue, which will be no less than six months, and how the monitoring will be documented. During the final 60 days of the Consultant's term, the Consultant shall prepare the Administrator to independently manage the Facility to ensure compliance with all applicable regulations governing assisted living residences. The Consultant shall make certain that the Administrator has tools and resources in place to maintain compliance. The Conditional license also read that examples of a material breach of the conditional license included, but was not limited to, the following:Failure of the Licensee to comply with all applicable state rules, regulations, and standards, including without limitation, Chapter 2, 7, and 24 of the Department's regulations at 6 CCR 1011-1, and the provisions of Articles 3 and 27 of Title 25, C.R.S. or a sustained finding of immediate jeopardy at any time. Department records read the residence had chosen the consultant on 5/31/22 and the contract for the consultant was received on 6/1/22. Therefore, on the day of the completion of the revisit, 2/14/23, the consultant was in the beginning of her eighth month as consultant for the residence. During the 2/14/23 revist, the revisit established there was current deficient practice, despite having a consultant in place. Eight deficiencies were cited, including Tags 540, 732, 734, 1110, 1180, 1350, 1468, 2982 (Cross-reference Q540, Q732, Q734, Q1110, Q1180, Q1350, Q1468, Q2982). On 2/14/23 at approximately 3:29 p.m., the administrator designee stated she was aware of the requirements of the conditional license. On 2/14/22 at approximately 12:36 p.m., the consultant stated the following:In regards to Tag 540, the consultant stated that she had done several reviews of COVID and the COVID vaccination plan. The consultant stated that she was aware that EMResource had not been updated. In regards to Tag 732, the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have first aid certification from a nationally recognized organization. In regards to Tag 734, the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have CPR certification from a nationally recognized organization. In regards to Tag 1110, the consultant stated that residents should have received personal services as indicated in their care plans. In regards to Tag 1180, the consultant stated she was aware that contracted staff were not provided fall related training. She stated she brought it to the residence's attention in January 2023, however, training still had not been implemented. She also stated the resident began using contracted staff on 1/4/23. In regards to Tag 1350, the consultant stated that she wrote about the residence phone not working in her report where family members could not reach their loved ones. The consultant stated that the residence had a main line that connected during business hours and was allegedly fixed. The consultant stated that she expected QMAP phones to be answered however, was aware it had been an issue. In regards to Tag 1468, the consultant confirmed there were still medications that were not administered as required. However, she stated she was working with the residence to ensure medications were being audited and ordered every week to avoid medications being unavailable. In regards to Tag 2982, the consultant stated she was concerned because the residence did not have sufficient staffing levels on the weekends. She added that sometimes staff will call off or contracted staff will not show up, resulting in even lower numbers of staff.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 26 current residents. Findings include:1. References and Residence Policya. The Ninth Amended State Public Health Order 20-20 (PHO) Requirements for Colorado Skilled Nursing Facilities, Assisted Living Residences, Intermediate Care Facilities and Group Homes for COVID-19 Prevention and Response, dated 10/11/22, required residences to:- Report to CDPHE information pertaining to their available resources to respond to the COVID-19 pandemic. The department will provide the reporting platforms and the form and format for submission of the required information. The residence must adhere to reporting requirements as specified in RCF Comprehensive Mitigation Guidance. b. The COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/7/23, required residences to: - Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month and period two, defined as days 15 to 31 of each month). 2. Record ReviewOn 2/13/23 at 9:57 a.m., a review of EMResource revealed that the residence's most current reporting occurred on 11/10/22, resulting in six missed periods during which the residence was required to report. EMResource read that there were still 30 residents, however, the day of the onsite survey the resident roster read there were only 26 current residents. 3. InterviewsOn 2/14/23 at approximately 12:36 p.m., the consultant stated that she had done several reviews of COVID and the COVID vaccination plan. The consultant stated that she was aware that EMResource had not been updated. On 2/14/23 at approximately 1:36 p.m., the resident services director stated that she did not know why the administrator had not updated EMResource since 11/10/22. The resident services director stated that she was aware of the requirement and thought that the administrator had updated EMResource.

Based on interviews and record review, the residence failed to have at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization, affecting 26 current residents. (Cross-reference Q734). This deficiency was cited previously during a state licensure survey 8/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence policya. The residence's First Aid policy, dated February 2022, read in part: "There is at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization."b. According to the National CPR Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own (teacher). Our services are designed with OSHA, the ECC (Emergency Cardiovascular Care)/ILCOR (The International Liaison Committee on Resuscitation) and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2022) Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/2. Record ReviewOn 2/13/23, review of staff first aid certifications provided by the resident services director revealed that Staff #33, #38 and #42 did not have first aid certifications from a nationally recognized organization. Additionally, staff first aid certifications revealed only one staff (#34) had certification from a nationally recognized organization. The staff schedule from 1/30-2/13/23 revealed there were no staff with certification on: 1/30 from 6:00 a.m. to 2:00 p.m. and 10:00 p.m. to 6:00 a.m., 1/31-2/2 all shifts, 2/3 and 2/4 on 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m., on 2/6 from 6:00 a.m. to 2:00 p.m. and 10:00 p.m. to 6:00 a.m., all shifts on 2/7, 2/8 from 6:00 a.m. and 2:00 p.m. to 10:00 p.m., 2/9 and 2/10 for all shifts, on 2/11 from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., on 2/12 all shifts, 2/13/23 from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. for a total of 34 shifts. Additionally, the schedule revealed that staff with certification from a not nationally recognized organization worked on 1/30 from 2:00 p.m. to 10:00 p.m., 2/3 from 10:00 p.m. to 6:00 a.m., 2/4 from 10:00 to 6:00 a.m., on 2/5 from 2:00 p.m. to 6:00 a.m., 2/8 from 6:00 a.m. to 2:00 p.m. and 2/13/23 from 6:00 a.m. to 2:00 p.m., for an additional seven shifts. 3. InterviewsOn 2/14/23 at approximately 12:35 p.m., the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have first aid certification from a nationally recognized organization. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated she was aware the residence was required to have first aid certified staff scheduled at all times. She stated the resident services director was responsible for the staff schedule. She added she was aware that some contracted staff had first aid certification from an organization that was not nationally recognized. The administrator designee stated this was not corrected because the residence had not audited contracted staff certifications. On 2/14/23 at 1:33 p.m., the resident services director stated she was responsible for creating the staff schedule. She added she was not aware that the residence did not have one staff on at all times with first aid certification.

Based on interviews and record review, the residence failed to 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, affecting 26 current residents who required assistance in the event of an obstructed airway. (Cross-reference Q732). This deficiency was cited previously during a state licensure survey 8/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence policya. The residence's CPR policy, dated February 2022, read in part: "There is at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation and obstructed airway techniques from a national recognized organization."b. According to the National CPR Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own (teacher). Our services are designed with OSHA, the ECC (Emergency Cardiovascular Care)/ILCOR (The International Liaison Committee on Resuscitation) and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2022) Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/c. According to Nolo Legal Encyclopedia, "A MOST (Medical Orders for Scope of Treatment) form is a doctor's order that helps you keep control over medical care at the end of life. Like a Colorado CPR Directive, the form tells emergency medical personnel and other health care providers whether or not to administer cardiopulmonary resuscitation (CPR) in the event of a medical emergency. A MOST form may be used in addition to -- or instead of -- a CPR Directive. The MOST form may also provide other information about your wishes for end-of-life health care." Irving, S., J.D., Colorado's Medical Orders for Scope of Treatment (MOST) Form, retrieved from: https://www.nolo.com/legal-encyclopedia/colorados-medical-orders-scope-treatment-most-form.html 2. Code status and schedulesRecords for Residents #35 and #37 contained medical orders for scope of treatment that directed the residence to perform CPR in the event of an emergency. On 2/13/23, review of staff CPR certifications provided by the resident services director revealed that Staff #32, #33, #38, #40 and #42 did not have CPR certifications from a nationally recognized organization. The staff schedule revealed the residence did not have a staff member who was CPR certified from a nationally recognized organization on 1/30 from 2:00 p.m. to 10:00 p.m., 2/5 from 2:00 p.m. to 10:00 p.m., 10:00 p.m. to 6:00 a.m., 2/9 through 2/11 from 10:00 p.m. to 6:00 a.m., 2/12 from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., for a total of eight shifts in two weeks. 3. InterviewsOn 2/14/23 at approximately 12:35 p.m., the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have CPR certification from a nationally recognized organization. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated she was aware the residence was required to have CPR certified staff scheduled at all times. She stated the resident services director was responsible for the staff schedule. She added she was aware that some contracted staff had CPR certification from an organization that was not nationally recognized. The administrator designee stated this was not corrected because the residence had not audited contracted staff certifications. On 2/14/23 at 1:33 p.m., the resident services director stated she was responsible for creating the staff schedule. She added she was not aware that the CPR certifications for Contracted Staff #32, #33, and #40 were not from a nationally recognized organization.

Based on record review and interview, the residence failed to make available, either directly or indirectly through a resident agreement, personal services, affecting three of seven sample residents (#32, #42, #43). Findings include:1. ReferenceChapter VII regulations governing assisted living residences, in section two, defines "Personal Services" as those services that an assisted living residence and its staff provide for each resident including, but not limited to, assistance with activities of daily living. The residence's resident agreement, dated May 2020, read in part the residence provided staff assistance with normal activities of daily living, such as dressing, bathing and general health supervision. 2. Resident #32 was admitted to the residence on 8/3/22 with a diagnosis of Alzheimer's disease. The care plan for Resident #32, updated 2/6/23, read in part that the resident required total assistance with toileting and required frequent changing in bed. Additionally, the care plan read that the resident required total assistance with grooming and dressing. On 2/14/23 at 8:43 a.m., an external hospice provider stated when she checked Resident #32 that morning, there was dried feces in his incontinence briefs. She stated the feces had likely been there for hours and she did not think staff changed his incontinence briefs as often as was needed. She added this happened at least once per week and sometimes more. The external hospice provider stated she did not think residence staff assisted Resident #32 with grooming and dressing and that residence staff relied on hospice providers. 3. Resident #42 was admitted to the residence on 1/9/23 with diagnoses including cognitive deficits. The care plan for Resident #42, dated February 2023, read in part that the resident wore and required assistance with incontinence briefs overnight. On 2/13/23 at approximately 1:00 p.m., an anonymous staff member stated Resident #42 was covered in dried feces that morning. She stated this happened about once per week. 4. Resident #43 was admitted to the residence on 12/13/22 with diagnoses including dementia. The undated care plan for Resident #43 read in part that the resident required assistance with incontinence episodes more than three times per week. On 12/13/23 at 12:40 p.m., an anonymous staff member stated that Resident #43 required assistance with incontinence. She added that she found the resident overly soiled and with a strong odor about three times per week because residence staff had not assisted with his incontinence as required. On 12/14/23 at 10:22 a.m., an external hospice provider stated that she started working with Resident #43 on 1/20/23 and had observed him and his bed soiled multiple times. On 2/14/23 at approximately 12:35 p.m., the consultant stated that residents should have received personal services as indicated in their care plans. On 2/14/23 at 1:30 p.m., the administrator designee stated that residents should have received personal services as indicated in their care plans. She stated she was unsure why this was not corrected. On 2/14/23 at approximately 1:33 p.m., the residence services director stated she was aware that Resident #42 was found soiled on 2/13/23. She stated that residents should have received personal services as indicated in their care plans.

7. Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and osteoporosis. An incident report, dated 10/2/22, read that Former Resident #18 had a fall with minor injury, that included a red bump on the side of her forehead. A progress note, dated 10/6/22, read that Former Resident #18 had a fall. An incident report, dated 10/24/22, read that Former Resident #18 had a fall with minor injury, that included a cut on the right side of former Resident #18's eye. A progress note, dated 10/28/22, read that Former Resident #18 had a fall and was found sitting on the floor. A hospital discharge summary, dated 11/5/22, read that Former Resident #18 received five staples due to injury to the right side of her head from tripping over a television cord. No other injuries. A progress note, dated 11/28/22, read that on 11/5/22, Former Resident #18 tripped over television cords, fell and hit her head, and required five staples. A progress note, dated 12/5/22 at 8:13 p.m., read that Former Resident #18 walked into a chair and fell. A progress note, dated 12/5/22 at 8:17 p.m., read that Former Resident #18 fell a second time from having walked too fast around the residence. A progress note, dated 12/21/22 at 12:58 p.m., read that Former Resident #18 had a fall. A comprehensive change in condition assessment dated 12/26/22, read that Former Resident #18 was a frequent fall risk and required redirection, assistance with ambulation, and reminders to use the walker. Former Resident #18 experienced frequent gait elevation and best practice is for staff to encourage the resident to sit down and rest. A progress note, dated 1/3/23, read that the administrator was made aware of an unreported fall with injury on 1/1/23 for Former Resident #18. The incident report further read that Former Resident #18 fell on her face which caused a nose bleed. The care plan for Former Resident #18, dated 1/6/23, read that Former Resident #18 was a high fall risk, and required redirection, an environment free of obstacles and assistance with ambulation. However, the care plan for Former Resident #18 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after each fall, on 10/2/22, 10/6/22, 10/24/22, and 10/28/22. On 2/13/23 at 11:23 a.m., Former Resident #18's family member stated that the former resident would often fall and she would not be informed of the fall. Former Resident #18's family member stated that the most recent fall on 1/1/23 Former Resident #18 was injured and Former Staff #26 did nothing and did not even report it. Former Resident #18's family member stated that staff did not know how to respond appropriately to Former Resident #18's falls. 8. Resident #22 was admitted to the residence on 8/5/21 with diagnoses including Alzheimer's disease. An incident report, dated 12/20/23, read the resident had a fall. A fall assessment, dated 1/12/23 read that Resident #22 was a fall risk. An incident report, dated 1/17/23, read the resident had a fall. A care plan, dated 1/19/23, read the resident's last fall was on 1/19/23. However, the care plan did not include detailed individualized approaches necessary to address the resident's fall risk. Additionally, contracted staff were not aware of the individualized approaches necessary to address fall risk. On 2/13/23 at approximately 12:40 p.m., Staff #29 stated that Resident #22 was a fall risk. However, she was unablt to recall any individualized approaches necessary to address the resident's fall risk. On 2/14/23 at 8:26 a.m., the responsible party for Resident #22 stated the resident was a fall risk. She stated she was unsure of individualized approaches the residence had to address the resident's fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware that Resident #22 was at risk for falls or the individualized approaches necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware that Resident #22 was at risk for falls or the individualized approaches necessary to address fall risk. 9. Staff trainingOn 2/13 and 2/14/23, personnel files for Contracted Staff #31-#33 revealed no evidence of training related to fall prevention. On 2/13/23 at 3:11 p.m., fall training for all contracted staff was requested. However, the residence was unable to provide the requested training documentation. The staff schedule revealed approximately six shifts worked in the previous two weeks with only contracted staff on shift and no residence staff. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/13/23 at 3:02 p.m., Contracted Staff #32 stated that she had picked up shifts at the residence for about three weeks. Contracted Staff #32 stated that the residence did not provide her with fall management training or education, and was only provided an online fall management training with her contracted agency, where she learned she was supposed to follow individual residence protocols for falls. Contracted Staff #32 stated that she was not sure what the residence's fall protocol was, or how to respond to a fall, since the residence had not taught her. On 2/14/23 at 8:33 a.m., Contracted Staff #40 stated she worked at the residence approximately eight times in the prior month. She stated she was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/14/23 at 9:00 a.m., Contracted Staff #41 stated he worked at the residence three times in the prior few weeks. He also stated he was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/14/23 at 11:04 a.m., the resident services director (RSD) stated the residence had not provided fall related training to contracted staff. On 2/14/23 at 11:04 a.m., the administrator designee acknowledged the residence had not provided fall related training to contracted staff. On 2/14/23 at 12:36 p.m., the consultant stated she was aware that contracted staff were not provided fall related training. She stated she brought it to the residence's attention in January 2023, however, training still had not been implemented. She also stated the resident began using contracted staff on 1/4/23. On 2/14/23 at 1:47 p.m., The RSD stated that she was responsible for updating care plans with the administrator. The resident services director stated that she had updated some of the care plans the week prior to the onsite survey. However she stated she had not had not gotten around to updating all of them, or had time to learn about what all needed to be included, since the administrator was still teaching her. The resident services director stated that she was aware that fall interventions needed to be updated after each fall. The resident services director stated that she provided staff with fall management orientation and training, however, did not provide training to contracted staff. The resident services director stated that she would make sure to train contracted staff moving forward. 10. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed 26 current residents at immediate jeopardy risk for falls with injury. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 2/14/23 at 12:45 p.m., the administrator designee submitted written evidence that read in pertinent part, "All (residence) and Agency (contracted) care staff on day, evening and overnight shift will be trained by RSD on fall intervention/fall management and residents who are high fall risk beginning today, 2/14/2023. Training / In-Service and discussion to continue at mandatory All-Staff meeting tomorrow, 2/15/2023.a. 2/14/2023 day staff to be trained before their shift ends today.b. 2/14/2023 evening staff to be trained at shift change / before their shift begins tonight.c. 2/14/2023 overnight staff to be trained at shift change / before their shift begins tonight.d. All staff required to attend monthly All-Staff meeting at 2:15 p.m. on Wed(nesday). 2/15/2023 to continue with this training and reiterate the importance of updated fall management.e. Continued training to be provided by RSDf. Training will be documented on In-Service sheets to be located/stored in In-Service binder in Administrator ' s office. 2. Fall Management Binder to be compiled immediately by Resident Services Director, and to include:a. Identify residents who are a high fall risk, including their photob. Inform of resident-specific interventions in placec. Identify recent fallsd. Binder to be located on bookshelf in Clock-in/Copier Room for all staff to access at any time and will be taken to each shift report, daily.e. RSD responsible for daily updates 3. Monitoring:a. Will be monitored daily by RSD for 90 days with any discrepancies discussed at weekly QMP (quality management program) meetings and additional training needs followed-upat that time. 4. Staff File Audits:a. BOM (business office manager)/RCC (resident care coordinator)/RSD to audit five staff files per month and discrepancies corrected immediately and discussed during weekly QMP meetings."However, the written evidence did not indicate the risk had been removed because it did not indicate who the scheduler would be aware of which staff were provided the required training. On 2/14/23 at 1:28 p.m., the administrator designee submitted additional written evidence that read in pertinent part, "Follow-up Question: how will scheduler know who from Agency has already had training and who is new and needs training?a. RSD and RCC shall create and utilize Audit sheet to verify Agency staff members have been trained prior to shift to identify residents who are at risk for falls and identify interventions."However, the written evidence did not indicate the risk had been removed because it did not indicate when the audit sheet would be created and a date as to when it would be implemented. On 2/14/24 at 2:14 p.m. the administrator designee submitted additional written evidence that read in pertinent part, "The audit form will be created and implemented today, 2/14/23."Based on observation, interview, and record review, the residence failed to implement a fall management program affecting 26 current residents. This deficiency was cited previously during a state licensure survey 8/31/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #43 was admitted to the residence on 12/13/22. Resident #43 sustained 12 falls in 44 days (12/16, 12/20, 12/21, 12/23, 12/24, 12/28/22, 1/1, 1/2, 1/5, 1/10, 1/12, and 1/30/23). Five of the falls resulted in injuries. On 12/16/22, the resident sustained an abrasion on his left leg. On 12/21/22, the resident had shoulder pain. On 12/23/22, the resident had knee pain. On 12/28/22, the resident reopened a scab on his leg. On 1/10/23, the resident had a skin tear on his left knee. A care plan, dated 1/12/23, read in part, the residence implemented several fall precautions such as external hospice services, a fall mat, and frequent safety checks. However, contracted staff were not aware of the individualized approach necessary to address the resident's fall risk. Specifically, Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease and Parkinson's Disease. A care plan, dated 1/5/23, read in part, the residence had implemented several fall precautions such as external hospice services, a fall mat, reminders to use a call pendant, changing his bed to a hospital bed, and frequent safety checks. However, contracted staff were not aware of the individualized approach necessary to address fall risk. Further, the resident had four falls from 1/10-2/7/23 with two injuries. Specifically, Resident #38 was admitted to the residence on 8/15/22 with diagnoses including Alzhemier's disease. The resident had a fall on 1/8 and 2/10/23 which resulted in bruises to his right shoulder. A care plan, dated 1/9 and 1/19/23, read the resident required two hour safety checks, however, it did not include that the resident was at risk for falls. Additionally, contracted staff were not aware the resident was at risk for falls or the individualized approach necessary to address fall risk. Specifically, Resident #42 was admitted to the residence on 1/11/23, with diagnoses including long term use of anticoagulants, lumbar vertebral osteoporotic fracture, and vascular dementia. The resident had a fall on 2/6/23 and had bruising to her hip. The resident fell again and hit her nose and hit her left elbow 2/8/23 and was hospitalized 2/9/23 due to pain and swelling of her elbow. A care plan, dated 1/26/23, read that Resident #42 used a walker, however did not did not include that the resident was at risk for falls. Additionally, contracted staff were not aware of the resident was a fall risk or of any approaches necessary to address falls due to the care plan that was not updated after Resident #42 had her first fall on 2/6/23. Specifically, Resident #19 was admitted to the residence on 10/29/21, with diagnoses including Alzheimer's disease, localized osteoporosis and abnormalities of gait and mobility. The resident fell out of bed at 5:30 a.m., on 2/10/23, and fell again in the dining room and hit her head and sustained a bruise on her right temple, at 10:10 a.m. on 2/10/23. A care plan, dated 1/5/23, read that Resident #19 had a history of falls, used a wheelchair, and had a fall mat and non-slip socks. However contracted staff were not aware of the individualized approach necessary to address fall risk. Specifically, Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and osteoporosis. The resident had sustained nine falls in the past two months on 10/2, 10/6, 10/24, 10/28, 11/5, 12/5 twice, 12/21/22 and 1/1/23. During the fall on 10/2/22, the resident sustained a red bump on the side of her forehead. On 10/24/22, the resident sustained a cut on the right side of her eye. On 11/5/22, the resident hit her head and received stitches from a major fall. On 1/1/23 the resident had a nose bleed from a major unreported fall with injury. The care plan for former Resident #18, updated on 12/27/22 and 1/6/23, read that former Resident #18 was a high fall risk, and required redirection, an environment free of obstacles and assistance with ambulation. However, the care plan for former Resident #18 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after each fall, on 10/2/22, 10/6/22, 10/24/22, and 10/28/22. Additionally, contracted staff were not aware of the individualized approach necessary to address fall risk. These failures created an immediate jeopardy risk of falls with injury to six sample residents residing in the residence. On 2/14/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Residence policyThe residence's Fall Management Program, dated February 2022, read in part, the residence would detail in each resident's care plan the individualized approach necessary to address fall risk and provide staff training related to fall prevention. 2. Resident #42 was admitted to the residence on 1/11/23, with diagnoses including long term use of anticoagulants, lumbar vertebral osteoporotic fracture, and vascular dementia. On 2/13/23 at 8:51 a.m., Resident #42 was lying on an elevated double mattress bed, and there were no assistive devices or other approaches observed to remove fall risk. An incident report, dated 2/6/23, read that Resident #42 had sustained a fall in the dining area, and hurt her hip. An incident report, dated 2/8/23, read that Resident #42 had sustained a fall, and staff found her laying on her back next to the east medication cart. Resident #42 had a bruise on her nose and was not in pain. A progress note, dated 2/10/23 at 5:01 p.m., read that Resident #42 had a swollen left elbow and complained of pain during the 2:00-10:00 p.m., shift on 2/9/23 and was sent out to the hospital. A hospital discharge summary, dated 2/9/23, read that Resident #42 had a fall with altered mental status. Labs and imaging showed no signs of intracranial hemorrhage or fractures. An incident report dated 2/13/23, read that Resident #42 had swelling in her left hand and discoloration on parts of her body and complained of pain. Resident was subsequently sent out to the hospital. A hospital discharge summary, dated 2/13/23, read that Resident #42 had multiple contusions and x-rays of the hands and hips were normal. Ice was recommended for the swelling and ibuprofen every four hours. The most current care plan for Resident #42, dated 1/26/23, read that Resident #42 used a walker and had no reported falls at home or a history of falls. Moreover, the care plan for Resident #42 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after she fell on 2/6, or 2/8/23. On 2/14/23 at 10:06 a.m., Resident #42's friend, stated that Resident #42 had no falls prior to moving into the residence, and since moving it she had sustained two falls and two fall-related emergency department visits. Resident #42's friend stated that Resident #42 had a walker when she was moved in, but was not aware of any fall interventions that were put in place since Resident #42 had her first fall at the residence on 2/6/23. On 2/14/23 at 11:12 p.m., the resident services director stated that Resident #42 was sent out 2/13/23 due to swelling and bruising that she suspected from the previous fall on 2/8/23 that had worsened. On 2/14/23 at 1:06 p.m., Staff #29 stated that she had found Resident #42 when she came on shift on 2/9/23, and night shift had never reported to her Resident #42 fell during the evening shift. Staff #29 stated that Resident #42 complained of pain when she dressed her in the morning of 2/9/23, and it was not until later that evening when they found out about Resident #42's fall, that she was finally taken to the hospital. Staff #29 stated that the night staff member who was either Staff #27 or #20, did not respond and report the fall appropriately, which was why there was a delayed action. On 2/14/23 at 1:44 p.m., the resident services director stated that she was aware that Resident #42 had no falls prior to admission to the residence and was aware she had not updated the care plan since she had her first fall. The resident services director acknowledged that the care plan should have been updated to include fall interventions after Resident #42 first fell on 2/6/23. 3. Resident #43 was admitted to the residence on 12/13/22 with diagnoses including dementia. A fall risk assessment, dated 1/10/23 read the resident was a high fall risk. A care plan, updated 1/12/23, read the resident had had 11 falls at the residence. The care plan detailed interventions including safety checks, non-slip socks, hospice, a new wheelchair, fall mat, and use of a hospital bed. However, the care plan was not updated to include an additional individualized approach necessary to address fall risk after the resident's fall on 1/30/23. Additionally, contracted staff were not aware of the individualized approach necessary to address fall risk. Incident reports revealed the following:12/16/22: Resident found on the floor with an abrasion to his left leg that looked like an old wound that was reopened. 12/20/22: Resident found on the floor. 12/21/22: Resident was found on the floor and stated his right shoulder was hurting. 12/23/22: The resident fell and stated he had pain in his knee. 12/24/22: The resident fell. 12/28/22: The resident fell and reopened a scab on his leg. 1/1/23: Resident found on the floor and is on two hour checks. 1/2/23: The resident fell. 1/5/23: Resident found on the floor. 1/10/23: Resident found on the floor with a skin tear on his left knee. 1/12/23: Resident found on the floor. 1/30/23: Resident found on the floor. On 2/13/23 at 12:40 p.m., Staff #29 stated that Resident #43 was a high fall risk and had several falls since he moved in. She added the resident had a new wheelchair and she was unsure of any additional individualized approaches necessary to prevent fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware that Resident #43 was at risk for falls or the individualized approaches necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware that Resident #43 was at risk for falls or the individualized approaches necessary to address fall risk. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated the resident was a fall risk and had fallen at the residence, which resulted in bruises, cuts, and scrapes. He added he was not sure of interventions the residence had in place to prevent future falls. On 2/14/23 at 10:22 a.m., an external hospice provider stated that Resident #43 was a fall risk. 4. Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease and Parkinson's Disease. A care plan, dated 1/5/23, read in part, the residence had implemented several fall preventions such as external hospice services, a fall mat, reminders to use a call pendant, changing his bed to a hospital bed, and frequent safety checks. However, contracted staff were not aware of the individualized approach necessary to address fall risk. A progress note, dated 1/10/23, read in part, the resident fell next to his night stand and wheelchair. The resident sustained redness to his forehead due to the fall. A care plan, dated 1/12/23, read in part, the residence placed signs in his room to remind him to use his call pendant for staff assistance with transfers. An incident report, dated 1/16/23, read in part, the resident was found on the floor next to his bed after a fall. The resident sustained a scratch above his eye. A care plan, dated 1/19/23, read in part, the residence increased external hospice visits to three times a week. An incident report, dated 1/23/23, read in part, the resident was found on the floor because he fell to the floor. An incident report, dated 2/7/23, read in part, the resident fell. Another care plan, dated 2/8/23, read in part, the residence implemented hourly checks and encouraged the resident to remain in common areas for supervision. On 2/13/23 at 1:06 p.m., the legal representative for Resident #2 stated the resident fell often because of poor safety awareness. He confirmed the residence implemented individualized approaches necessary to address fall risk, however, he stated the contracted staff were not trained or aware of the approaches necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 8:14 a.m., the external hospice nurse stated the resident was at risk for falls and was required to be provided with hourly safety checks. She stated she did not think contracted staff implemented the individualized approaches necessary to address fall risk because they were not aware that Resident #2 was at risk for falls. On 2/14/23 at 8:33 a.m., Contracted Staff #40 stated she worked at the residence approximately eight times in the prior month. She stated she was unaware that Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 9:00 a.m., Contracted Staff #41 stated he worked at the residence three times in the prior few weeks. He also stated he was not aware that Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. 5. Resident #19 was admitted to the residence on 10/29/21, with diagnoses including Alzheimer's disease, localized osteoporosis and abnormalities of gait and mobility. An incident report, dated 2/10/23 at 5:30 a.m., written by a contracted staff member, read that Resident #19 was found on the floor next to her bed, and family and hospice was notified. A progress note, dated 2/10/23 at 10:10 a.m., read that Resident #19 slid from her wheelchair in the dining room and hit the right side of her temple on another resident's wheelchair. A comprehensive assessment, dated 9/13/22, read that Resident #19 was at a high risk for falls and required staff assistance with wheelchair transfers and ambulation. The most current care plan for Resident #19, dated 1/5/23, read that Resident #19 had a history of falls, used a wheelchair, and had a fall mat and non-slip socks. However, the care plan for Resident #19 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after either of Resident #19's falls on 2/10/23. On 2/13/23 at 2:37 p.m., Resident #19's family member stated that Resident #19 had a history of falls, however, she had a reduced number of falls since Resident #19 had gotten a new mattress in October 2022. Resident #19's family member stated that he was aware of Resident #19's fall where she hit her head against another resident's wheelchair, however, he stated that he was not aware that Resident #19 had also fallen out of bed earlier that same morning on 2/10/23. 6. Resident #38 was admitted to the residence on 8/15/22 with diagnoses including Alzhemier's disease. A progress note, dated 1/8/23, read in part, the resident fell. The resident required two hour safety checks. A care plan, dated 1/9/23, read in part, the resident required two hour safety checks and a two hour toileting schedule. A care plan, dated 1/19/23, read in part, the resident required two hour safety checks. However, the care plan did not include that the resident was at risk for falls. A progress note, dated 2/10/23, read in part, the resident had two bruises on the right shoulder due to a fall. Staff were required to provide the resident with hourly safety checks. On 2/13/23 at 12:47 p.m., the legal representative for Resident #38 stated the resident was at risk for falls because he would forget to use his walker which resulted in falls. She also stated the resident fell on 2/10/23 which resulted in bruises. Further the legal representative stated contracted staff worked at the residence often and were not aware of the resident's fall prevention plan. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware Resident #38 was at risk for falls or the individualized approach necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware Resident #38 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 8:33 a.m., Contracted Staff #40 stated she worked at the residence approximately eight times in the prior month. She stated she was unaware that Resident #38 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 9:00 a.m., Contracted Staff #41 stated he worked at the residence three times in the prior few weeks. He also stated he was not aware that Resident #38 was at risk for falls or the individualized approach necessary to address fall risk.

Based on observations, record review and interviews, the residence failed to implement an internal process to ensure routine and prompt handling of grievances or complaints brought by family members or advocates, affecting 26 current residents. This deficiency was cited previously during a state licensure survey 8/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence grievance policy, dated 2/22/22, read in part: "Most problems can be easily resolved by contacting the administrator of the (residence). The administrator will document all complaints/grievances brought to his attention ...the complaint will be documented and reviewed with the individual who registered the complaint within 3-5 days of the complaint ...community staff will provide assistance as indicated to any individual who wishes to implement the grievance procedure."1. ObservationsOn 2/14/23 at 1:10 p.m., a phone charging station was on a table in a locked back room behind the staff office on the east side of the residence. However, there were no phone chargers on either medication cart on the east or west side of the residence. On 2/14/23 at 1:56 p.m., Staff #29 telephoned Staff #36 on the only resident telephone in the residence that was located in the television room on the west side of the residence, and the telephone screen read "emergency calls only."2. Record ReviewA grievance, dated 1/18/23, read that the responsible party for Resident #40 attempted to contact the resident by calling the residence. However, the responsible party was unable to get a hold of staff when using the residence phone number. On 2/14/23 at 1:24 p.m., Staff #29 provided a missed call log on her phone of all the unanswered calls from family members. The missed calls on the staff phone revealed that between 2/9/23 and 2/13/23 the following calls by family members were unanswered by residence staff:-The family member for Resident #2 had called the residence six times.-The family member for Resident #27 had called the residence three times.-The family member for Resident #29 had called the residence once.-The family member for Resident #43 had called the residence once. 3. Interviews On 2/13/23 at former Resident #18's family member stated that she had expressed concerns about former Resident #18's care during a conference on 8/31/22, and reached out to the residence again in September and October 2022 with no response. On 2/14/23 at 8:26 a.m., the responsible party for Resident #22 stated that residence phones had gone missing, which made it difficult for her to contact Resident #22. On 2/14/23 at 8:41 a.m., outside agency representative stated she had to reach out to the residence on behalf of Former Resident #18, and received a response on 10/27/22. A meeting with herself and the residence was held on 11/3/22, and she had discovered that prior to November 3, 2022, the residence did not have a formal grievance process. The outside agency representative stated that she had received concerns from former Resident #18's family member, as well as other family members of residents, about not being able to get in touch with the residence about concerns they had. On 2/14/23 at approximately 12:36 p.m., the consultant stated that she wrote about the residence phone not working in her report where family members could not reach their loved ones. The consultant stated that the residence had a main line that connected during business hours and was allegedly fixed. The consultant stated that she expected staff telephones to be answered however, was aware it had been an issue. On 2/14/23 at 1:06 p.m., Staff #29 stated that they only had one phone charging station in the back room behind the staff office on the east side of the residence. Staff #29 stated that it had been an ongoing issue where nightshift staff would not charge their phones or answer family phone calls, and when the morning shift came on, all the phones would be dead and with unanswered missed calls from families. On 2/14/23 at 1:33 p.m., the resident services director stated that there were phones on the east and west side in the television rooms that could connect with family members. The resident services director stated that all calls that come in after hours go to staff cellular telephones, and staff telephones had been going dead at night. The staff further stated the residence was working on obtaining telephone chargers for the medication carts. The resident services director stated that she was aware that it was an issue with family members not being able to get through. On 2/14/23 at 2:02 p.m., Staff #29 stated that the residence only had one telephone in the west side television room, however, it had only worked to call emergency services in the case of an emergency, and was not capable of dialing any other numbers or connecting residents with family members. Staff #29 stated that family members of residents would have to telephone the staff telephones in order to get in touch with their loved ones. Staff #29 stated that she was not aware why the telephone on the west side would only dial emergency services and stated that the telephone "would not work."

Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of five sample residents (#2, #32, #38, #43) and two former residents (#18, #44). This deficiency was cited previously during a state licensure survey 8/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Medication Administration policy, dated February 2022, read in part: "The community (residence) is responsible for complying with practitioner orders, associated with the administration of medication or treatment."2. Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease, major depressive disorder, and Parkinson's disease.a. OmeprazoleA written practitioner's order, dated 2/23/21, directed the residence to administer omeprazole 20 mg twice daily. However, the January 2023 medication administration record (MAR) read the medication was not administered in the morning on 1/14, 1/15, and 1/26 and in the evening on 1/1/23, for a total of four missed doses due to the medication being unavailable.b. LorazepamA written practitioner's order, dated 12/12/22, directed the residence to administer lorazepam 2 mg/mL oral concentrate 0.5 mg twice daily. However, the January 2023 MAR read the medication was not administered twice on 1/14 and in the evening on 1/31/23, for a total of three missed doses due to the medication being unavailable.c. QuetiapineA written practitioner's order, dated 2/23/21, directed the residence to administer quetiapine 100 mg twice daily. However, the January 2023 MAR read the residence did not administer the medication in the morning on 1/28 and 1/29 and in the evening on 1/28/23, for a total of three missed doses due to the medication being unavailable.d. DuloxetineA written practitioner's order, dated 4/19/22, directed the residence to administer duloxetine 40 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/7/23, for a total of one missed dose due to the medication being unavailable.e. TamsulosinA written practitioner's order, dated 2/23/21, directed the residence to administer tamsulosin 0.4 mg daily. However, the January 2023 MAR read the medication was not administered on 1/7/23, for a total of one missed dose due to the medication being unavailable. On 2/13/23 at 1:06 p.m., the legal representative for Resident #2 stated he was not aware of any medications being unavailable. 3. Resident #32 was admitted to the residence on 8/3/22. a. AmlodipineA written practitioner's order, dated 8/3/22, directed the residence to administer amlodipine 5 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/16, 1/18, and 1/19/23 for a total of three missed doses due to the medication being out of stock.b. RivastigmineA written practitioner's order, dated 8/3/22, directed the residence to administer a rivastigmine patch 4.6 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/3-1/6/23 for a total of four missed doses due to the medication being out of stock. 4. Resident #43 was admitted to the residence on 12/13/22.a. DivalproexA written practitioner's order, dated 11/22/22, directed the residence to administer divalproex 250 mg twice daily. However, the January 2023 MAR read the medication was not administered on 1/14/23 due to the medication being out of stock. b. HaloperidolA written practitioner's order, dated 11/22/22, directed the residence to administer haloperidol 5 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/17 and 1/18/23 for a total of two missed doses due to the medication being out of stock. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated he was not aware of medications being out of stock. 5. Former Resident #44 was admitted to the residence on 11/14/22. A written practitioner's order, dated 11/14/22, directed the residence to administer Xarelto 10 mg once daily. However, the November 2022 MAR read the medication was not administered on 11/27/22 for a total of one missed dose due to the medication being out of stock. On 2/13/23 at approximately 1:00 p.m., an anonymous staff member stated she remembered an issue with Former Resident #44's Xarelto, however, she could not recall what happened exactly. On 2/13/23 at 2:20 p.m., the responsible party for Former Resident #44 stated the resident's Xarelto went missing at the end of November and the resident missed at least one dose. 6. Resident #38 was admitted to the residence on 8/15/22. A written practitioner's order dated, 12/6/22, directed the residence to administer lidocaine cream 4% twice daily to the left side of his face. However, the January 2023 MAR read the medication was not administered in the evening on 1/4-1/6 and 1/10 and once in the morning on 1/10/23, for a total of five missed doses due to the medication being out of stock. On 2/13/23 at 12:47 p.m., the legal representative for Resident #38 stated she was not aware of the lidocaine ever being out of stock. 7. Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and major depressive disorder.a. Quetiapine 50 mgA written practitioner's order, dated 3/18/21, directed the residence to administer quetiapine 50 mg three times daily until discontinued on 9/2/22. A written practitioner's order dated 9/2/22, directed the residence to administer quetiapine 50 mg once at bedtime. However, quetiapine 50 mg was not administered on 9/2/22 in the evening, and was administered 9/2/22 in the morning instead, and was not administered 9/3-9/5/22, due to being inactive in the MAR, for a total of three missed doses. In addition, on 9/6 and 9/7/22, quetiapine 50 mg was administered in the afternoon instead of at bedtime as ordered. On 2/14/23 at 7:18 a.m., Staff #29 stated that former Staff #18 had messed up the charting and acknowledged that former Resident #18 was not given her quetiapine 50 mg at bedtime on 9/6/22 and instead was given it in the afternoon. Staff #29 stated that quetiapine was inactive in the MAR on 9/3-9/5/22, which was why it was not administered. On 2/14/23 at 1:33 p.m., the resident services director stated that medications that were inactive were not given at all. The resident services director acknowledged that former Resident #18's quetiapine 50 mg was not being administered as ordered and stated that as a result, evening doses were missed. b. Quetiapine 25 mgA written practitioner's order, dated 9/2/22, directed the residence to administer quetiapine 25 mg once every morning. A practitioner's order, dated 9/19/22, directed the residence to discontinue the current 25 mg once in the morning dose of quetiapine, and administer 25 mg three times daily. However, on 9/3/22 and 9/20/22, Quetiapine was not administered in the morning due to the medication being inactive in the MAR, for a total of two missed doses. On 2/14/23 at 7:18 a.m., Staff #29 stated that quetiapine was inactive on the MARs with the new orders and order changes, which was why it was marked as inactive. On 2/14/23 at 12:26 p.m., the consultant confirmed there were still medications that were not administered as required. However, she stated she was working with the residence to ensure medications were being audited and ordered every week to avoid medications being unavailable. On 2/14/23 at 1:30 p.m., the administrator designee stated she expected the residence to administer all prescribed doses of medication to residents as ordered. She stated that qualified administration persons reordered medications when they ran low. She added she was not aware that medication compliance was still an issue and was unsure why it had not been corrected. On 2/14/23 at approximately 1:33 p.m., the residence services director stated she was aware that some resident medications were out of stock.

Based on record review and interview, the assisted living residence failed to ensure an appropriate level of staffing to meet day to day resident needs affecting 26 current residents. (Cross-reference Q1110). This deficiency was cited previously during a state licensure survey on 8/31/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Staffing Requirements policy, dated February 2022, read in part: "To determine appropriate routine staffing levels, the community (residence) considers, at a minimum, the following items: The acuity and needs of the residence; The services outlined in the care plan; The services set forth in the resident agreement ... This community has a sufficient number of trained staff members on duty in the secure environment to ensure each resident's physical, social and emotional health care and safety needs are met in accordance with their individualized care plan." 2. Record ReviewThe staff schedule revealed the following:Only two staff members worked the evening shift (2:00 p.m. to 10:00 p.m.) on 1/30, 2/6, and 2/12/23. Only two staff members worked the night shift (10:00 p.m. to 6:00 a.m.) on 2/8-2/10/23. Only three staff members worked the evening shift on 2/5, 2/9, and 2/11/23.3. InterviewOn 2/13/23 at 8:53 a.m., the resident services director stated the staff schedule provided was accurate. She stated she edited the staff schedule daily to maintain accuracy. On 2/13/23 at 12:40 p.m., an anonymous staff member stated she was concerned about staffing levels during the weekends. She stated the majority of weekend staff were contracted staff and there were not enough of them. She added this resulted in residents being soiled when she arrived for her shift Monday mornings. On 2/13/23 at 2:20 p.m., the responsible party for Former Resident #44 stated the residence did not have an appropriate level of staffing to meet day to day resident needs. She stated the lack of staff caused Former Resident #44 to miss hygiene and incontinence care that he needed. She added she had to wait five or more minutes for staff to let her in and out of the secure environment entrance. On 2/14/23 at 8:26 a.m., the responsible party for Resident #22 stated she visited the residence at least once per week. She stated that the residence did not have enough staff. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated the residence had a low number of staff during the weekends and he came in to assist caring for Resident #43. On 2/14/23 at 12:35 p.m., the consultant stated she was concerned because the residence did not have sufficient staffing levels on the weekends. She added that sometimes staff will call off or contracted staff will not show up, resulting in even lower numbers of staff. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated the expectation was for the day shift to have five to six staff members, the evening shift to have four to five staff members, and the night shift to have three staff members. On 2/14/23 at 1:33 p.m., the resident services director stated she tried to schedule at least three staff members for the evening shift and night shifts over the weekends. She added that she was not always successful because staff would call off or not show up. The resident services director acknowledged the residence had low staff levels over the weekends.

A licensure complaint, prompted by #CO30543, #CO30594, #CO30645, #CO30872, #CO30874 was completed on 2/14/23. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure a Colorado Adult Protective Services Data Systems (CAPS) check was performed prior to hiring one of three sample staff (#33) who provided direct care to at-risk residents, affecting 26 current residents. Findings include:1. Referencesa. According to Colorado Revised Statutes (2017) 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. (F) Is mentally impaired as defined in Section 24-34-501(1.3)(b)(II), C.R.S.; 2. The personnel file for Staff #33 read she worked as a qualified medication administration personnel. Staff #33 worked five times in the previous two weeks as follows: 2/5, 2/8, and 2/11-2/13/23. On 2/14/22 at 1:30 p.m., the administrator designee confirmed she had not performed a CAPS check prior to hire for Staff #33. She stated Staff #33 was a contracted staff and the contracted company did not provide the residence with a CAPS check for Staff #33. Additionally, she confirmed she was aware that CAPS checks were required to be performed prior to hire however, it was not for Staff #33. The administrator designee confirmed the residents were at risk due to their impaired cognition.

Based upon observation, record review and interview, the residence failed to comply with conditions imposed by the department, affecting 26 current residents. Findings include: On 5/10/22 the department issued a Conditional License to the residence. The Conditional License read that the residence was required to maintain operational conditions during the term of the Conditional License. Following the completion of Event ZH3B12 on 12/8/21, a complaint investigation, the department imposed a consultant for 11 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The Conditional License required the residence to comply and maintain the following:Commencing the first week of the first full month, the licensee shall submit a written monthly report to the department that addresses each of the following areas of concern. The licensee shall include written monthly reports to the department information from audits performed during the previous month regarding how the licensee was ensuring compliance. Within the first 30 days of the Consultant's term, the Consultant shall review each of the cited deficiencies identified in the opportunities to present written data, views, and arguments dated January 26, 2022, with the administrator, and evaluate the facility's (residence's) current compliance with the corresponding regulations, as outlined in 6 C.C.R. 1011-1 Chapters 2, 7, and 24, where applicable. Within the first 45 days of the Consultant's term, the Consultant shall evaluate the Facility's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Facility on any additional areas of noncompliance. The Consultant shall also implement a monitoring program, to be completed at least monthly, to ensure the Facility remains in compliance with previously cited deficiencies. The monitoring program shall be incorporated into the Facility's ongoing quality management program (QMP), in accordance with 6 C.C.R. 1011-1 Chapter 2, Section 4. The Consultant shall make certain that the QMP is designed to improve resident safety and well-being, and promotes continued quality improvement to enhance service delivery. The Consultant shall make certain that the Administrator has a process in place to correct the identified deficiency, which includes utilizing the above-referenced monitoring program to ensure the deficient practice does not reoccur. The Consultant shall make certain that the monitoring identifies the scope of review, how a sample is identified for monitoring purposes, the total length of time the monitoring will continue, which will be no less than six months, and how the monitoring will be documented. During the final 60 days of the Consultant's term, the Consultant shall prepare the Administrator to independently manage the Facility to ensure compliance with all applicable regulations governing assisted living residences. The Consultant shall make certain that the Administrator has tools and resources in place to maintain compliance. The Conditional license also read that examples of a material breach of the conditional license included, but was not limited to, the following:Failure of the Licensee to comply with all applicable state rules, regulations, and standards, including without limitation, Chapter 2, 7, and 24 of the Department's regulations at 6 CCR 1011-1, and the provisions of Articles 3 and 27 of Title 25, C.R.S. or a sustained finding of immediate jeopardy at any time. Department records read the residence had chosen the consultant on 5/31/22 and the contract for the consultant was received on 6/1/22. Therefore, on the day of the completion of the complaint investigation, 2/14/23, the consultant was in the beginning of her eighth month as consultant for the residence. During the 2/14/23 complaint investigation, the investigation established there was current deficient practice, despite having a consultant in place. Seventeen deficiencies were cited, including Tags 540, 610, 652, 732, 734, 910, 1110, 1146, 1150, 1180, 1212, 1350, 1468, 1510, 2056, 2412, 2982 (Cross-reference Q540, Q610, Q652, Q732, Q734, Q910, Q1110, Q1146, Q1150, Q1180, Q1212, Q1350, Q1468, Q1510, Q2056, Q2412, Q2982). On 2/14/23 at approximately 3:29 p.m., the administrator designee stated she was aware of the requirements of the conditional license. On 2/14/22 at approximately 12:36 p.m., the consultant stated the following:In regards to Tag 540, the consultant stated that she had done several reviews of COVID and the COVID vaccination plan. The consultant stated that she was aware that EMResource had not been updated. In regards to Tag 610, the consultant stated she was aware that criminal history checks were required to be performed prior to hire. She stated the residence used contracted staff often and were currently auditing the contracted staff personnel files to ensure criminal history checks were performed for each staff. However, she stated not all contracted staff personnel files had been audited yet. In regards to Tag 652, the consultant stated she was aware that staff were required to wear name tags. She stated she discussed with the residence the importance of wearing name tags in January 2023. In regards to Tag 732, the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have first aid certification from a nationally recognized organization. In regards to Tag 734, the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have CPR certification from a nationally recognized organization. In regards to Tag 910, the consultant stated there was a resident roster in the front room of the residence. However, she stated she was not aware that staff were not educated on where to find the roster. In regards to Tag 1110, the consultant stated that residents should have received personal services as indicated in their care plans. In regards to Tag 1146, the consultant stated that an assessment should be completed whenever a resident had a change in condition. The consultant expressed concerns that Resident #42's had not been assessed after her first fall on 2/6/23, when she had no history of falls, and fell again 2/8/23. In regards to Tag 1150, the consultant stated that engagement opportunities that match resident personal choice and needs should be included in their care plan. She added she identified and discussed the need for the residence to ensure all care plan requirements were met in January 2023. In regards to Tag 1180, the consultant stated she was aware that contracted staff were not provided fall related training. She stated she brought it to the residence's attention in January 2023. However, training still had not been implemented. She also stated the resident began using contracted staff on 1/4/23. In regards to Tag 1212, the consultant stated that she had looked at the activities calendar and the activity director was very involved. Activities not being provided on the weekends had been addressed in the quality management program. However, she stated activities were not brought up in resident council meetings. The consultant stated that the residence tried to get more activities on the weekend since it had been lacking, and a family member would come in on Sundays to facilitate religious activities. In regards to Tag 1350, the consultant stated that she wrote about the residence phone not working in her report where family members could not reach their loved ones. The consultant stated that the residence had a main line that connected during business hours and was allegedly fixed. The consultant stated that she expected staff telephones to be answered however, she was aware it had been an issue. In regards to Tag 1468, the consultant confirmed there were still medications that were not administered as required. However, she stated she was working with the residence to ensure medications were being audited and ordered every week to avoid medications being unavailable. In regards to Tag 1510, the consultant stated she was aware the medication administration records (MARs) were inaccurate. She stated she was in the process of implementing a new system for contracted staff to document that medications were administered. She also stated she discussed the issue of inaccurate MARs with the residence in January 2023. In regards to Tag 2056, the consultant stated staff needed to be trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional to physically assist with feeding Resident #32. In regards to Tag 2412, the consultant stated that the residence had a bid to have the work outside in the courtyards completed, however, snow had been a problem and outdoor contractors would not come until the spring of 2023. The consultant stated there was no date assigned they would come. The consultant stated one side of the courtyard had been fixed, she thought the east, and thought it was corrected, however could be wrong. The consultant stated the residence was aware of this safety issue. In regards to Tag 2982, the consultant stated she was concerned because the residence did not have sufficient staffing levels on the weekends. She added that sometimes staff will call off or contracted staff will not show up, resulting in even lower numbers of staff.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 26 current residents. Findings include:1. References and Residence Policya. The Ninth Amended State Public Health Order 20-20 (PHO) Requirements for Colorado Skilled Nursing Facilities, Assisted Living Residences, Intermediate Care Facilities and Group Homes for COVID-19 Prevention and Response, dated 10/11/22, required residences to:- Report to CDPHE information pertaining to their available resources to respond to the COVID-19 pandemic. The department will provide the reporting platforms and the form and format for submission of the required information. The residence must adhere to reporting requirements as specified in RCF Comprehensive Mitigation Guidance. b. The COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/7/23, required residences to: - Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month and period two, defined as days 15 to 31 of each month). 2. Record ReviewOn 2/13/23 at 9:57 a.m., a review of EMResource revealed that the residence's most current reporting occurred on 11/10/22, resulting in six missed periods during which the residence was required to report. EMResource read that there were still 30 residents, however, the day of the onsite survey the resident roster read there were only 26 current residents. 3. InterviewsOn 2/14/23 at approximately 12:36 p.m., the consultant stated that she had done several reviews of COVID and the COVID vaccination plan. The consultant stated that she was aware that EMResource had not been updated. On 2/14/23 at approximately 1:36 p.m., the resident services director stated that she did not know why the administrator had not updated EMResource since 11/10/22. The resident services director stated that she was aware of the requirement and thought that the administrator had updated EMResource.

