BONAVENTURE OF CASTLE ROCK

A revisit survey was completed on 3/26/24 for all previous deficiencies cited on 6/28/23. The facility is in compliance with all deficiencies that were cited.

A relicensure survey prompted by complaint #CO33956, was completed on 1/23/24. Deficiencies were cited.

12.2.2 Infection Control Officer (A) Applicability (1) The requirements of this part 12.2.2 shall apply to the following licensed facility types only, except where otherwise indicated: (a) Assisted Living Residences; (b) Nursing Care Facilities; and (c) Facilities for Persons with Intellectual and Developmental Disabilities, including both Group Homes and Intermediate Care Facilities for persons with intellectual and developmental disabilities. (B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following: (1) Completing an infection prevention and control training from a nationally recognized provider or the Department's training program within two (2) weeks of appointment/designation that meets the following requirements based on facility type; (6) Maintaining a facility respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard. Based on observation, interview and record review, the residence failed to develop and maintain a respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard affecting 36 current residents. (Cross-reference Q2320 )Findings include:1. Residence Policy and Referencesa. The residence's Respiratory Protection Program (RPP), dated 12/3/23, read in part: The assistant executive director (AED) was designated as the respirator program administrator and the backup person was the registered nurse (RN) manager. The AED and RN manager were expected to be knowledgeable about OSHA standards with regards to the respiratory protection program and the administrator responsible to ensure success of the program. The residence was required to conduct a hazard assessment for selecting appropriate respiratory protection, purchasing the equipment and developing and implementing policies and procedures. Supervisors were responsible for ensuring those employed were fit-tested; have their medical clearance, and training during work hours. Employees who entered an airborne infection isolation room or other areas occupied by residents suspected or confirmed with a disease requiring airborne precautions; performing, or present during routine resident care and support; staff cleaning or disinfecting an area occupied by a resident with suspected or confirmed illness. The following employees could be required to wear N95 respirators: Caregiver, qualified medication administration personnel (QMAP), AED, administrator, administrator living director (ALD). The RPP would ensure that the following records were maintained: Personnel medical records that stated if someone were cleared to wear a respirator to ensure all staff had received fit tests and had been trained initially. b. According to OSHA.gov: The employer is required to do have the following provisions in their policy:"To develop and implement a written respiratory protection program with required worksite-specific procedures and elements for required respirator use. The program must be administered by a suitably trained program administrator. In addition, certain program elements may be required for voluntary use to prevent potential hazards associated with the use of the respirator ...Training of employees in respiratory hazards to which they are potentially exposed to during routine and emergency situations. The employer shall designate a program administrator who is qualified by appropriate training ... provide training and medical evaluations at no cost to the employee ... The employer shall provide a medical evaluation to determine the employee's ability to use a respirator, before the employee is fit tested or required to use the respirator in the workplace. The employer may discontinue an employee's medical evaluations when the employee is no longer required to use arespirator." Retrieved from the U.S. Department of Labor website at https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134. (Occupational Safety and Health Administration Standards, 2019). 2. ObservationOn 1/23/24 at 7:16 a.m., Staff #4 was located in the residence's secure environment without any personal protective equipment (PPE). On 1/23/24 at 7:51 a.m., Staff #3 entered the residence's secure environment without any PPE on. On 1/23/24 at 7:57 a.m., Staff #1 entered the secure environment and prompted Staff #3 and #4 to don a mask. On 1/23/24 at 8:49 a.m., the assistant executive director and the assisted living administrator arrived in the residence's secure environment and directed Staff #1, #3 and #4 to don N-95 masks. On 1/23/24 during the twelve and a half hour onsite visit from 7:00 a.m. through 7:32 p.m., no staff, visitors or residents were observed in the assisted living portion of the residence wearing PPE. 3. InterviewsOn 1/23/24 at 7:16 a.m., Staff #4 stated she had been employed at the residence for three days. She stated she was told a resident had respiratory synclinal virus (RSV); however, she was unsure which resident. On 1/23/24 at 8:49 a.m., Staff #1 stated he had been employed at the residence for approximately four months. He stated he found out on 1/22/24 that the residence was experiencing an RSV outbreak. He stated he had not been fit tested since he was employed at the residence. On 1/23/24 at 8:49 a.m., the AED stated the RSV outbreak started at the residence the day prior to the onsite visit and investigation. On 1/23/24 at 8:52 a.m., Staff #3 stated he had been employed at the residence for approximately four months. He stated he had never been fit tested and was not aware the residence was in an RSV outbreak. On 1/23/24 at 3:44 p.m., the AED stated the registered nurse (RN) manager was responsible for overseeing the respiratory precaution program. On 1/23/24 at approximately 3:40 p.m., the RN manager stated she was the infection prevention person. She stated she was made aware of the first positive case of RSV on 1/12/24. She stated staff should wash their hands and wear a mask. She stated she had never worked in an assisted living residence before and was not aware of the requirements for a respiratory precaution program. On 1/23/24 at 6:13 p.m., the regional nurse consultant stated the RN manager was in charge of the respiratory precaution program along with the administrator and they should have had staff fit tested. On 1/23/24 at 6:44 p.m., the administrator stated the residence had gone through fit testing in November 2023; however, the administrator stated she could not say with confidence that newly hired employees had been fit tested. The administrator added the assistant executive director was in charge of fit testing.

