CAPPELLA OF GRAND JUNCTION

A relicensure survey with complaint #CO39826, #CO40493, and #CO40926 was completed on 5/6/26. No deficiencies were cited.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised to review and maintain the following processes in accordance with the existing program regulations at 6 CCR 1011-1, Chapter 7.(U1568) 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.(U1600) 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner.(D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.(U2706) 22.32 The assisted living residence shall ensure that oxygen tanks are secured upright at all times in a manner that prevents tanks from falling over, being dropped, or striking each other.

A licensure complaint, prompted by #CO38832, was completed on 2/19/25. No deficiencies were cited.

A licensure complaint revisit was completed on 1/18/24 for the previous deficiency cited on 1/5/23. The residence is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO34556 and #CO34061, was completed on 1/18/24. No deficiencies were cited.

A revisit survey was completed on 6/2/23 for all previous deficiencies cited on 12/14/22. No deficiencies were cited.

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

A licensure complaint, prompted by #CO30510, was completed on 1/5/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated when the resident's condition changed from baseline status, affecting two of three sample residents (#1, #3). (Cross-reference Q1180)Findings include: 1. Residence Policy The residence's Change of Condition policy, dated November 2021, read in part: "Documentation in the medical record will include notifications, new interventions and provided support, assessment findings, resident's response to changes and residents/families communication." 2. Resident #1 was admitted to the residence on 12/12/19 with a diagnosis of Alzheimer's disease. Residence incident reports read Resident #1 had falls on 11/11, 12/6, 12/13/22, and 1/1/23. Additionally, the reports read Resident #1 was hospitalized on 12/22/22. Residence progress notes for Resident #1 read as follows: 11/9/22: Resident #1 showed confusion on where he was and staff offered to show resident where his room was 11/11/22: Resident #1 was found laying on floor of bedroom after sliding from bed 11/21/22: Resident #1 asked why he was by the dining room as the resident was unsure why he was there. Staff returned Resident #1 to his apartment. Later that day, the resident had trouble walking down to breakfast. 12/1/22: The resident's foot hurt and swollen. 12/6/22: Resident #1 slammed the bedroom door and informed staff he did not know where he was or what he was doing. 12/7/22: Resident #1 got off of the bed using his walker, tripped and ended up on the floor. 12/13/22: Resident #1 was found laying on the floor. 12/16/22: Resident #1 was slowing down with his walking and needing the walker for longer distances. 12/22/22: Resident #1 was hospitalized. 1/1/23: Resident #1 had fall and was hospitalized. Blister on inner left leg. The residence completed level of care evaluations on 10/20/22 and 12/27/22. The 10/20/22 and 12/27/22 assessments read Resident #1 was at a for falls, used a walker, and had weakness in his legs which could result in using a wheelchair for longer distances. However, the resident experienced changes from baseline between these dates and no assessment was completed. On 1/5/23 at 1:20 p.m., the resident care coordinator (RCC) stated Resident #1 six months prior to the onsite had experienced a change from baseline status. The RCC stated she believed the resident needed a higher level of care and stated he had not been wanting to eat or move around and had been having increased difficulty with ambulation. On 1/5/23 at approximately 2:45 p.m., the administrator stated Resident #1 had a level of care evaluation done in late December 2022 due to the wound that had shown up on the resident. Further, she added Resident #1 had some mobility decline and stated he had not been the same emotionally for approximately one month. 