Based on record review and interviews, the residence failed to request, prior to hire, a name-based criminal history record check for each prospective staff member, for one of three sample staff (#33), affecting 26 current residents. Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 2.45, defines "Staff" means employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein. On 2/13/23 from 7:00 a.m. to 2:00 p.m., Staff #33 provided personal care and services to residents. The February 2023 staff schedule revealed Staff #33 worked five times in the previous two weeks as follows: 2/5, 2/8, and 2/11-2/13/23. The residence was unable to provide a criminal history record check for Staff #33 that was dated prior to 2/14/23 (the date of the onsite investigation). On 2/14/23 at 12:36 p.m., the consultant stated she was aware that criminal history checks were required to be performed prior to hire. She stated the residence used contracted staff often and were currently auditing the contracted staff personnel files to ensure criminal history checks were performed for each staff. However, she stated not all contracted staff personnel files had been audited yet. On 2/14/22 at 1:30 p.m., the administrator designee confirmed she had not performed a criminal history record check prior to hire for Staff #33. She stated Staff #33 was a contracted staff and the contracted company did not provide the residence with a criminal history check for Staff #33. Additionally, she confirmed she was aware that criminal history checks were required to be performed prior to hire, however, it was not for Staff #33.

Based on observations, interviews and record review the residence failed to ensure four of four staff (#35-#38) wore name tags, affecting 26 current residents. Findings include:1. ObservationsOn 2/13/23 from 7:00 a.m. to 2:00 p.m., Staff #35 was not wearing a name tag or any other form of identification. On 2/13/23 from 7:00 a.m to 2:00 p.m., Staff #36 was not wearing a name tag or any other form of identification. On 2/13/23 at 3:00 p.m., Contracted Staff #37 and #38 were not wearing a name tag or any other form of identification. 3. InterviewsOn 2/13/23 at 8:03 a.m., Resident #35 stated she wished residence staff would wear a name tag so she knew who she was speaking to. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not required to wear a name tag or identification. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not required to wear a name tag or identification. On 2/14/23 at 12:36 p.m., the consultant stated she was aware that staff were required to wear name tags. She stated she discussed with the residence the importance of wearing name tags in January 2023. On 2/14/23 at 1:30 p.m., the administrator designee stated she was aware that staff were required to wear name tags. However, she stated she was not aware why staff were not wearing name tags as required. Further, she stated contracted staff were not provided with name tags. On 2/14/23 at 2:20 p.m., the responsible party for Former Resident #18 stated residence staff did not wear name tags. She stated the former resident was often confused because he was unable to identify the staff members that went in and out of his room.

Based on interviews and record review, the residence failed to have at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization, affecting 26 current residents. (Cross-reference Q734). Findings include:1. Reference and Residence policya. The residence's First Aid policy, dated February 2022, read in part: "There is at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization."b. According to the National CPR Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own (teacher). Our services are designed with OSHA, the ECC (Emergency Cardiovascular Care)/ILCOR (The International Liaison Committee on Resuscitation) and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2022) Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/2. Record ReviewOn 2/13/23, review of staff first aid certifications provided by the resident services director revealed that Staff #33, #38 and #42 did not have first aid certifications from a nationally recognized organization. Additionally, staff first aid certifications revealed only one staff (#34) had certification from a nationally recognized organization. The staff schedule from 1/30-2/13/23 revealed there were no staff with certification on: 1/30 from 6:00 a.m. to 2:00 p.m. and 10:00 p.m. to 6:00 a.m., 1/31-2/2 all shifts, 2/3 and 2/4 on 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m., on 2/6 from 6:00 a.m. to 2:00 p.m. and 10:00 p.m. to 6:00 a.m., all shifts on 2/7, 2/8 from 6:00 a.m. and 2:00 p.m. to 10:00 p.m., 2/9 and 2/10 for all shifts, on 2/11 from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., on 2/12 all shifts, 2/13/23 from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. for a total of 34 shifts. Additionally, the schedule revealed that staff with certification from a not nationally recognized organization worked on 1/30 from 2:00 p.m. to 10:00 p.m., 2/3 from 10:00 p.m. to 6:00 a.m., 2/4 from 10:00 to 6:00 a.m., on 2/5 from 2:00 p.m. to 6:00 a.m., 2/8 from 6:00 a.m. to 2:00 p.m. and 2/13/23 from 6:00 a.m. to 2:00 p.m., for an additional seven shifts. 3. InterviewsOn 2/14/23 at approximately 12:35 p.m., the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have first aid certification from a nationally recognized organization. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated she was aware the residence was required to have first aid certified staff scheduled at all times. She stated the resident services director was responsible for the staff schedule. She added she was aware that some contracted staff had first aid certification from an organization that was not nationally recognized. On 2/14/23 at 1:33 p.m., the resident services director stated she was responsible for creating the staff schedule. She added she was not aware that the residence did not have one staff on at all times with first aid certification.

Based on interviews and record review, the residence failed to 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, affecting 26 current residents who required assistance in the event of an obstructed airway. (Cross-reference Q732). Findings include:1. Reference and Residence policya. The residence's CPR policy, dated February 2022, read in part: "There is at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation and obstructed airway techniques from a national recognized organization."b. According to the National CPR Foundation, "(National CPR Foundation) NCPRF provides self-training through the materials found on the Website(s) you're your own (teacher). Our services are designed with OSHA, the ECC (Emergency Cardiovascular Care)/ILCOR (The International Liaison Committee on Resuscitation) and The American Heart Association's guidelines in recommendation. At no time does NCPRF represent any person in their certification needs - it is up to our client to choose freely in His/Her own direction. The certificate does not represent, warrant or guarantee that the purchaser is properly prepared or equipped to perform any course materials, CPR or First Aid assistance." National CPR Foundation (2022) Terms and Conditions, retrieved from: https://www.nationalcprfoundation.com/terms-conditions/c. According to Nolo Legal Encyclopedia, "A MOST (Medical Orders for Scope of Treatment) form is a doctor's order that helps you keep control over medical care at the end of life. Like a Colorado CPR Directive, the form tells emergency medical personnel and other health care providers whether or not to administer cardiopulmonary resuscitation (CPR) in the event of a medical emergency. A MOST form may be used in addition to -- or instead of -- a CPR Directive. The MOST form may also provide other information about your wishes for end-of-life health care." Irving, S., J.D., Colorado's Medical Orders for Scope of Treatment (MOST) Form, retrieved from: https://www.nolo.com/legal-encyclopedia/colorados-medical-orders-scope-treatment-most-form.html 2. Code status and schedulesRecords for Residents #35 and #37 contained medical orders for scope of treatment that directed the residence to perform CPR in the event of an emergency. On 2/13/23, review of staff CPR certifications provided by the resident services director revealed that Staff #32, #33, #38, #40 and #42 did not have CPR certifications from a nationally recognized organization. The staff schedule revealed the residence did not have a staff member who was CPR certified from a nationally recognized organization on 1/30 from 2:00 p.m. to 10:00 p.m., 2/5 from 2:00 p.m. to 10:00 p.m., 10:00 p.m. to 6:00 a.m., 2/9 through 2/11 from 10:00 p.m. to 6:00 a.m., 2/12 from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., for a total of eight shifts in two weeks. 3. InterviewsOn 2/14/23 at approximately 12:35 p.m., the consultant stated she had not audited contracted staff files and was not aware that some contracted staff did not have CPR certification from a nationally recognized organization. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated she was aware the residence was required to have CPR certified staff scheduled at all times. She stated the resident services director was responsible for the staff schedule. She added she was aware that some contracted staff had CPR certification from an organization that was not nationally recognized. On 2/14/23 at 1:33 p.m., the resident services director stated she was responsible for creating the staff schedule. She added she was not aware that the CPR certifications for Contracted Staff #32, #33, and #40 were not from a nationally recognized organization.

Based on interview and record review, the residence failed to have readily available a roster of current residents with emergency contact information, along with a residence diagram showing room locations, affecting 26 current residents. Findings include:On 2/13/23 at approximately 7:00 a.m., a current resident roster was requested from the Staff #29, however, the resident roster provided did not include residents' emergency contact information or a diagram that showed room locations. Additionally, the resident roster did not accurately list all residents who resided in the residence and included residents that had been discharged from the residence. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not sure where he could locate a resident roster to provide during emergencies. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware of where to locate a resident roster. On 2/14/23 at 12:36 p.m., the consultant stated there was a resident roster in the front room of the residence. However, she stated she was not aware that staff were not educated on where to find the roster. On 2/14/23 at 1:30 p.m., the administrator designee stated she was aware that the residence was required to have a readily available roster of current residents. Further she stated she was not aware that staff did not know where to locate the resident roster and that the roster provided was outdated and incorrect.

Based on record review and interview, the residence failed to make available, either directly or indirectly through a resident agreement, personal services, affecting three of seven sample residents (#32, #42, #43). Findings include:1. ReferenceChapter VII regulations governing assisted living residences, in section two, defines "Personal Services" as those services that an assisted living residence and its staff provide for each resident including, but not limited to, assistance with activities of daily living. The residence's resident agreement, dated May 2020, read in part the residence provided staff assistance with normal activities of daily living, such as dressing, bathing and general health supervision. 2. Resident #32 was admitted to the residence on 8/3/22 with a diagnosis of Alzheimer's disease. The care plan for Resident #32, updated 2/6/23, read in part that the resident required total assistance with toileting and required frequent changing in bed. Additionally, the care plan read that the resident required total assistance with grooming and dressing. On 2/14/23 at 8:43 a.m., an external hospice provider stated when she checked Resident #32 that morning, there was dried feces in his incontinence briefs. She stated the feces had likely been there for hours and she did not think staff changed his incontinence briefs as often as was needed. She added this happened at least once per week and sometimes more. The external hospice provider stated she did not think residence staff assisted Resident #32 with grooming and dressing and that residence staff relied on hospice providers. 3. Resident #42 was admitted to the residence on 1/9/23 with diagnoses including cognitive deficits. The care plan for Resident #42, dated February 2023, read in part that the resident wore and required assistance with incontinence briefs overnight. On 2/13/23 at approximately 1:00 p.m., an anonymous staff member stated Resident #42 was covered in dried feces that morning. She stated this happened about once per week. 4. Resident #43 was admitted to the residence on 12/13/22 with diagnoses including dementia. The undated care plan for Resident #43 read in part that the resident required assistance with incontinence episodes more than three times per week. On 12/13/23 at 12:40 p.m., an anonymous staff member stated that Resident #43 required assistance with incontinence. She added that she found the resident overly soiled and with a strong odor about three times per week because residence staff had not assisted with his incontinence as required. On 12/14/23 at 10:22 a.m., an external hospice provider stated that she started working with Resident #43 on 1/20/23 and had observed him and his bed soiled multiple times. On 2/14/23 at approximately 12:35 p.m., the consultant stated that residents should have received personal services as indicated in their care plans. On 2/14/23 at 1:30 p.m., the administrator designee stated that residents should have received personal services as indicated in their care plans. On 2/14/23 at approximately 1:33 p.m., the residence services director stated she was aware that Resident #42 was found soiled on 2/13/23. She stated that residents should have received personal services as indicated in their care plans.

Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated for residents whenever residents' conditions changed from baseline status, affecting one of seven sample residents (#39) who experienced a change in condition. (Cross-reference Q1180) 1. Reference and Residence Policiesa. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(D) Communication ability and any specific needs to facilitate effective communication;(G) Individual bathroom routines, sleep and awake patterns;(H) Reactions to the environment and others, including changes that may occur at certain times or in certain circumstances(J) History and circumstances of recent falls and any known approaches to prevent future falls;(K) Safety awareness;(L) Types of physical, mental, and social support required.b. The residence's Comprehensive Resident Assessment policy, dated 2/22/22, read in part: "the comprehensive assessment shall be updated for each resident at least annually and whenever a resident's condition changes from baseline status ... The (residence) administrator or wellness coordinator and his/her designee, conducts an in-person assessment of individual residents, and all assessment information is recorded on the proper forms and is filed in the resident record."2. Resident #42 was admitted to the residence on 1/11/23, with diagnoses including long term use of anticoagulants, lumbar vertebral osteoporotic fracture and vascular dementia. On 2/13/23 at approximately 9:30 a.m., Resident #42 was sent out to the hospital due to swelling on the left side of her arm. A comprehensive pre-admission assessment dated 1/9/23,and a comprehensive 30-day post admission assessment dated 2/6/23, did not include that Resident #42 was a fall risk or had a history of falls. An undated and incomplete fall risk assessment initiated on 2/9/23, listed Resident #42 as a fall risk however, did not contain any interventions or approaches for staff to mitigate future falls. There were no other assessments in the record for Resident #42. An incident report, dated 2/6/23, read that Resident #42 had sustained a fall in the dining area, and complained of pain in her right hip. The physician and family were notified. However, Resident #42 was not reassessed by the residence after her first fall on 2/6/23. An incident report, created by Staff #27, dated 2/8/23, read that Resident #42 had sustained a fall, and staff found her laying on her back next to the east medication cart. Resident #42 had a bruise on her nose and was not in pain. No vitals were included. A progress note, dated 2/9/23 at 7:09 p.m., read that Resident #42 was sent out to the hospital. A hospital discharge summary, dated 2/9/23, read that Resident #42 had a fall with altered mental status. Labs and imaging showed no signs of intracranial hemorrhage or fractures. A progress note, dated 2/10/23 at 5:01 p.m., read that Resident #42 had a swollen left elbow and complained of pain during the 2:00-10:00 p.m., shift on 2/9/23 and was sent out to the emergency department. A progress note, dated 2/10/23 at 6:43 p.m., read that Resident #42 came back from the emergency department. An incident report dated 2/13/23, read that Resident #42 had swelling in her left hand and discoloration on parts of her body and complained of pain. Resident #42 was subsequently sent out to the emergency department. A emergency department discharge summary, dated 2/13/23, read that Resident #42 had multiple contusions and x-rays of the hands and hips were normal. Ice was recommended for the swelling and ibuprofen every four hours. 3. InterviewsOn 2/14/23 at 10:06 a.m., Resident #42's friend, stated that Resident #42 had no falls prior to moving into the residence, and since moving it she had sustained two falls and two fall-related emergency department visits. Resident #42's friend acknowledged that Resident #42's two falls since she had moved into the residence on 1/11/23, were a change in condition from her baseline of no falls. On 2/14/23 at 11:12 p.m., the resident services director stated that Resident #42 was sent out 2/13/23 due to swelling and bruising that she suspected from the previous fall on 2/8/23 that had worsened. On 2/14/23 at approximately 12:36 p.m., the consultant stated that an assessment should have been completed whenever a resident had a change in condition. The consultant stated that it concerned her that Resident #42's had not been assessed after her first fall on 2/6/23, when she had no history of falls, and fell again 2/8/23. On 2/14/23 at 1:44 p.m., the resident services director stated that a resident should have been reassessed after any change in condition, and stated herself and the administrator were both responsible for assessments. The resident services director stated that she was aware that Resident #42 did not have a history of falls prior to being admitted to the residence, and acknowledged that she should have been assessed after her first fall at the residence.