Based on interview and record review the residence failed to ensure there was at least one staff member on-site at all times with current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization affecting 36 current residents. (Cross-reference S736)Findings include:1. Record ReviewOn 1/23/24 at 9:04 a.m., CPR certifications for all current staff were requested from the administrator. On 1/23/24 from 12:46 p.m. to 5:58 p.m., CPR certifications were provided by the administrator. The January 2024 staff schedule, time cards and CPR certifications revealed the second shift on 1/12, 1/13 and the second and third shift on 1/21/24 failed to have at least one staff member certified in CPR onsite at all times. A document provided by the administrator read 10 out of the 36 residents required CPR in case of an emergency. 2. InterviewOn 1/23/24 at 5:07 p.m., the administrator confirmed there were shifts in which there was no staff certified in CPR onsite and stated she was aware the residence was required to have one staff member certified onsite at all times.

Based on observation and interview the residence failed to ensure there was a list of all staff who had current certification in first aid and cardiopulmonary resuscitation (CPR) in a visible location and readily available at all times affecting 36 current residents. (Cross-reference S0734, S0738)Findings include:ObservationOn 1/23/24 at approximately 7:30 a.m., an environmental tour of the residence revealed no evidence of a list of CPR and first aid certified staff. Interview On 1/23/24 at 6:44 p.m., the administrator confirmed the residence did not have a list of current CPR and\ first aid certified staff readily available and up to date. She further stated she was not aware the residence was required to have one.

Based on interview and record review the residence failed to ensure there was one staff onsite at all times certified in first aid and obstructive airway affecting 36 current residents. (Cross-reference S0736, S0738)Findings include:The residence's resident agreement, dated 1/9/24, read in part: The residence had staff available to perform basic first aid. On 1/23/24 at 9:04 a.m., first aid certifications for all current staff were requested from the administrator. On 1/23/24 from 12:46 p.m. to 5:58 p.m., first aid certifications were provided by the administrator and revealed five staff (#11, #7, #1, #12, assistant executive director) at the residence were certified in first aid. The January 2024 staff schedule, time cards and CPR certifications revealed the second shift on 1/12, 1/13 and the second and third shift on 1/21/24 failed to have at least one staff member certified in first aid onsite at all times. On 1/23/24 at 6:44 p.m., the administrator confirmed there were shifts in which there was no first aid certified staff.