3. Resident #3 was admitted to the residence on 9/21/22. On 1/5/23 at 9:10 a.m., Staff #1, Staff #2, and a third staff member were observed providing assistance to Resident #3. All three staff members had to assist in transferring Resident #3 from the toilet to her wheelchair. Residence incident reports read Resident #3 had falls on 10/1/22, 11/25/22, and 12/17/22. Residence progress notes for Resident #3 read as follows:11/10/22: Resident #3 refused to get out of bed and could not walk, hold up her head or body due to being too weak. 11/16/22: Resident #3 had a hard time getting up from the toilet and transferring from the recliner to the wheelchair. 11/24/22: Resident #3 tired and could not walk, hold herself up or dress or undress herself. 11/28/22: Resident #3 was unable to help with transfers and was not able to stand with the bar in the bathroom. 12/11/22: Resident #3 was not able to participate in transfers. The resident needed two staff to assist with a transfer. 12/17/22: Resident #3 was unable to bend her knee due to pain when transferring, which caused the resident to slip out of staff's hands. Resident #3 subsequently resident was placed on the floor. 12/18/22: Resident #3's right knee and lower leg were larger than the left knee 12/19/22: Resident #3 complainant her knee hurt after the fall, swelling was observed but no other injuries were noted. The residence had completed a level of care assessment on Resident #3 however; no assessment had been completed since although the resident had experienced changes in her baseline. The care assessment, dated 11/16/22, read Resident #3 required one staff member for assitance with transferring and did not require an assistive device to transfer to the bed, chair, or toilet. On 1/5/23 at 8:11 a.m., Staff #1 stated Resident #3 had become more than a two person transfer approximately one week prior to the onsite visit. On 1/5/23 at 8:11 a.m., Staff #2 stated Resident #3 had been having a change in condition that started a few days prior to the onsite visit. On 1/5/23 at 8:22 a.m., Resident #3 stated she had been having more pain in her leg. She stated due to the pain, it was more comfortable for her to stay in bed. On 1/5/23 at 12:08 p.m., Resident #3's family member stated Resident #3 had been having new knee pain for approximately three weeks at the time of the onsite visit. He stated approximately two weeks prior to the onsite visit, he was at the residence and Resident #3 was able to stand and get into her wheelchair but stated she no longer could stand up. On 1/5/23 at approximately 2:45 p.m., the administrator stated Resident #3 needed a higher level of care. She stated on 1/4/23 she had received a report from Resident #3's external service provider which read Resident #3 was a maximum assistance with transfers. The administrator added she had been informed the resident required three staff members for transfer on 1/5/23. She stated prior to 1/5/23, Resident #3 was a one to two person transfer depending on the staff member. On 1/5/23 at approximately 2:45 p.m., the administrator stated a change of condition would be anything outside of the residents baseline, such as a new diagnosis, a change in activities of daily living, hospitalizations, and falls if they are recurring. She stated Resident #1 was a resident with recurring falls. The administrator added within 72 hours of a resident having a fall, she would prefer an assessment was completed. Further, she stated Resident #1 should have had assessments completed for his fall. The administrator confirmed she had only completed one change in baseline assessment since she took over the task on 12/30/22.