Based on record review and interview, the residence failed to ensure each resident's care plan detailed engagement opportunities that matched the resident's personal choice and needs, affecting two of eight sample residents. Findings include:1. Resident #22 was admitted to the residence on 8/5/21 with diagnoses including Alzheimer's disease. The care plan for Resident #22, dated 1/19/23, did not include information regarding the engagement opportunities that matched the resident's personal choice and needs. On 2/14/23 at 8:26 a.m., the responsible party for Resident #22 stated the resident enjoyed games and music. 2. Resident #43 was admitted to the residence on 12/13/22 with diagnoses including dementia. The care plan for Resident #43, dated 1/12/23, did not include information regarding the engagement opportunities that matched the resident's personal choice and needs. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated the resident enjoyed being physically active. 3. InterviewOn 2/14/23 at 12:35 p.m., the consultant stated that engagement opportunities that matched resident personal choice and needs should be included in their care plan. She added she identified and discussed the need for the residence to ensure all care plan requirements were met in January 2023. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated she was aware that care plans were required to detail engagement opportunities that matched resident personal choice and needs. She stated she was not aware that the care plans for Resident #22 and #43 were missing the engagement opportunities requirement. The administrator designee stated the activities director was responsible for ensuring engagement opportunities that match resident personal choice and needs were in the care plan. On 2/14/23 at approximately 1:33 p.m., the resident services director stated she was not aware the care plans were required to detail engagement opportunities that match resident personal choice and needs.

Based on observation, interview, and record review, the residence failed to implement a fall management program affecting 26 current residents. (Cross-reference Q1146). Specifically, Resident #43 was admitted to the residence on 12/13/22. Resident #43 sustained 12 falls in 44 days (12/16, 12/20, 12/21, 12/23, 12/24, 12/28/22, 1/1, 1/2, 1/5, 1/10, 1/12, and 1/30/23). Five of the falls resulted in injuries. On 12/16/22, the resident sustained an abrasion on his left leg. On 12/21/22, the resident had shoulder pain. On 12/23/22, the resident had knee pain. On 12/28/22, the resident reopened a scab on his leg. On 1/10/23, the resident had a skin tear on his left knee. A care plan, dated 1/12/23, read in part, the residence implemented several fall precautions such as external hospice services, a fall mat, and frequent safety checks. However, contracted staff were not aware of the individualized approach necessary to address the resident's fall risk. Specifically, Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease and Parkinson's Disease. A care plan, dated 1/5/23, read in part, the residence had implemented several fall precautions such as external hospice services, a fall mat, reminders to use a call pendant, changing his bed to a hospital bed, and frequent safety checks. However, contracted staff were not aware of the individualized approach necessary to address fall risk. Further, the resident had four falls from 1/10-2/7/23 with two injuries. Specifically, Resident #38 was admitted to the residence on 8/15/22 with diagnoses including Alzhemier's disease. The resident had a fall on 1/8 and 2/10/23 which resulted in bruises to his right shoulder. A care plan, dated 1/9 and 1/19/23, read the resident required two hour safety checks, however, it did not include that the resident was at risk for falls. Additionally, contracted staff were not aware the resident was at risk for falls or the individualized approach necessary to address fall risk. Specifically, Resident #42 was admitted to the residence on 1/11/23, with diagnoses including long term use of anticoagulants, lumbar vertebral osteoporotic fracture, and vascular dementia. The resident had a fall on 2/6/23 and had bruising to her hip. The resident fell again and hit her nose and hit her left elbow 2/8/23 and was hospitalized 2/9/23 due to pain and swelling of her elbow. A care plan, dated 1/26/23, read that Resident #42 used a walker, however did not did not include that the resident was at risk for falls. Additionally, contracted staff were not aware of the resident was a fall risk or of any approaches necessary to address falls due to the care plan that was not updated after Resident #42 had her first fall on 2/6/23. Specifically, Resident #19 was admitted to the residence on 10/29/21, with diagnoses including Alzheimer's disease, localized osteoporosis and abnormalities of gait and mobility. The resident fell out of bed at 5:30 a.m., on 2/10/23, and fell again in the dining room and hit her head and sustained a bruise on her right temple, at 10:10 a.m. on 2/10/23. A care plan, dated 1/5/23, read that Resident #19 had a history of falls, used a wheelchair, and had a fall mat and non-slip socks. However contracted staff were not aware of the individualized approach necessary to address fall risk. Specifically, Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and osteoporosis. The resident had sustained nine falls in the past two months on 10/2, 10/6, 10/24, 10/28, 11/5, 12/5 twice, 12/21/22 and 1/1/23. During the fall on 10/2/22, the resident sustained a red bump on the side of her forehead. On 10/24/22, the resident sustained a cut on the right side of her eye. On 11/5/22, the resident hit her head and received stitches from a major fall. On 1/1/23 the resident had a nose bleed from a major unreported fall with injury. The care plan for former Resident #18, updated on 12/27/22 and 1/6/23, read that former Resident #18 was a high fall risk, and required redirection, an environment free of obstacles and assistance with ambulation. However, the care plan for former Resident #18 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after each fall, on 10/2/22, 10/6/22, 10/24/22, and 10/28/22. Additionally, contracted staff were not aware of the individualized approach necessary to address fall risk. These failures created an immediate jeopardy risk of falls with injury to six sample residents residing in the residence. On 2/14/23, the department directed the residence to provide written evidence that the risk had been removed. 1. Residence policyThe residence's Fall Management Program, dated February 2022, read in part, the residence would detail in each resident's care plan the individualized approach necessary to address fall risk and provide staff training related to fall prevention. 2. Resident #42 was admitted to the residence on 1/11/23, with diagnoses including long term use of anticoagulants, lumbar vertebral osteoporotic fracture, and vascular dementia. On 2/13/23 at 8:51 a.m., Resident #42 was lying on an elevated double mattress bed, and there were no assistive devices or other approaches observed to remove fall risk. An incident report, dated 2/6/23, read that Resident #42 had sustained a fall in the dining area, and hurt her hip. An incident report, dated 2/8/23, read that Resident #42 had sustained a fall, and staff found her laying on her back next to the east medication cart. Resident #42 had a bruise on her nose and was not in pain. A progress note, dated 2/10/23 at 5:01 p.m., read that Resident #42 had a swollen left elbow and complained of pain during the 2:00-10:00 p.m., shift on 2/9/23 and was sent out to the hospital. A hospital discharge summary, dated 2/9/23, read that Resident #42 had a fall with altered mental status. Labs and imaging showed no signs of intracranial hemorrhage or fractures. An incident report dated 2/13/23, read that Resident #42 had swelling in her left hand and discoloration on parts of her body and complained of pain. Resident was subsequently sent out to the hospital. A hospital discharge summary, dated 2/13/23, read that Resident #42 had multiple contusions and x-rays of the hands and hips were normal. Ice was recommended for the swelling and ibuprofen every four hours. The most current care plan for Resident #42, dated 1/26/23, read that Resident #42 used a walker and had no reported falls at home or a history of falls. Moreover, the care plan for Resident #42 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after she fell on 2/6, or 2/8/23. On 2/14/23 at 10:06 a.m., Resident #42's friend, stated that Resident #42 had no falls prior to moving into the residence, and since moving it she had sustained two falls and two fall-related emergency department visits. Resident #42's friend stated that Resident #42 had a walker when she was moved in, but was not aware of any fall interventions that were put in place since Resident #42 had her first fall at the residence on 2/6/23. On 2/14/23 at 11:12 p.m., the resident services director stated that Resident #42 was sent out 2/13/23 due to swelling and bruising that she suspected from the previous fall on 2/8/23 that had worsened. On 2/14/23 at 1:06 p.m., Staff #29 stated that she had found Resident #42 when she came on shift on 2/9/23, and night shift had never reported to her Resident #42 fell during the evening shift. Staff #29 stated that Resident #42 complained of pain when she dressed her in the morning of 2/9/23, and it was not until later that evening when they found out about Resident #42's fall, that she was finally taken to the hospital. Staff #29 stated that the night staff member who was either Staff #27 or #20, did not respond and report the fall appropriately, which was why there was a delayed action. On 2/14/23 at 1:44 p.m., the resident services director stated that she was aware that Resident #42 had no falls prior to admission to the residence and was aware she had not updated the care plan since she had her first fall. The resident services director acknowledged that the care plan should have been updated to include fall interventions after Resident #42 first fell on 2/6/23. 3. Resident #43 was admitted to the residence on 12/13/22 with diagnoses including dementia. A fall risk assessment, dated 1/10/23 read the resident was a high fall risk. A care plan, updated 1/12/23, read the resident had had 11 falls at the residence. The care plan detailed interventions including safety checks, non-slip socks, hospice, a new wheelchair, fall mat, and use of a hospital bed. However, the care plan was not updated to include an additional individualized approach necessary to address fall risk after the resident's fall on 1/30/23. Additionally, contracted staff were not aware of the individualized approach necessary to address fall risk. Incident reports revealed the following:12/16/22: Resident found on the floor with an abrasion to his left leg that looked like an old wound that was reopened. 12/20/22: Resident found on the floor. 12/21/22: Resident was found on the floor and stated his right shoulder was hurting. 12/23/22: The resident fell and stated he had pain in his knee. 12/24/22: The resident fell. 12/28/22: The resident fell and reopened a scab on his leg. 1/1/23: Resident found on the floor and is on two hour checks. 1/2/23: The resident fell. 1/5/23: Resident found on the floor. 1/10/23: Resident found on the floor with a skin tear on his left knee. 1/12/23: Resident found on the floor. 1/30/23: Resident found on the floor. On 2/13/23 at 12:40 p.m., Staff #29 stated that Resident #43 was a high fall risk and had several falls since he moved in. She added the resident had a new wheelchair and she was unsure of any additional individualized approaches necessary to prevent fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware that Resident #43 was at risk for falls or the individualized approaches necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware that Resident #43 was at risk for falls or the individualized approaches necessary to address fall risk. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated the resident was a fall risk and had fallen at the residence, which resulted in bruises, cuts, and scrapes. He added he was not sure of interventions the residence had in place to prevent future falls. On 2/14/23 at 10:22 a.m., an external hospice provider stated that Resident #43 was a fall risk. 4. Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease and Parkinson's Disease. A care plan, dated 1/5/23, read in part, the residence had implemented several fall preventions such as external hospice services, a fall mat, reminders to use a call pendant, changing his bed to a hospital bed, and frequent safety checks. However, contracted staff were not aware of the individualized approach necessary to address fall risk. A progress note, dated 1/10/23, read in part, the resident fell next to his night stand and wheelchair. The resident sustained redness to his forehead due to the fall. A care plan, dated 1/12/23, read in part, the residence placed signs in his room to remind him to use his call pendant for staff assistance with transfers. An incident report, dated 1/16/23, read in part, the resident was found on the floor next to his bed after a fall. The resident sustained a scratch above his eye. A care plan, dated 1/19/23, read in part, the residence increased external hospice visits to three times a week. An incident report, dated 1/23/23, read in part, the resident was found on the floor because he fell to the floor. An incident report, dated2/7/23, read in part, the resident fell. Another care plan, dated 2/8/23, read in part, the residence implemented hourly checks and encouraged the resident to remain in common areas for supervision. On 2/13/23 at 1:06 p.m., the legal representative for Resident #2 stated the resident fell often because of poor safety awareness. He confirmed the residence implemented individualized approaches necessary to address fall risk, however, he stated the contracted staff were not trained or aware of the approaches necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 8:14 a.m., the external hospice nurse stated the resident was at risk for falls and was required to be provided with hourly safety checks. She stated she did not think contracted staff implemented the individualized approaches necessary to address fall risk because they were not aware that Resident #2 was at risk for falls. On 2/14/23 at 8:33 a.m., Contracted Staff #40 stated she worked at the residence approximately eight times in the prior month. She stated she was unaware that Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 9:00 a.m., Contracted Staff #41 stated he worked at the residence three times in the prior few weeks. He also stated he was not aware that Resident #2 was at risk for falls or the individualized approach necessary to address fall risk. 5. Resident #19 was admitted to the residence on 10/29/21, with diagnoses including Alzheimer's disease, localized osteoporosis and abnormalities of gait and mobility. An incident report, dated 2/10/23 at 5:30 a.m., written by a contracted staff member, read that Resident #19 was found on the floor next to her bed, and family and hospice was notified. A progress note, dated 2/10/23 at 10:10 a.m., read that Resident #19 slid from her wheelchair in the dining room and hit the right side of her temple on another resident's wheelchair. A comprehensive assessment, dated 9/13/22, read that Resident #19 was at a high risk for falls and required staff assistance with wheelchair transfers and ambulation. The most current care plan for Resident #19, dated 1/5/23, read that Resident #19 had a history of falls, used a wheelchair, and had a fall mat and non-slip socks. However, the care plan for Resident #19 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after either of Resident #19's falls on 2/10/23. On 2/13/23 at 2:37 p.m., Resident #19's family member stated that Resident #19 had a history of falls, however, she had a reduced number of falls since Resident #19 had gotten a new mattress in October 2022. Resident #19's family member stated that he was aware of Resident #19's fall where she hit her head against another resident's wheelchair, however, he stated that he was not aware that Resident #19 had also fallen out of bed earlier that same morning on 2/10/23. 6. Resident #38 was admitted to the residence on 8/15/22 with diagnoses including Alzhemier's disease. A progress note, dated 1/8/23, read in part, the resident fell. The resident required two hour safety checks. A care plan, dated 1/9/23, read in part, the resident required two hour safety checks and a two hour toileting schedule. A care plan, dated 1/19/23, read in part, the resident required two hour safety checks. However, the care plan did not include that the resident was at risk for falls. A progress note, dated 2/10/23, read in part, the resident had two bruises on the right shoulder due to a fall. Staff were required to provide the resident with hourly safety checks. On 2/13/23 at 12:47 p.m., the legal representative for Resident #38 stated the resident was at risk for falls because he would forget to use his walker which resulted in falls. She also stated the resident fell on 2/10/23 which resulted in bruises. Further the legal representative stated contracted staff worked at the residence often and were not aware of the resident's fall prevention plan. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware Resident #38 was at risk for falls or the individualized approach necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware Resident #38 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 8:33 a.m., Contracted Staff #40 stated she worked at the residence approximately eight times in the prior month. She stated she was unaware that Resident #38 was at risk for falls or the individualized approach necessary to address fall risk. On 2/14/23 at 9:00 a.m., Contracted Staff #41 stated he worked at the residence three times in the prior few weeks. He also stated he was not aware that Resident #38 was at risk for falls or the individualized approach necessary to address fall risk. 7. Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and osteoporosis. An incident report, dated 10/2/22, read that Former Resident #18 had a fall with minor injury, that included a red bump on the side of her forehead. A progress note, dated 10/6/22, read that Former Resident #18 had a fall. An incident report, dated 10/24/22, read that Former Resident #18 had a fall with minor injury, that included a cut on the right side of former Resident #18's eye. A progress note, dated 10/28/22, read that Former Resident #18 had a fall and was found sitting on the floor. A hospital discharge summary, dated 11/5/22, read that Former Resident #18 received five staples due to injury to the right side of her head from tripping over a television cord. No other injuries. A progress note, dated 11/28/22, read that on 11/5/22, Former Resident #18 tripped over television cords, fell and hit her head, and required five staples. A progress note, dated 12/5/22 at 8:13 p.m., read that Former Resident #18 walked into a chair and fell. A progress note, dated 12/5/22 at 8:17 p.m., read that Former Resident #18 fell a second time from having walked too fast around the residence. A progress note, dated 12/21/22 at 12:58 p.m., read that Former Resident #18 had a fall. A comprehensive change in condition assessment dated 12/26/22, read that Former Resident #18 was a frequent fall risk and required redirection, assistance with ambulation, and reminders to use the walker. Former Resident #18 experienced frequent gait elevation and best practice is for staff to encourage the resident to sit down and rest. A progress note, dated 1/3/23, read that the administrator was made aware of an unreported fall with injury on 1/1/23 for Former Resident #18. The incident report further read that Former Resident #18 fell on her face which caused a nose bleed. The care plan for Former Resident #18, dated 1/6/23, read that Former Resident #18 was a high fall risk, and required redirection, an environment free of obstacles and assistance with ambulation. However, the care plan for Former Resident #18 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after each fall, on 10/2/22, 10/6/22, 10/24/22, and 10/28/22. On 2/13/23 at 11:23 a.m., Former Resident #18's family member stated that the former resident would often fall and she would not be informed of the fall. Former Resident #18's family member stated that the most recent fall on 1/1/23 Former Resident #18 was injured and Former Staff #26 did nothing and did not even report it. Former Resident #18's family member stated that staff did not know how to respond appropriately to Former Resident #18's falls. 8. Resident #22 was admitted to the residence on 8/5/21 with diagnoses including Alzheimer's disease. An incident report, dated 12/20/23, read the resident had a fall. A fall assessment, dated 1/12/23 read that Resident #22 was a fall risk. An incident report, dated 1/17/23, read the resident had a fall. A care plan, dated 1/19/23, read the resident's last fall was on 1/19/23. However, the care plan did not include detailed individualized approaches necessary to address the resident's fall risk. Additionally, contracted staff were not aware of the individualized approaches necessary to address fall risk. On 2/13/23 at approximately 12:40 p.m., Staff #29 stated that Resident #22 was a fall risk. However, she was unablt to recall any individualized approaches necessary to address the resident's fall risk. On 2/14/23 at 8:26 a.m., the responsible party for Resident #22 stated the resident was a fall risk. She stated she was unsure of individualized approaches the residence had to address the resident's fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not aware that Resident #22 was at risk for falls or the individualized approaches necessary to address fall risk. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not aware that Resident #22 was at risk for falls or the individualized approaches necessary to address fall risk. 9. Staff trainingOn 2/13 and 2/14/23, personnel files for Contracted Staff #31-#33 revealed no evidence of training related to fall prevention. On 2/13/23 at 3:11 p.m., fall training for all contracted staff was requested. However, the residence was unable to provide the requested training documentation. The staff schedule revealed approximately six shifts worked in the previous two weeks with only contracted staff on shift and no residence staff. On 2/13/23 at 3:00 p.m., Contracted Staff #37 stated he was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/13/23 at 3:00 p.m., Contracted Staff #38 stated she was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/13/23 at 3:02 p.m., Contracted Staff #32 stated that she had picked up shifts at the residence for about three weeks. Contracted Staff #32 stated that the residence did not provide her with fall management training or education, and was only provided an online fall management training with her contracted agency, where she learned she was supposed to follow individual residence protocols for falls. Contracted Staff #32 stated that she was not sure what the residence's fall protocol was, or how to respond to a fall, since the residence had not taught her. On 2/14/23 at 8:33 a.m., Contracted Staff #40 stated she worked at the residence approximately eight times in the prior month. She stated she was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/14/23 at 9:00 a.m., Contracted Staff #41 stated he worked at the residence three times in the prior few weeks. He also stated he was not provided training related to fall prevention and was unaware of which residents were at risk for falls. On 2/14/23 at 11:04 a.m., the resident services director (RSD) stated the residence had not provided fall related training to contracted staff. On 2/14/23 at 11:04 a.m., the administrator designee acknowledged the residence had not provided fall related training to contracted staff. On 2/14/23 at 12:36 p.m., the consultant stated she was aware that contracted staff were not provided fall related training. She stated she brought it to the residence's attention in January 2023, however, training still had not been implemented. She also stated the resident began using contracted staff on 1/4/23. On 2/14/23 at 1:47 p.m., The RSD stated that she was responsible for updating care plans with the administrator. The resident services director stated that she had updated some of the care plans the week priorto the onsite survey. However she stated she had not had not gotten around to updating all of them, or had time to learn about what all needed to be included, since the administrator was still teaching her. The resident services director stated that she was aware that fall interventions needed to be updated after each fall. The resident services director stated that she provided staff with fall management orientation and training, however, did not provide training to contracted staff. The resident services director stated that she would make sure to train contracted staff moving forward. 10. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed 26 current residents at immediate jeopardy risk for falls with injury. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 2/14/23 at 12:45 p.m., the administrator designee submitted written evidence that read in pertinent part, "All (residence) and Agency (contracted) care staff on day, evening and overnight shift will be trained by RSD on fall intervention/fall management and residents who are high fall risk beginning today, 2/14/2023. Training / In-Service and discussion to continue at mandatory All-Staff meeting tomorrow, 2/15/2023.a. 2/14/2023 day staff to be trained before their shift ends today.b. 2/14/2023 evening staff to be trained at shift change / before their shift begins tonight.c. 2/14/2023 overnight staff to be trained at shift change / before their shift begins tonight.d. All staff required to attend monthly All-Staff meeting at 2:15 p.m. on Wed(nesday). 2/15/2023 to continue with this training and reiterate the importance of updated fall management.e. Continued training to be provided by RSDf. Training will be documented on In-Service sheets to be located/stored in In-Service binder in Administrator ' s office. 2. Fall Management Binder to be compiled immediately by Resident Services Director, and to include:a. Identify residents who are a high fall risk, including their photob. Inform of resident-specific interventions in placec. Identify recent fallsd. Binder to be located on bookshelf in Clock-in/Copier Room for all staff to access at any time and will be taken to each shift report, daily.e. RSD responsible for daily updates 3. Monitoring:a. Will be monitored daily by RSD for 90 days with any discrepancies discussed at weekly QMP (quality management program) meetings and additional training needs followed-upat that time. 4. Staff File Audits:a. BOM (business office manager)/RCC (resident care coordinator)/RSD to audit five staff files per month and discrepancies corrected immediately and discussed during weekly QMP meetings."However, the written evidence did not indicate the risk had been removed because it did not indicate who the scheduler would be aware of which staff were provided the required training. On 2/14/23 at 1:28 p.m., the administrator designee submitted additional written evidence that read in pertinent part, "Follow-up Question: how will scheduler know who from Agency has already had training and who is new and needs training?a. RSD and RCC shall create and utilize Audit sheet to verify Agency staff members have been trained prior to shift to identify residents who are at risk for falls and identify interventions."However, the written evidence did not indicate the risk had been removed because it did not indicate when the audit sheet would be created and a date as to when it would be implemented. On 2/14/24 at 2:14 p.m. the administrator designee submitted additional written evidence that read in pertinent part, "The audit form will be created and implemented today, 2/14/23."