Based on observation, interview and record review, the residence failed to develop and implement a visitation policy which described any restriction or limitation necessary to ensure the health and safety of residents, staff and visitors, affecting 36 current residents. (Cross-reference S0814, S1596, S2320) Findings include:1. Record ReviewThe residence's visitation policy, dated 1/23/24, located in the resident agreement read in part: It's encouraged for residents to invite visitors and socialize in common areas. Visitors are requested to sign in and out to ensure the residence is aware of the people in and out at all times, especially in times of an emergency. However, the policy failed to include the following required elements:(B) Describe any restriction or limitation necessary to ensure the health and safety of residents, staff, or visitors and the reasons for such restriction or limitation;(C) Be available for inspection at the request of the Department;(D) Be provided to residents and/or family members upon request; and(E) Include the right of each resident of an assisted living residence to have at least one visitor of the resident's choosing during their stay at the residence, unless restrictions or limitations under federal law or regulation, other state statute, or state or local public health order apply. This visitation right shall be exercised in accordance with the following:(1) A visitor to provide a compassionate care visit to alleviate the resident's physical or mental distress.(2) For a resident with a disability:(a) A visitor or support person, designated by the resident, orally or in writing, to support the resident during the course of their residency. The support person may visit the resident and may exercise the resident's visitation rights even when the resident is incapacitated or otherwise unable to communicate.(b) When the resident has not otherwise designated a support person and the resident is incapacitated or otherwise unable to communicate their wishes, an individual may provide an advance medical directive designating the individual as the resident's support person or another term indicating that the individual is authorized to exercise visitation rights on behalf of the resident. 2. ObservationDuring the on-site visit from 7:00 a.m. to 7:32 p.m. visitors were observed entering the residence. 3. Interview On 1/23/24, the administrator stated she was unaware the residence's visitation policy was missing the required elements.

Based on observation, interview and record review the residence failed to develop and implement a visitation policy which described limitations on visitor rights, affecting 36 residents. (Cross-reference S0812)Findings include:1. Record ReviewThe residence's visitation policy, dated 1/23/24, located in the resident agreement read in part: It's encouraged for residents to invite visitors and socialize in common areas. Visitors are requested to sign in and out to ensure the residence is aware of the people in and out at all times, especially in times of an emergency. However, the policy was missing the following required elements: (F) The policies and procedures may impose limitations on visitation rights. During a period when the risk of transmission of a communicable disease is heightened, an assisted living residence may:(1) Require visitors to enter the residence through a single, designated entrance;(2) Deny entrance to a visitor who has known symptoms of the communicable disease;(3) Require visitors to use medical masks, face-coverings, or other personal protective equipment while on the assisted living residence premises or in specific areas of the residence;(4) Require visitors to sign a document acknowledging:(a) The risks of entering the residence while the risk of transmission of a communicable disease is heightened; and(b) That menacing and physical assaults on health-care workers and other employees of the residence will not be tolerated;(5) Require all visitors, before entering the residence, to be screened for symptoms of the communicable disease and deny entrance to any visitor who has symptoms of the communicable disease;(6) Require all visitors to the residence to be tested for the communicable disease and deny entry for those who have a positive test result; and(7) Restrict the movement of visitors within the residence, including restricting access to where immunocompromised or otherwise vulnerable populations are at greater risk of being harmed by a communicable disease.(8) If an assisted living residence requires that a visitor use a medical mask, face covering, or other personal protective equipment or to take a test for a communicable disease in order to visit a resident at the assisted living residence, nothing in these regulations:(a) Requires the residence allow a visitor to enter, if the required equipment or test is not available due to lack of supply;(b) Requires the residence to supply the required equipment or test to the visitor, or bear the cost of the equipment for the visitor; or(c) Precludes the health-care residence from supplying the required equipment or test to the visitor.(G) The policies and procedures may impose additional limitations for the visitors of a resident with a communicable disease who is isolated. In this case, the residence may impose additional restrictions including:(1) Limiting visitation to essential caregivers who are helping to provide care to the resident;(2) Limiting visitation to one caregiver at a time per resident with a communicable disease;(3) Scheduling visitors to allow for adequate time for screening, education, and training of visitors and to comply with any limits on the number of visitors permitted in the isolated area at the time; and(4) Prohibiting the presence of visitors during aerosol-generating procedures or during collection of respiratory specimens.(H) Any limitations imposed shall be consistent with applicable federal law and regulation and other state statute. 2. ObservationsDuring the on-site visit from 7:00 a.m. to 7:32 p.m. visitors were observed entering the residence visiting staff and residents. On 1/23/24 at approximately 10:15 a.m., a sign was posted at the residence main entrance that read the residence was currently experiencing an outbreak of respiratory syncytial virus. 3. InterviewOn 1/23/24, the administrator stated she was unaware the residence's visitation policy was missing the required elements.