Based on record review and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting two of three sample residents (#1, #3). (Cross-Reference Q1146)Specifically, Resident #1 had falls on 11/11, 12/6, and 12/13/22. The 12/13/22 fall resulted in pain and bruising over the left side of the resident's body. The residence failed to update the care plan for Resident #1 for the falls on 11/11, 12/6, and 12/13/22 detailing the individualized approach necessary to address fall risks. On 12/27/22 the residence updated the care plan for Resident #1; however, it was not updated after the resident sustained another fall on 1/1/23. Findings include: 1. Residence Policy The residence's fall management policy, dated December 2021, read in part: "The health and wellness director/assisted living director or designee will investigate the fall with the intention of preventing further falls for the person who fell and for other people who may be in a similar situation. Changes to service plans will be made, as needed." 2. Resident #1 was admitted to the residence on 12/12/19 with a diagnosis of Alzheimer's disease. Residence incident reports read Resident #1 had falls on 11/11, 12/6, 12/13/22, and 1/1/23. Additionally, the reports read Resident #1 had a hospitalization on 12/22/22. Residence progress notes for Resident #1 read as follows: 11/11/22: Resident #1 was found laying on floor between his bed and dresser, the resident stated he slid out of bed 12/7/22: Resident #1 was found sitting on floor in the bathroom doorway. The resident stated he was getting off of his bed, using his walker and tripped. 12/13/22: Resident #1 was observed lying on the floor between the dinner table and the wall. 12/14/22: Resident #1 stated his left shoulder was sore all over and his elbow was tender. The resident's left hip had scrapes and small skin tear with large area of discolored skin. 12/17/22: A family member notified the residence that left side of Resident #1's the body was discolored. 12/18/22: Resident #1 had dark discoloration on the left side of his body as well as discoloration on right side of the his body by the waist 1/1/23: Resident #1 was on the floor laying between the bed and bathroom door with mattress pulled halfway off of the bed, his wheelchair was by the foot of the bed. The resident stated he was in pain and did not know how he got there. The residence's care plan for Resident #1 read a revision was completed on 12/27/22. The revision read for fall interventions, staff were to ensure Resident #1 had appropriate footwear on and that he was fully awake before attempting to stand and walk. Prior to the 12/27/22 revision, no additional fall interventions by staff had been added to the care plan since 1/14/21, although Resident #3 had falls on 11/11/22, 12/6/22, and 12/13/22. Additionally, the care plan read on 12/27/22 a revision was made to include the resident chose to sleep with his legs off the bed and laid sideways however; it did not read what staff were to do about his sleeping position. Residence fall assessments for Resident #1, dated 10/20/22 and 12/27/22 read Resident #3 was a high fall risk. On 1/5/23 at approximately 7:50 a.m., Staff #1 stated Resident #1 had a fall she was aware of however; she stated she was not at the residence when it occurred. Staff #1 stated she observed bruising on Resident #1's left side of his body. On 1/5/23 at 8:11 a.m., Staff #2 stated she had not seen Resident #1's fall but stated a few days after the fall, Resident #1 had complained of pain. On 1/5/23 at 10:58 a.m., Resident #1's practitioner stated she had seen Resident #1 on 12/19/22 and had noticed bruising throughout the left side of his body as well as small healing abrasions. On 1/5/23 at 12:31 p.m., the residence's former resident care coordinator stated she had responded to Resident #1's fall on 12/13/22. She stated the resident did not report pain at the time and did not appear to have inquiries. However, she added a few days following the fall, she noticed what appeared to be a large bruise on Resident #1. On 1/5/23 at 1:20 p.m., the resident care coordinator (RCC) stated Resident #1 had falls due to how he shuffled his feet when he walked. She stated he did not pick up his feet correctly when he walked. The RCC added Resident #1 did not walk close enough to this walker and stated he slept halfway off of his bed. Further, she stated she was aware Resident #1 had multiple falls. On 1/5/23 at approximately 2:45 p.m., the administrator stated the infection presenting as a blister on Resident #1's leg was more than likely what had contributed to the falls. She stated Resident#1 had fallen in the past. The administrator added the interventions the residence had in place to prevent Resident #1's falls were ensuring he knew how to use his call button, more frequent checks, and taking to him about movements and how he can move with his walker. Further, she stated Resident #1 had a tendency to get ahead of himself due to his mind telling him he could move faster than his body could. On 1/5/23 at 3:17 p.m., the family member for Resident #1 stated she saw Resident #1 on 12/14/22 and he stated his arm hurt but she did not look to see if he was injured. The family member stated on 12/15/22, she saw the bruises on Resident #1. The family member added Resident #1 did not lay correctly on his bed and that the practitioner at the emergency room informed her the falls could be related to Resident #1's infection on his leg. 3. Resident #3 was admitted to the residence on 9/21/22. Residence incident reports read Resident #3 had falls on 10/1/22, 11/25/22, and 12/17/22. Residence progress notes for Resident #3 read as follows: 10/1/22: Resident #3 slipped to the floor with staff member as the resident had difficulty when walking. 12/17/22: Resident #3 was unable to bend her knee due to pain when transferring, which caused resident to slip out of staff's hands. Subsequently Resident #3 was placed on the floor. 12/19/22: Resident #3 complained that her knee hurt after the fall. Swelling was observed and no other injuries were noted. The care plan for Resident #3, last updated on 9/29/22, read the resident needed reminders to call for assistance and that staff were to do stand by for transfers. The care plan did not read individualized approaches by staff to help prevent falls for Resident #3. The care plan had not been updated following the falls on 10/1, 11/25 and 12/17/22. The residence's fall risk assessment, dated 11/16/22, for Resident #3 read she was a high fall risk. On 1/5/23 at 12:08 p.m., the family member for Resident #3 stated he was aware of Resident #3's falls. On 1/5/23 at approximately 2:45 p.m., the administrator stated prior to being admitted to the residence, Resident #3 had mobility issues from a fall. She added, due to Resident #3's knee giving out during care, she had a fall. On 1/5/23 at approximately 2:45 p.m., the administrator stated if a resident had three falls within a 90 day period, they were considered a frequent faller by the residence. She stated the expectation would be for interventions to be in care plans for residents who had fallen, especially if they were rated a high fall risk on the assessment. The administrator confirmed she was not aware the care plans for Resident #1 and Resident #3 had not been updated after each of their falls.