Based on record review and interviews, the residence failed to provide residents with regular opportunities to participate in structured engagement activities on the weekends, affecting 26 current residents. (Cross-reference 1150). Findings include: 1. Residence PolicyA residence engagement policy, dated 2/22/22, read in part: "the residence would provide all residents with regular opportunities to participate in structured social and recreational engagement opportunities, and would support the pursuit of each resident's interests and wishes ...Staff were responsible for ensuring that the daily schedule of recreational social engagement opportunities was implemented and offered to all residents."2. Record ReviewAn activity calendar was posted for the month of February 2023. The calendar had the following activities listed over the previous two weekends prior to the onsite visit:On Saturday 2/4/23: Sit and be fit, daily chronicle, story time, and hallmark shows. On Sunday 2/5/23: Faith gathering and worship service, daily chronicle, hand massage, and guest. On Saturday 2/11/23: Sit and be fit, daily chronicle, story time, and hallmark shows. On Sunday 2/12/23: Church hymns, faith gathering and worship services, daily chronicle and painted nails. 3. InterviewsOn 2/13/23 at 8:03 a.m., Staff #39 stated that she had worked at the residence for almost four months, and worked most Saturdays. Staff #39 stated that she had never seen activities provided to residents on Saturdays because the activities director was only at the residence Monday through Friday. Staff #39 stated someone outside the residence came in on Sundays to lead a church service, however, that was the only activity on the weekends. On 2/13/23 at 8:47 a.m., Staff #25 stated that she worked weekends at the residence, and there was not enough staff on weekends to be able to get everything done, and as a result, no activities were provided to residents on Saturdays or Sundays by staff. Staff #25 stated that there was only a bible study on Sundays, but not every resident would attend it. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated he visited the residence almost daily and that opportunities for engagement for the residents were not offered to the residents during the weekends. On 2/14/23 at approximately 12:36 p.m., the consultant stated that she had looked at the activities calendar and the activity director was very involved. She stated activities not being provided on the weekends had been addressed in the QMP; however, activities on the weekend was not brought up in resident council meetings. The consultant stated that the residence was in the process of scheduling more activities on the weekend since it had been lacking, and a family member would come in on Sundays to facilitate religious activities. On 2/14/23 at 12:56 p.m., the activities director stated that she provided structured activities Monday through Friday and set up activities such as bingo, crossword puzzles, word sheets, and other games on the weekends for staff to provide. The activities director stated that she had conversations with staff in the past, and stated that it was staff responsibility to ensure that activities were done on weekends. The activities director stated that she knew for sure that a resident's husband provided a church service on Sundays, and there was a family member of a former resident that read to residents on Saturdays, however, they had to cut back due to loss of resident interest.

Based on observations, record review and interviews, the residence failed to implement an internal process to ensure routine and prompt handling of grievances or complaints brought by family members or advocates, affecting 26 current residents. Findings include:1. Residence PolicyThe residence grievance policy, dated 2/22/22, read in part: "Most problems can be easily resolved by contacting the administrator of the (residence). The administrator will document all complaints/grievances brought to his attention ...the complaint will be documented and reviewed with the individual who registered the complaint within 3-5 days of the complaint ...community staff will provide assistance as indicated to any individual who wishes to implement the grievance procedure."1. ObservationsOn 2/14/23 at 1:10 p.m., a phone charging station was on a table in a locked back room behind the staff office on the east side of the residence. However, there were no phone chargers on either medication cart on the east or west side of the residence. On 2/14/23 at 1:56 p.m., Staff #29 telephoned Staff #36 on the only resident telephone in the residence that was located in the television room on the west side of the residence, and the telephone screen read "emergency calls only."2. Record ReviewA grievance, dated 1/18/23, read that the responsible party for Resident #40 attempted to contact the resident by calling the residence. However, the responsible party was unable to get a hold of staff when using the residence phone number. On 2/14/23 at 1:24 p.m., Staff #29 provided a missed call log on her phone of all the unanswered calls from family members. The missed calls on the staff phone revealed that between 2/9/23 and 2/13/23 the following calls by family members were unanswered by residence staff:-The family member for Resident #2 had called the residence six times.-The family member for Resident #27 had called the residence three times.-The family member for Resident #29 had called the residence once.-The family member for Resident #43 had called the residence once. 3. Interviews On 2/13/23 at former Resident #18's family member stated that she had expressed concerns about former Resident #18's care during a conference on 8/31/22, and reached out to the residence again in September and October 2022 with no response. On 2/14/23 at 8:26 a.m., the responsible party for Resident #22 stated that residence phones had gone missing, which made it difficult for her to contact Resident #22. On 2/14/23 at 8:41 a.m., an outside agency representative stated she had to reach out to the residence on behalf of Former Resident #18, and received a response on 10/27/22. A meeting with herself and the residence was held on 11/3/22, and she had discovered that prior to November 3, 2022, the residence did not have a formal grievance process. The outside agency representative stated that she had received concerns from former Resident #18's family member, as well as other family members of residents, about not being able to get in touch with the residence about concerns they had. On 2/14/23 at approximately 12:36 p.m., the consultant stated that she wrote about the residence phone not working in her report where family members could not reach their loved ones. The consultant stated that the residence had a main line that connected during business hours and was allegedly fixed. The consultant stated that she expected staff telephones to be answered however, was aware it had been an issue. On 2/14/23 at 1:06 p.m., Staff #29 stated that they only had one phone charging station in the back room behind the staff office on the east side of the residence. Staff #29 stated that it had been an ongoing issue where nightshift staff would not charge their phones or answer family phone calls, and when the morning shift came on, all the phones would be dead and with unanswered missed calls from families. On 2/14/23 at 1:33 p.m., the resident services director stated that there were phones on the east and west side in the television rooms that could connect with family members. The resident services director stated that all calls that come in after hours go to staff cellular telephones, and staff telephones had been going dead at night. The staff further stated the residence was working on obtaining telephone chargers for the medication carts. The resident services director stated that she was aware that it was an issue with family members not being able to get through. On 2/14/23 at 2:02 p.m., Staff #29 stated that the residence only had one telephone in the west side television room, however, it had only worked to call emergency services in the case of an emergency, and was not capable of dialing any other numbers or connecting residents with family members. Staff #29 stated that family members of residents would have to telephone the staff telephones in order to get in touch with their loved ones. Staff #29 stated that she was not aware why the telephone on the west side would only dial emergency services and stated that the telephone "would not work."

Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of five sample residents (#2, #32, #38, #43) and two former residents (#18, #44). Findings include:1. Residence policyThe residence's Medication Administration policy, dated February 2022, read in part: "The community (residence) is responsible for complying with practitioner orders, associated with the administration of medication or treatment."2. Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease, major depressive disorder, and Parkinson's disease.a. OmeprazoleA written practitioner's order, dated 2/23/21, directed the residence to administer omeprazole 20 mg twice daily. However, the January 2023 medication administration record (MAR) read the medication was not administered in the morning on 1/14, 1/15, and 1/26 and in the evening on 1/1/23, for a total of four missed doses due to the medication being unavailable.b. LorazepamA written practitioner's order, dated 12/12/22, directed the residence to administer lorazepam 2 mg/mL oral concentrate 0.5 mg twice daily. However, the January 2023 MAR read the medication was not administered twice on 1/14 and in the evening on 1/31/23, for a total of three missed doses due to the medication being unavailable.c. QuetiapineA written practitioner's order, dated 2/23/21, directed the residence to administer quetiapine 100 mg twice daily. However, the January 2023 MAR read the residence did not administer the medication in the morning on 1/28 and 1/29 and in the evening on 1/28/23, for a total of three missed doses due to the medication being unavailable.d. DuloxetineA written practitioner's order, dated 4/19/22, directed the residence to administer duloxetine 40 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/7/23, for a total of one missed dose due to the medication being unavailable.e. TamsulosinA written practitioner's order, dated 2/23/21, directed the residence to administer tamsulosin 0.4 mg daily. However, the January 2023 MAR read the medication was not administered on 1/7/23, for a total of one missed dose due to the medication being unavailable. On 2/13/23 at 1:06 p.m., the legal representative for Resident #2 stated he was not aware of any medications being unavailable. 3. Resident #32 was admitted to the residence on 8/3/22. a. AmlodipineA written practitioner's order, dated 8/3/22, directed the residence to administer amlodipine 5 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/16, 1/18, and 1/19/23 for a total of three missed doses due to the medication being out of stock.b. RivastigmineA written practitioner's order, dated 8/3/22, directed the residence to administer a rivastigmine patch 4.6 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/3-1/6/23 for a total of four missed doses due to the medication being out of stock. 4. Resident #43 was admitted to the residence on 12/13/22.a. DivalproexA written practitioner's order, dated 11/22/22, directed the residence to administer divalproex 250 mg twice daily. However, the January 2023 MAR read the medication was not administered on 1/14/23 due to the medication being out of stock. b. HaloperidolA written practitioner's order, dated 11/22/22, directed the residence to administer haloperidol 5 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/17 and 1/18/23 for a total of two missed doses due to the medication being out of stock. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated he was not aware of medications being out of stock. 5. Former Resident #44 was admitted to the residence on 11/14/22. A written practitioner's order, dated 11/14/22, directed the residence to administer Xarelto 10 mg once daily. However, the November 2022 MAR read the medication was not administered on 11/27/22 for a total of one missed dose due to the medication being out of stock. On 2/13/23 at approximately 1:00 p.m., an anonymous staff member stated she remembered an issue with Former Resident #44's Xarelto, however, she could not recall what happened exactly. On 2/13/23 at 2:20 p.m., the responsible party for Former Resident #44 stated the resident's Xarelto went missing at the end of November and the resident missed at least one dose. 6. Resident #38 was admitted to the residence on 8/15/22. A written practitioner's order dated, 12/6/22, directed the residence to administer lidocaine cream 4% twice daily to the left side of his face. However, the January 2023 MAR read the medication was not administered in the evening on 1/4-1/6 and 1/10 and once in the morning on 1/10/23, for a total of five missed doses due to the medication being out of stock. On 2/13/23 at 12:47 p.m., the legal representative for Resident #38 stated she was not aware of the lidocaine ever being out of stock. 7. Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and major depressive disorder.a. Quetiapine 50 mgA written practitioner's order, dated 3/18/21, directed the residence to administer quetiapine 50 mg three times daily until discontinued on 9/2/22. A written practitioner's order dated 9/2/22, directed the residence to administer quetiapine 50 mg once at bedtime. However, quetiapine 50 mg was not administered on 9/2/22 in the evening, and was administered 9/2/22 in the morning instead, and was not administered 9/3-9/5/22, due to being inactive in the MAR, for a total of three missed doses. In addition, on 9/6 and 9/7/22, quetiapine 50 mg was administered in the afternoon instead of at bedtime as ordered. On 2/14/23 at 7:18 a.m., Staff #29 stated that former Staff #18 had messed up the charting and acknowledged that former Resident #18 was not given her quetiapine 50 mg at bedtime on 9/6/22 and instead was given it in the afternoon. Staff #29 stated that quetiapine was inactive in the MAR on 9/3-9/5/22, which was why it was not administered. On 2/14/23 at 1:33 p.m., the resident services director stated that medications that were inactive were not given at all. The resident services director acknowledged that former Resident #18's quetiapine 50 mg was not being administered as ordered and stated that as a result, evening doses were missed. b. Quetiapine 25 mgA written practitioner's order, dated 9/2/22, directed the residence to administer quetiapine 25 mg once every morning. A practitioner's order, dated 9/19/22, directed the residence to discontinue the current 25 mg once in the morning dose of quetiapine, and administer 25 mg three times daily. However, on 9/3/22 and 9/20/22, Quetiapine was not administered in the morning due to the medication being inactive in the MAR, for a total of two missed doses. On 2/14/23 at 7:18 a.m., Staff #29 stated that quetiapine was inactive on the MARs with the new orders and order changes, which was why it was marked as inactive. On 2/14/23 at 12:26 p.m., the consultant confirmed there were still medications that were not administered as required. However, she stated she was working with the residence to ensure medications were being audited and ordered every week to avoid medications being unavailable. On 2/14/23 at 1:30 p.m., the administrator designee stated she expected the residence to administer all prescribed doses of medication to residents as ordered. She stated that qualified administration persons reordered medications when they ran low. She added she was not aware that medication compliance was still an issue and was unsure why it had not been corrected. On 2/14/23 at approximately 1:33 p.m., the residence services director stated she was aware that some resident medications were out of stock.