Based on interview and record review the residence failed to develop and implement an involuntary discharge grievance policy affecting 36 current residents. Findings include:1. Residence PolicyThe residence's agreement dated, 1/22/24. read in part: A resident may be given a 30 day notice/request to move out by community management under the following circumstances:a. Resident's needs exceed the level of service the community provides. The community must have shown and documented their efforts to provide or arrange for the require services.b. Resident exhibits behavior or actions that repeatedly and substantially interfere with the rights or well being of other residents despite the prudent and reasonable interventions. c. Resident, due to sever cognitive decline, was not able to respond to verbal instructions, recognize danger, make basic care decisions, express need, or summon assistance. d. Resident has a medically complex, unstable or unpredictable condition for which services could have not been appropriately developed and implemented in the assisted living environment.e. Resident requires supervision or assistance on the dining room due to an ongoing medical condition, such as a swallowing disorder.f. Resident requires consistent two-person transfer assistance.g. Resident or resident's representative has defaulted in payment of monthly rent, care service fees and/or other monthly charges. The resident was subject to no less than a 14 day notice/request to move out by the community management under the following circumstances:a. Resident exhibits behavior that is an immediate danger to self or others, including without limitation, smoking inside the community. b. Resident has a sudden change of condition that requires medical care outside the community and reevaluation of the resident's needs determine that the resident needs exceeded the community's level of service.c. Community is unable to accomplish resident evacuation within the time frame required. d. Resident requires 24 hour, seven day per week nursing supervision. If the resident objects to the request for move-out:a. Resident would be given the opportunity to have an informal conference within ten days of receipt of notice to move out, except in the event of a 14 day move out notice in which case, the resident has five days within which to request an informal conference. b. If a resolution was reached at the informal conference, no formal hearing would be held, and if resolution was not reached, the resident may request a formal hearing. The residence offered resident opportunity to enter into an agreement to submit a dispute between them and medication or binding arbitration. That agreement, titled Dispute Resolution Agreement, was located in the resident agreement. The resident had up to 30 days to rescind, provided resident duly completed the notice of recession which was also attached. All written notices would be personally delivered or sent by an overnight courier to the residence addressed to the administrator. However, the policy failed to include the following required elements:(B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence.(C) The ability for the resident, or other person to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence.(D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows:(1) In writing, or(2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence.(a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness's name and contact information, and shall keep that information as part of the grievance documentation.(E) A requirement that no later than five business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows:(1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman.(2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate.(3) The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation."(F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S.(G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part.(H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending.(I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply:(1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board,(2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and(3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. 2. InterviewOn 1/23/24 at 6:44 p.m., the administrator stated she was not aware of the changes in the regulation and confirmed the policy was missing the required elements.

Based on interview and record review the residence failed to have a roster readily available affecting 36 current residents. Findings include:On 1/24/24 at 7:12 a.m., Staff #1 provided the resident roster with the resident names and room numbers; however, it failed to include a diagram showing the room locations and emergency contacts. On 1/24/24 at 9:18 a.m., the administrator provided another version of the resident roster; however, it failed to include a diagram showing the room locations and emergency contacts. On 1/24/24 at 6:44 p.m., the administrator stated that she did not have a diagram showing the room locations included with the resident roster.

Based on observation, interview and record review the residence failed to ensure either directly or indirectly through a resident agreement a physically safe environment and protective oversight affecting six current residents in the secure environment. Findings include:1. ReferencesThe residence's resident agreement, read in part: The residence made every effort to monitor and safeguard resident's health and wellbeing. 2. Protective OversightResident #5 was admitted to the residence on 5/23/23. During morning medication administration on 1/23/24 at 9:12 a.m., Staff #1 administered medications for Resident #6 which included liquid Morphine. The staff subsequently entered the resident's room and informed her he was going to administer her medications. Resident #6 was laying in bed with a pillow under part of her shoulder with her head leaning on the bed. Staff #1 then administered the liquid Morphine while the resident was laying down. Staff #6 before administering the remainder of the medication stated he needed to assist the resident into the seated position and altered the mechanical bed by approximately 60 degrees and administered the remainder of the medication which was crushed and placed in yogurt . Staff #1 subsequently stated the resident's mouth was dry and retrieved water with a sponge. The staff subsequently stated the resident was not able to drink water and stated he had to use a saturated sponge. On 1/23/24 at 6:44 p.m., the administrator confirmed it was not considered safe to administer medication while laying down. 3. Safe EnvironmentDuring an environmental tour on 1/23/24 at approximately 8:15 a.m., in the residence's secure environment the dining room floor was observed to be unsafe as follows:The area located in front of the secure environment kitchen by the dining room tables was raised and bubbling up causing the surface to be uneven. The floor when stepped on, had air pockets which released with each step and caused the floor to sink. This area was approximately 12 and a half feet by eight feet and was the path that lead to the residence's secure outdoor environment. On 1/23/24 at 8:15 a.m., Staff #1 stated he had been employed at the residence for four months and primarily worked in the secure environment. He stated the floor in the dining room had been that way since he started. Staff #1 further stated the floor was bad and was a safety hazard for the residents. On 1/23/24 at 6:44 p.m., the administrator confirmed the flooring in the secure dining room was bubbled and a safety hazard. She stated the floor had been that way since before she started in her position (June 2023). She stated she had been attempting to get the flooring replaced and stated it was scheduled to be completed within the next two weeks.

Based on observation, interview and record review, the residence failed to ensure the comprehensive assessment was updated with a resident experienced a change in condition affecting residents two of two sample residents in the secure environment (#1, #3). (Cross-reference Q1180). Findings include:1. Residence Policy and Referencea. Chapter VII regulations governing assisted living residences require 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; (C) Information regarding the resident ' s advance directives; (D) Communication ability and any specific needs to facilitate effective communication; (E) Current diagnoses and any known or anticipated need or impact related to the diagnoses; (F) Food and dining preferences, unique needs and restrictions; (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; (I) Routines and interests; (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; and (M) Personal background, including information regarding any other individuals who are supportive of the resident, cultural preferences, and spiritual needsb. According to RSV and ME, "Respiratory syncytial virus (RSV) is a common, contagious virus that usually causes mild symptoms. In older adults and adults with certain underlying conditions, RSV can cause severe infections".https://www.rsvandme.com/2. Resident #1 was admitted to the residence on 12/7/23 and readmitted to the residence on 1/5/2 with a diagnosis of a re-fractured left pubic bone. On 1/23/24 at approximately 9:00 a.m., Resident #1 was brought to the dining room by Staff #1. She was seated in her wheelchair coughing at the table. A preadmission assessment for Resident #1, dated 12/8/23, read in part: Resident #1 was unsteady, has fallen in the past 12 months and required a wheelchair. Progress notes revealed the resident experienced a change in condition from 12/11/23 to 1/23/24 as follows:On 12/11/23 at approximately 5:00 p.m., Resident #1 was found on the floor in her room. She was taken to the hospital and diagnosed with a broken hip due to a fall. On 1/5/24 at approximately 4:00 p.m., Resident #1 returned back to the residence from the hospital. Hospital discharge orders, dated 1/5/24, read the residence experienced a fall and re-fractured her hip. On 1/11/24 at approximately 1:30 p.m., Resident #1 was admitted to the hospital and was diagnosed with respiratory syncytial (RSV). On 1/15/24, Resident #1 was discharged from the hospital and returned to the residence. On 1/20/24, Resident #1 was sent to the hospital after another unwitnessed fall. She returned back to the residence that same day. The record for Resident #1 contained no evidence the residence completed a comprehensive assessment after the resident experience a change from baseline status, fractured her hip, was hospitalized for 12 days and was diagnosed with RSV.On 1/23/24 at approximately 3:22 p.m., the administrator stated that when Resident #1 returned back from the hospital on 1/5/24, her comprehensive assessment was not updated. She also confirmed that a change of condition is when a person returns from the hospital/rehabilitation. 3. Resident #3 was admitted to the residence on 8/21/23 with diagnoses of hypertension, dementia, atrial fibrillation, arthritis, cardiomyopathy and myocardial infarction. An assessment for Resident #3, dated 8/21/23, read in part, Resident #3 was unsteady, had fallen in the past 12 months with no pattern to his falls. Resident #3 used a wheelchair and a walker depending on his mood. Staff were to retrieve his walker, when he forgot. An incident report, dated 9/16/23, read in part, Resident #3 had an unwitnessed fall with injury. An updated assessment for Resident #3, dated 12/26/23, read in part: Resident ambulates with a four wheel walker, required reminders to use it, has an unsteady gait and has not fallen since 9/20/23. An incident report, dated 1/2/24, read in part, Resident #3 had an unwitnessed fall resulting in a black eye. The incident report further read contributing factors to the fall was the resident was unable to sleep at night. A practitioner's visit dated 1/3/24, read in part, Resident #3 had an unwitnessed fall resulting in a black eye. A third updated assessment dated, 1/4/24, read in part, Resident #3 used a cane and walked with a slow steady gait. It further read he had not had any falls in the past quarter. The assessment was not updated with circumstances of recent falls and any known approaches to prevent future falls and safety awarenessOn 1/23/24, Resident #3 was observed walking around the residence without a walker during the following times: 7:55 a.m., 8:10 a.m., approximately 8:20 a.m., 8:41 a.m. and approximately 9:15 a.m. At 6:44 p.m., the administrator confirmed an assessment should have been updated for Resident #3 after he had a change in condition. She stated at the beginning of January 2024 she was made aware residents in the secure environment had not had updated assessments. The administrator stated the former memory care coordinator failed to update assessments with changes in condition.