Based on record review and interview, the residence failed to maintain an accurate medication administration record (MAR), affecting five of seven sample residents (#19, #22, #32, #42, #43). Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated February 2022, read in part, "As part of the medication administration record, the community maintains a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials."2. Record Reviewa. The January and February 2023 MARs for Residents #19, #22, #32, #42, #43 contained a section for staff signatures, their titles, and the initials or code they used to sign off medications on the MAR. On each of the residents' January and February 2023 MARs were the following two entries:Agency Staff, AS, BVAgency 2 Staff, AS, BXb. Review of the January and February 2023 MARs revealed morning medications were signed off with the code BV or BX as follows:Resident #22 - 1/14, 1/21, 1/28, 2/4, 2/5, and 2/11/23Resident #32 - 1/14, 1/21, 1/28, 1/29, 2/4 and 2/5/23Resident #43 - 1/15, 1/21, 1/22, 1/28, 2/4-2/6, 2/11 and 2/12/23 Resident #42- 1/28, 2/4 and 2/6/23Resident #19- 1/14-1/15, 1/28, 2/4-2/6, and 2/11-2/12/23.c. Review of the January and February 2023 MARS revealed the afternoon medications were signed off with the code BV or BX as follows:Resident #19- 1/14-1/15, 1/21-1/22, 1/29, 2/4-2/6 and 2/11-2/12/23Resident #43 - 1/14, 1/15, 1/21, 1/22, 1/29/22, 2/4-2/6, 2/11 and 2/12/23d. Review of the January and February 2023 MARs revealed the evening medications were signed off with the code BV or BX as follows:Resident #22 - 1/14, 1/20, 1/21, 1/28, 1/29, 2/4-2/6, and 2/12/23. Resident #32 - 1/13, 1/14, 1/20, 1/21, 1/28, 1/29, 2/3-2/6 and 2/12/23Resident #43 - 1/4, 1/7, 1/13/22, 2/3-2/6, 2/11 and 2/12/23Resident #19- 1/4, 1/7, 1/13-1/14, 1/20, 1/29, 2/3, 2/4, 2/6, 2/11, and 2/12/23. Resident #42- 2/3-2/4, 2/6, and 2/11-2/12/23.3. InterviewOn 2/14/23 at approximately 12:36 p.m., the consultant stated she was aware the MARs were inaccurate. She stated she was in the process of implementing a new system for contracted staff to document that medications were administered. She also stated she discussed the issue of inaccurate MARs with the residence in January 2023. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated contracted staff used the same codes when documenting on the MAR. She stated she would be unable to tell who administered medication when the codes BV and BX were used. The administrator designee acknowledged that contracted staff should have their signatures and own codes to document on the MARs.

Based on observation, interview and record review, the residence failed to ensure staff who assist feeding a resident shall be trained in the proper techniques for supporting nutrition and hydration by a licensed registered professional and training to assess choking risks, affecting one resident that required feeding assistance (#32). Findings include:1. Residence PolicyThe residence's Assisting with Dining and Feeding policy, dated February 2022, read in part: "Staff who assist feeding a resident are trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional qualified by education and training to assess choking risks, such as a registered nurse, speech language pathologist or registered dietitian." The residence's Procedure to Assist with Eating policy, dated February 2022, read in part: "Only personal care workers trained by a licensed professional may assist with feeding residents."2. ObservationOn 12/13/23 at 12:40 p.m., Staff #29 provided full feeding assistance to Resident #32.3. Record ReviewOn 12/14/23 at approximately 1:30 p.m., documentation of feeding training by the registered nurse consultant was requested from the consultant and administrator designee. The training documentation was requested again from the resident services director at approximately 2:15 p.m. as of 2:45 p.m., the training documentation was not provided. The care plan for Resident #32, updated February 2023, read in part: "Maximum help with eating: Resident is confined to bed per hospice and on a puree diet, staff to assist with feeding (three times) per day and provide room trays."4. InterviewOn 2/13/23 at 8:33 a.m., Staff #29 stated staff were not provided feeding assistance training. She also stated contracted staff often fed Resident #32 and were also not provided any feeding assistance training. On 2/13/23 at approximately 8:07 a.m., Staff #36 stated that Resident #32 required feeding assistance. She added she was not trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional qualified by education and training to assess choking risks, such as a registered nurse, speech language pathologist or registered dietitian. On 2/13/23 at 12:40 p.m., Staff #29 stated that Resident #32 required feeding assistance. She added she was not trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional qualified by education and training to assess choking risks, such as a registered nurse, speech language pathologist or registered dietitian. On 2/14/23 at 8:42 a.m., an external hospice provider stated that Resident #32 required feeding assistance. She stated that residence staff assisted feeding Resident #32. On 2/14/23 at approximately 12:36 p.m., the consultant stated staff needed to be trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional to physically assist with feeding Resident #32. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated a training was held by the registered nurse consultant on 12/8/22. She stated she did not know why staff reported they were not trained. She added that the residence had not provided training in the proper techniques for supporting nutrition and hydration by a licensed or registered professional to contracted staff and she was aware that agency staff provided feeding assistance to Resident #32. On 2/14/23 at approximately 1:33 p.m., the resident services director stated that Resident #32 required feeding assistance and that residence staff provided feeding assistance. She added that contracted staff were not trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional qualified by education and training to assess choking risks, such as a registered nurse, speech language pathologist or registered dietitian.

Based on observations, interviews, and record review, the residence failed to ensure the residence grounds were maintained to protect residents from hazards, affecting 26 current residents. Findings include: 1. ObservationsOn 2/13/23 at 7:30 a.m., an outside environmental tour was conducted of the east and west secure courtyard area which revealed un-repaired hazardous safety on the east and west sides. The following was observed:An area of the sidewalk on the east side of the secure outdoor courtyard had a drop off that measured 2.5 inches deep. An area of the sidewalk on the west side of the secure outdoor courtyard had a drop off that measured 3 inches deep on one side, and 2.5 inches deep on the other side of the sidewalk. 2. InterviewsOn 2/14/23 at 12:36 p.m., the consultant stated that the residence had a bid to have the work outside in the courtyards completed. However, she stated the snow had been a problem and outdoor contractors would not come until the spring of 2023. The consultant stated there was no date assigned they would come. The consultant further stated one side of the courtyard had been fixed, she thought the east, and thought it was corrected. The consultant stated the residence was aware of this safety issue. On 2/14/23 at 2:02 p.m., the resident services director stated that Resident #32 and Resident #42 went out into the courtyards, however, had not lately since it was winter. The resident services director stated that she was aware that the concrete had been an issue, however, was unable to get it fixed because of the weather.

Based on record review and interview, the assisted living residence failed to ensure an appropriate level of staffing to meet day to day resident needs affecting 26 current residents. (Cross-reference Q1110, Q1212). Findings include:1. Residence policyThe residence's Staffing Requirements policy, dated February 2022, read in part: "To determine appropriate routine staffing levels, the community (residence) considers, at a minimum, the following items: The acuity and needs of the residence; The services outlined in the care plan; The services set forth in the resident agreement ... This community has a sufficient number of trained staff members on duty in the secure environment to ensure each resident's physical, social and emotional health care and safety needs are met in accordance with their individualized care plan." 2. Record ReviewThe staff schedule revealed the following:Only two staff members worked the evening shift (2:00 p.m. to 10:00 p.m.) on 1/30, 2/6, and 2/12/23. Only two staff members worked the night shift (10:00 p.m. to 6:00 a.m.) on 2/8-2/10/23. Only three staff members worked the evening shift on 2/5, 2/9, and 2/11/23.3. InterviewOn 2/13/23 at 8:53 a.m., the resident services director stated the staff schedule provided was accurate. She stated she edited the staff schedule daily to maintain accuracy. On 2/13/23 at 12:40 p.m., an anonymous staff member stated she was concerned about staffing levels during the weekends. She stated the majority of weekend staff were contracted staff and there were not enough of them. She added this resulted in residents being soiled when she arrived for her shift Monday mornings. On 2/13/23 at 2:20 p.m., the responsible party for Former Resident #44 stated the residence did not have an appropriate level of staffing to meet day to day resident needs. She stated the lack of staff caused Former Resident #44 to miss hygiene and incontinence care that he needed. She added she had to wait five or more minutes for staff to let her in and out of the secure environment entrance. On 2/14/23 at 8:26 a.m., the responsible party for Resident #22 stated she visited the residence at least once per week. She stated that the residence did not have enough staff. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated the residence had a low number of staff during the weekends and he came in to assist caring for Resident #43. On 2/14/23 at 12:35 p.m., the consultant stated she was concerned because the residence did not have sufficient staffing levels on the weekends. She added that sometimes staff will call off or contracted staff will not show up, resulting in even lower numbers of staff. On 2/14/23 at approximately 1:30 p.m., the administrator designee stated the expectation was for the day shift to have five to six staff members, the evening shift to have four to five staff members, and the night shift to have three staff members. On 2/14/23 at 1:33 p.m., the resident services director stated she tried to schedule at least three staff members for the evening shift and night shifts over the weekends. She added that she was not always successful because staff would call off or not show up. The resident services director acknowledged the residence had low staff levels over the weekends.

A licensure revisit was completed on 2/14/23 for all previous deficiencies cited on 8/31/22. Deficiencies were cited.

Based upon observation, record review and interview, the residence failed to comply with conditions imposed by the department, affecting 26 current residents. Findings include: On 5/10/22 the department issued a Conditional License to the residence. The Conditional License read that the residence was required to maintain operational conditions during the term of the Conditional License. Following the completion of Event ZH3B12 on 12/8/21, a complaint investigation, the department imposed a consultant for 11 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The Conditional License required the residence to comply and maintain the following:Commencing the first week of the first full month, the licensee shall submit a written monthly report to the department that addresses each of the following areas of concern. The licensee shall include written monthly reports to the department information from audits performed during the previous month regarding how the licensee was ensuring compliance. Within the first 30 days of the Consultant's term, the Consultant shall review each of the cited deficiencies identified in the opportunities to present written data, views, and arguments dated January 26, 2022, with the administrator, and evaluate the facility's (residence's) current compliance with the corresponding regulations, as outlined in 6 C.C.R. 1011-1 Chapters 2, 7, and 24, where applicable. Within the first 45 days of the Consultant's term, the Consultant shall evaluate the Facility's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Facility on any additional areas of noncompliance. The Consultant shall also implement a monitoring program, to be completed at least monthly, to ensure the Facility remains in compliance with previously cited deficiencies. The monitoring program shall be incorporated into the Facility's ongoing quality management program (QMP), in accordance with 6 C.C.R. 1011-1 Chapter 2, Section 4. The Consultant shall make certain that the QMP is designed to improve resident safety and well-being, and promotes continued quality improvement to enhance service delivery. The Consultant shall make certain that the Administrator has a process in place to correct the identified deficiency, which includes utilizing the above-referenced monitoring program to ensure the deficient practice does not reoccur. The Consultant shall make certain that the monitoring identifies the scope of review, how a sample is identified for monitoring purposes, the total length of time the monitoring will continue, which will be no less than six months, and how the monitoring will be documented. During the final 60 days of the Consultant's term, the Consultant shall prepare the Administrator to independently manage the Facility to ensure compliance with all applicable regulations governing assisted living residences. The Consultant shall make certain that the Administrator has tools and resources in place to maintain compliance. The Conditional license also read that examples of a material breach of the conditional license included, but was not limited to, the following:Failure of the Licensee to comply with all applicable state rules, regulations, and standards, including without limitation, Chapter 2, 7, and 24 of the Department's regulations at 6 CCR 1011-1, and the provisions of Articles 3 and 27 of Title 25, C.R.S. or a sustained finding of immediate jeopardy at any time. Department records read the residence had chosen the consultant on 5/31/22 and the contract for the consultant was received on 6/1/22. Therefore, on the day of the completion of the complaint investigation, 2/14/23, the consultant was in the beginning of her eighth month as consultant for the residence. During the 2/14/23 revisit, the revisit established there was current deficient practice, despite having a consultant in place. Seventeen deficiencies were cited, including Tag 540 (Cross-reference Q540). On 2/14/23 at approximately 3:29 p.m., the administrator designee stated she was aware of the requirements of the conditional license. On 2/14/22 at approximately 12:36 p.m., the consultant stated that she had done several reviews of COVID and the COVID vaccination plan. The consultant stated that she was aware that EMResource had not been updated.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 26 current residents. Findings include:1. References and Residence Policya. The Ninth Amended State Public Health Order 20-20 (PHO) Requirements for Colorado Skilled Nursing Facilities, Assisted Living Residences, Intermediate Care Facilities and Group Homes for COVID-19 Prevention and Response, dated 10/11/22, required residences to:- Report to CDPHE information pertaining to their available resources to respond to the COVID-19 pandemic. The department will provide the reporting platforms and the form and format for submission of the required information. The residence must adhere to reporting requirements as specified in RCF Comprehensive Mitigation Guidance. b. The COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/7/23, required residences to: - Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month and period two, defined as days 15 to 31 of each month). 2. Record ReviewOn 2/13/23 at 9:57 a.m., a review of EMResource revealed that the residence's most current reporting occurred on 11/10/22, resulting in six missed periods during which the residence was required to report. EMResource read that there were still 30 residents, however, the day of the onsite survey the resident roster read there were only 26 current residents. 3. InterviewsOn 2/14/23 at approximately 12:36 p.m., the consultant stated that she had done several reviews of COVID and the COVID vaccination plan. The consultant stated that she was aware that EMResource had not been updated. On 2/14/23 at approximately 1:36 p.m., the resident services director stated that she did not know why the administrator had not updated EMResource since 11/10/22. The resident services director stated that she was aware of the requirement and thought that the administrator had updated EMResource.

A licensure revisit was completed on 2/14/23 for all previous deficiencies cited on 8/31/22. Deficiencies were cited.

Based upon observation, record review and interview, the residence failed to comply with conditions imposed by the department, affecting 26 current residents. Findings include: On 5/10/22 the department issued a Conditional License to the residence. The Conditional License read that the residence was required to maintain operational conditions during the term of the Conditional License. Following the completion of Event ZH3B12 on 12/8/21, a complaint investigation, the department imposed a consultant for 11 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The Conditional License required the residence to comply and maintain the following:Commencing the first week of the first full month, the licensee shall submit a written monthly report to the department that addresses each of the following areas of concern. The licensee shall include written monthly reports to the department information from audits performed during the previous month regarding how the licensee was ensuring compliance. Within the first 30 days of the Consultant's term, the Consultant shall review each of the cited deficiencies identified in the opportunities to present written data, views, and arguments dated January 26, 2022, with the administrator, and evaluate the facility's (residence's) current compliance with the corresponding regulations, as outlined in 6 C.C.R. 1011-1 Chapters 2, 7, and 24, where applicable. Within the first 45 days of the Consultant's term, the Consultant shall evaluate the Facility's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Facility on any additional areas of noncompliance. The Consultant shall also implement a monitoring program, to be completed at least monthly, to ensure the Facility remains in compliance with previously cited deficiencies. The monitoring program shall be incorporated into the Facility's ongoing quality management program (QMP), in accordance with 6 C.C.R. 1011-1 Chapter 2, Section 4. The Consultant shall make certain that the QMP is designed to improve resident safety and well-being, and promotes continued quality improvement to enhance service delivery. The Consultant shall make certain that the Administrator has a process in place to correct the identified deficiency, which includes utilizing the above-referenced monitoring program to ensure the deficient practice does not reoccur. The Consultant shall make certain that the monitoring identifies the scope of review, how a sample is identified for monitoring purposes, the total length of time the monitoring will continue, which will be no less than six months, and how the monitoring will be documented. During the final 60 days of the Consultant's term, the Consultant shall prepare the Administrator to independently manage the Facility to ensure compliance with all applicable regulations governing assisted living residences. The Consultant shall make certain that the Administrator has tools and resources in place to maintain compliance. The Conditional license also read that examples of a material breach of the conditional license included, but was not limited to, the following:Failure of the Licensee to comply with all applicable state rules, regulations, and standards, including without limitation, Chapter 2, 7, and 24 of the Department's regulations at 6 CCR 1011-1, and the provisions of Articles 3 and 27 of Title 25, C.R.S. or a sustained finding of immediate jeopardy at any time. Department records read the residence had chosen the consultant on 5/31/22 and the contract for the consultant was received on 6/1/22. Therefore, on the day of the completion of the complaint investigation, 2/14/23, the consultant was in the beginning of her eighth month as consultant for the residence. During the 2/14/23 revisit, the revisit established there was current deficient practice, despite having a consultant in place. Six deficiencies were cited, including Tag 1468 (Cross-reference Q1468). On 2/14/23 at approximately 3:29 p.m., the administrator designee stated she was aware of the requirements of the conditional license. On 2/14/22 at approximately 12:36 p.m., the consultant confirmed there were still medications that were not administered as required. However, she stated she was working with the residence to ensure medications were being audited and ordered every week to avoid medications being unavailable.

Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of five sample residents (#2, #32, #38, #43) and two former residents (#18, #44). This deficiency was cited previously during a state licensure survey 8/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Medication Administration policy, dated February 2022, read in part: "The community (residence) is responsible for complying with practitioner orders, associated with the administration of medication or treatment."2. Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease, major depressive disorder, and Parkinson's disease.a. OmeprazoleA written practitioner's order, dated 2/23/21, directed the residence to administer omeprazole 20 mg twice daily. However, the January 2023 medication administration record (MAR) read the medication was not administered in the morning on 1/14, 1/15, and 1/26 and in the evening on 1/1/23, for a total of four missed doses due to the medication being unavailable.b. LorazepamA written practitioner's order, dated 12/12/22, directed the residence to administer lorazepam 2 mg/mL oral concentrate 0.5 mg twice daily. However, the January 2023 MAR read the medication was not administered twice on 1/14 and in the evening on 1/31/23, for a total of three missed doses due to the medication being unavailable.c. QuetiapineA written practitioner's order, dated 2/23/21, directed the residence to administer quetiapine 100 mg twice daily. However, the January 2023 MAR read the residence did not administer the medication in the morning on 1/28 and 1/29 and in the evening on 1/28/23, for a total of three missed doses due to the medication being unavailable.d. DuloxetineA written practitioner's order, dated 4/19/22, directed the residence to administer duloxetine 40 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/7/23, for a total of one missed dose due to the medication being unavailable.e. TamsulosinA written practitioner's order, dated 2/23/21, directed the residence to administer tamsulosin 0.4 mg daily. However, the January 2023 MAR read the medication was not administered on 1/7/23, for a total of one missed dose due to the medication being unavailable. On 2/13/23 at 1:06 p.m., the legal representative for Resident #2 stated he was not aware of any medications being unavailable. 3. Resident #32 was admitted to the residence on 8/3/22. a. AmlodipineA written practitioner's order, dated 8/3/22, directed the residence to administer amlodipine 5 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/16, 1/18, and 1/19/23 for a total of three missed doses due to the medication being out of stock.b. RivastigmineA written practitioner's order, dated 8/3/22, directed the residence to administer a rivastigmine patch 4.6 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/3-1/6/23 for a total of four missed doses due to the medication being out of stock. 4. Resident #43 was admitted to the residence on 12/13/22.a. DivalproexA written practitioner's order, dated 11/22/22, directed the residence to administer divalproex 250 mg twice daily. However, the January 2023 MAR read the medication was not administered on 1/14/23 due to the medication being out of stock. b. HaloperidolA written practitioner's order, dated 11/22/22, directed the residence to administer haloperidol 5 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/17 and 1/18/23 for a total of two missed doses due to the medication being out of stock. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated he was not aware of medications being out of stock. 5. Former Resident #44 was admitted to the residence on 11/14/22. A written practitioner's order, dated 11/14/22, directed the residence to administer Xarelto 10 mg once daily. However, the November 2022 MAR read the medication was not administered on 11/27/22 for a total of one missed dose due to the medication being out of stock. On 2/13/23 at approximately 1:00 p.m., an anonymous staff member stated she remembered an issue with Former Resident #44's Xarelto, however, she could not recall what happened exactly. On 2/13/23 at 2:20 p.m., the responsible party for Former Resident #44 stated the resident's Xarelto went missing at the end of November and the resident missed at least one dose. 6. Resident #38 was admitted to the residence on 8/15/22. A written practitioner's order dated, 12/6/22, directed the residence to administer lidocaine cream 4% twice daily to the left side of his face. However, the January 2023 MAR read the medication was not administered in the evening on 1/4-1/6 and 1/10 and once in the morning on 1/10/23, for a total of five missed doses due to the medication being out of stock. On 2/13/23 at 12:47 p.m., the legal representative for Resident #38 stated she was not aware of the lidocaine ever being out of stock. 7. Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and major depressive disorder.a. Quetiapine 50 mgA written practitioner's order, dated 3/18/21, directed the residence to administer quetiapine 50 mg three times daily until discontinued on 9/2/22. A written practitioner's order dated 9/2/22, directed the residence to administer quetiapine 50 mg once at bedtime. However, quetiapine 50 mg was not administered on 9/2/22 in the evening, and was administered 9/2/22 in the morning instead, and was not administered 9/3-9/5/22, due to being inactive in the MAR, for a total of three missed doses. In addition, on 9/6 and 9/7/22, quetiapine 50 mg was administered in the afternoon instead of at bedtime as ordered. On 2/14/23 at 7:18 a.m., Staff #29 stated that former Staff #18 had messed up the charting and acknowledged that former Resident #18 was not given her quetiapine 50 mg at bedtime on 9/6/22 and instead was given it in the afternoon. Staff #29 stated that quetiapine was inactive in the MAR on 9/3-9/5/22, which was why it was not administered. On 2/14/23 at 1:33 p.m., the resident services director stated that medications that were inactive were not given at all. The resident services director acknowledged that former Resident #18's quetiapine 50 mg was not being administered as ordered and stated that as a result, evening doses were missed. b. Quetiapine 25 mgA written practitioner's order, dated 9/2/22, directed the residence to administer quetiapine 25 mg once every morning. A practitioner's order, dated 9/19/22, directed the residence to discontinue the current 25 mg once in the morning dose of quetiapine, and administer 25 mg three times daily. However, on 9/3/22 and 9/20/22, Quetiapine was not administered in the morning due to the medication being inactive in the MAR, for a total of two missed doses. On 2/14/23 at 7:18 a.m., Staff #29 stated that quetiapine was inactive on the MARs with the new orders and order changes, which was why it was marked as inactive. On 2/14/23 at 12:26 p.m., the consultant confirmed there were still medications that were not administered as required. However, she stated she was working with the residence to ensure medications were being audited and ordered every week to avoid medications being unavailable. On 2/14/23 at 1:30 p.m., the administrator designee stated she expected the residence to administer all prescribed doses of medication to residents as ordered. She stated that qualified administration persons reordered medications when they ran low. She added she was not aware that medication compliance was still an issue and was unsure why it had not been corrected. On 2/14/23 at approximately 1:33 p.m., the residence services director stated she was aware that some resident medications were out of stock.

A licensure revisit was completed on 2/14/23 for all previous deficiencies cited on 10/10/22. The residence is in compliance with all regulations surveyed.

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

A licensure revisit was completed on 2/14/23 for all previous deficiencies cited on 8/31/22. Deficiencies were cited.

Based upon observation, record review and interview, the residence failed to comply with conditions imposed by the department, affecting 26 current residents. Findings include: On 5/10/22 the department issued a Conditional License to the residence. The Conditional License read that the residence was required to maintain operational conditions during the term of the Conditional License. Following the completion of Event ZH3B12 on 12/8/21, a complaint investigation, the department imposed a consultant for 11 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The Conditional License required the residence to comply and maintain the following:Commencing the first week of the first full month, the licensee shall submit a written monthly report to the department that addresses each of the following areas of concern. The licensee shall include written monthly reports to the department information from audits performed during the previous month regarding how the licensee was ensuring compliance. Within the first 30 days of the Consultant's term, the Consultant shall review each of the cited deficiencies identified in the opportunities to present written data, views, and arguments dated January 26, 2022, with the administrator, and evaluate the facility's (residence's) current compliance with the corresponding regulations, as outlined in 6 C.C.R. 1011-1 Chapters 2, 7, and 24, where applicable. Within the first 45 days of the Consultant's term, the Consultant shall evaluate the Facility's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Facility on any additional areas of noncompliance. The Consultant shall also implement a monitoring program, to be completed at least monthly, to ensure the Facility remains in compliance with previously cited deficiencies. The monitoring program shall be incorporated into the Facility's ongoing quality management program (QMP), in accordance with 6 C.C.R. 1011-1 Chapter 2, Section 4. The Consultant shall make certain that the QMP is designed to improve resident safety and well-being, and promotes continued quality improvement to enhance service delivery. The Consultant shall make certain that the Administrator has a process in place to correct the identified deficiency, which includes utilizing the above-referenced monitoring program to ensure the deficient practice does not reoccur. The Consultant shall make certain that the monitoring identifies the scope of review, how a sample is identified for monitoring purposes, the total length of time the monitoring will continue, which will be no less than six months, and how the monitoring will be documented. During the final 60 days of the Consultant's term, the Consultant shall prepare the Administrator to independently manage the Facility to ensure compliance with all applicable regulations governing assisted living residences. The Consultant shall make certain that the Administrator has tools and resources in place to maintain compliance. The Conditional license also read that examples of a material breach of the conditional license included, but was not limited to, the following:Failure of the Licensee to comply with all applicable state rules, regulations, and standards, including without limitation, Chapter 2, 7, and 24 of the Department's regulations at 6 CCR 1011-1, and the provisions of Articles 3 and 27 of Title 25, C.R.S. or a sustained finding of immediate jeopardy at any time. Department records read the residence had chosen the consultant on 5/31/22 and the contract for the consultant was received on 6/1/22. Therefore, on the day of the completion of the complaint investigation, 2/14/23, the consultant was in the beginning of her eighth month as consultant for the residence. During the 2/14/23 revisit, the revisit established there was current deficient practice, despite having a consultant in place. Six deficiencies were cited, including Tags 540 and 1468 (Cross-reference Q540, Q1468). On 2/14/23 at approximately 3:29 p.m., the administrator designee stated she was aware of the requirements of the conditional license. On 2/14/22 at approximately 12:36 p.m., the consultant stated the following:In regards to Tag 540, the consultant stated that she had done several reviews of COVID and the COVID vaccination plan. The consultant stated that she was aware that EMResource had not been updated. In regards to Tag 1468, the consultant confirmed there were still medications that were not administered as required. However, she stated she was working with the residence to ensure medications were being audited and ordered every week to avoid medications being unavailable.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 26 current residents. This deficiency was cited previously during a state licensure survey 8/31/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. References and Residence Policya. The Ninth Amended State Public Health Order 20-20 (PHO) Requirements for Colorado Skilled Nursing Facilities, Assisted Living Residences, Intermediate Care Facilities and Group Homes for COVID-19 Prevention and Response, dated 10/11/22, required residences to:- Report to CDPHE information pertaining to their available resources to respond to the COVID-19 pandemic. The department will provide the reporting platforms and the form and format for submission of the required information. The residence must adhere to reporting requirements as specified in RCF Comprehensive Mitigation Guidance. b. The COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/7/23, required residences to: - Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month and period two, defined as days 15 to 31 of each month). 2. Record ReviewOn 2/13/23 at 9:57 a.m., a review of EMResource revealed that the residence's most current reporting occurred on 11/10/22, resulting in six missed periods during which the residence was required to report. EMResource read that there were still 30 residents, however, the day of the onsite survey the resident roster read there were only 26 current residents. 3. InterviewsOn 2/14/23 at approximately 12:36 p.m., the consultant stated that she had done several reviews of COVID and the COVID vaccination plan. The consultant stated that she was aware that EMResource had not been updated. On 2/14/23 at approximately 1:36 p.m., the resident services director stated that she did not know why the administrator had not updated EMResource since 11/10/22. The resident services director stated that she was aware of the requirement and thought that the administrator had updated EMResource.

Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of five sample residents (#2, #32, #38, #43) and two former residents (#18, #44). This deficiency was cited previously during a state licensure survey 8/31/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Medication Administration policy, dated February 2022, read in part: "The community (residence) is responsible for complying with practitioner orders, associated with the administration of medication or treatment."2. Resident #2 was admitted to the residence on 6/30/19 with diagnoses including Alzheimer's disease, major depressive disorder, and Parkinson's disease.a. OmeprazoleA written practitioner's order, dated 2/23/21, directed the residence to administer omeprazole 20 mg twice daily. However, the January 2023 medication administration record (MAR) read the medication was not administered in the morning on 1/14, 1/15, and 1/26 and in the evening on 1/1/23, for a total of four missed doses due to the medication being unavailable.b. LorazepamA written practitioner's order, dated 12/12/22, directed the residence to administer lorazepam 2 mg/mL oral concentrate 0.5 mg twice daily. However, the January 2023 MAR read the medication was not administered twice on 1/14 and in the evening on 1/31/23, for a total of three missed doses due to the medication being unavailable.c. QuetiapineA written practitioner's order, dated 2/23/21, directed the residence to administer quetiapine 100 mg twice daily. However, the January 2023 MAR read the residence did not administer the medication in the morning on 1/28 and 1/29 and in the evening on 1/28/23, for a total of three missed doses due to the medication being unavailable.d. DuloxetineA written practitioner's order, dated 4/19/22, directed the residence to administer duloxetine 40 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/7/23, for a total of one missed dose due to the medication being unavailable.e. TamsulosinA written practitioner's order, dated 2/23/21, directed the residence to administer tamsulosin 0.4 mg daily. However, the January 2023 MAR read the medication was not administered on 1/7/23, for a total of one missed dose due to the medication being unavailable. On 2/13/23 at 1:06 p.m., the legal representative for Resident #2 stated he was not aware of any medications being unavailable. 3. Resident #32 was admitted to the residence on 8/3/22. a. AmlodipineA written practitioner's order, dated 8/3/22, directed the residence to administer amlodipine 5 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/16, 1/18, and 1/19/23 for a total of three missed doses due to the medication being out of stock.b. RivastigmineA written practitioner's order, dated 8/3/22, directed the residence to administer a rivastigmine patch 4.6 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/3-1/6/23 for a total of four missed doses due to the medication being out of stock. 4. Resident #43 was admitted to the residence on 12/13/22.a. DivalproexA written practitioner's order, dated 11/22/22, directed the residence to administer divalproex 250 mg twice daily. However, the January 2023 MAR read the medication was not administered on 1/14/23 due to the medication being out of stock. b. HaloperidolA written practitioner's order, dated 11/22/22, directed the residence to administer haloperidol 5 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/17 and 1/18/23 for a total of two missed doses due to the medication being out of stock. On 2/14/23 at 8:59 a.m., the responsible party for Resident #43 stated he was not aware of medications being out of stock. 5. Former Resident #44 was admitted to the residence on 11/14/22. A written practitioner's order, dated 11/14/22, directed the residence to administer Xarelto 10 mg once daily. However, the November 2022 MAR read the medication was not administered on 11/27/22 for a total of one missed dose due to the medication being out of stock. On 2/13/23 at approximately 1:00 p.m., an anonymous staff member stated she remembered an issue with Former Resident #44's Xarelto, however, she could not recall what happened exactly. On 2/13/23 at 2:20 p.m., the responsible party for Former Resident #44 stated the resident's Xarelto went missing at the end of November and the resident missed at least one dose. 6. Resident #38 was admitted to the residence on 8/15/22. A written practitioner's order dated, 12/6/22, directed the residence to administer lidocaine cream 4% twice daily to the left side of his face. However, the January 2023 MAR read the medication was not administered in the evening on 1/4-1/6 and 1/10 and once in the morning on 1/10/23, for a total of five missed doses due to the medication being out of stock. On 2/13/23 at 12:47 p.m., the legal representative for Resident #38 stated she was not aware of the lidocaine ever being out of stock. 7. Former Resident #18 was admitted to the residence on 8/23/17, with diagnoses including Alzheimer's disease and major depressive disorder.a. Quetiapine 50 mgA written practitioner's order, dated 3/18/21, directed the residence to administer quetiapine 50 mg three times daily until discontinued on 9/2/22. A written practitioner's order dated 9/2/22, directed the residence to administer quetiapine 50 mg once at bedtime. However, quetiapine 50 mg was not administered on 9/2/22 in the evening, and was administered 9/2/22 in the morning instead, and was not administered 9/3-9/5/22, due to being inactive in the MAR, for a total of three missed doses. In addition, on 9/6 and 9/7/22, quetiapine 50 mg was administered in the afternoon instead of at bedtime as ordered. On 2/14/23 at 7:18 a.m., Staff #29 stated that former Staff #18 had messed up the charting and acknowledged that former Resident #18 was not given her quetiapine 50 mg at bedtime on 9/6/22 and instead was given it in the afternoon. Staff #29 stated that quetiapine was inactive in the MAR on 9/3-9/5/22, which was why it was not administered. On 2/14/23 at 1:33 p.m., the resident services director stated that medications that were inactive were not given at all. The resident services director acknowledged that former Resident #18's quetiapine 50 mg was not being administered as ordered and stated that as a result, evening doses were missed. b. Quetiapine 25 mgA written practitioner's order, dated 9/2/22, directed the residence to administer quetiapine 25 mg once every morning. A practitioner's order, dated 9/19/22, directed the residence to discontinue the current 25 mg once in the morning dose of quetiapine, and administer 25 mg three times daily. However, on 9/3/22 and 9/20/22, Quetiapine was not administered in the morning due to the medication being inactive in the MAR, for a total of two missed doses. On 2/14/23 at 7:18 a.m., Staff #29 stated that quetiapine was inactive on the MARs with the new orders and order changes, which was why it was marked as inactive. On 2/14/23 at 12:26 p.m., the consultant confirmed there were still medications that were not administered as required. However, she stated she was working with the residence to ensure medications were being audited and ordered every week to avoid medications being unavailable. On 2/14/23 at 1:30 p.m., the administrator designee stated she expected the residence to administer all prescribed doses of medication to residents as ordered. She stated that qualified administration persons reordered medications when they ran low. She added she was not aware that medication compliance was still an issue and was unsure why it had not been corrected. On 2/14/23 at approximately 1:33 p.m., the residence services director stated she was aware that some resident medications were out of stock.