Based on observation, interview and record review the residence failed to develop and implement a fall management program affecting two of two sample residents in the secure environment with falls (#1, #3). (Cross-reference S1146) Findings include:1. Residence PolicyThe safe resident handling evaluating resident's fall potential, dated 10/11/23, read in part: That the residence wouls provide an initial and ongoing evaluations of each resident's needs as well as seek to minimize the risk of injury from falls while promoting resident independence and safety. The policy also read ongoing training was completed to help minimize the risk of falls and safety. The residence's fall management policy, dated 10/30/23, read in part: That ongoing effort was made to identify a resident's risk for falling through the service planning and resident assessment processes. In conjunction with these processes steps will be taken to identify potential interventions to help reduce a resident's risk of experiencing falls. 2. Resident #1 was admitted to the residence on 12/7/23 with diagnoses of Alzheimer's disease and anemia history of left pubis fracture. Resident #1 was re-admitted to the residence on 1/5/24 with a diagnosis of a second fracture. The record for Resident #1 revealed the resident experienced two falls in which there was no evidence of individualized approaches necessary to address falls risks as follows:The care plan for Resident #1, dated 12/8/23, read in part: that Resident #1 had multiple falls prior to admission and was at the residence for four days before the resident had a fall and was admitted to the hospital. The care plan read the resident sometimes ambulated with a four wheel walker and other times required a wheelchair for mobility. Staff were required to stand by the resident when ambulating and transferring. Resident required hands on assistance with toileting to ensure she did not fallA progress note, dated 12/11/23 at approximately 5:00 p.m., Resident #1 was found on the floor in her room. She was taken to the hospital and diagnosed with a broken hip due to a fall. A progress note, dated 1/5/24 at approximately 4:00 p.m., Resident #1 returned back to the residence from the hospital. Hospital discharge orders, dated 1/5/24, read the residence experienced a fall and re-fractured her hip. A progress note, dated 1/20/24, Resident #1 was sent to the hospital after another unwitnessed fall. She returned back to the residence that same day. Emergency department discharge orders, dated 1/20/24, read the resident was last seen at shift change the night before and at shift change this morning, she was found next to her bed laying face down. Resident #1 did not recall what happened; however, a complaint of right shoulder, right arm pain. The record for Resident #1 revealed no evidence that the care plan was updated after Resident #1 fell with injury on 12/11/23 and again on 1/20/24 with individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication. On 1/23/24 at approximately 7:30 a.m., Staff #4 stated Resident #1 had recently returned from the hospital and had a history of falls. She stated the residence had trained her on fall management; however, nothing specifically for Resident #1 other than to check on her often. On 1/23/24 at approximately 8:50 a.m., Staff #3 stated Resident #1 had a history of falls and the most recent fall was one week prior to the onsite visit. He stated he did routine checks on the resident to prevent falls. On 1/23/24 at 2:37 p.m., the administrator stated Resident #1 was admitted to the residence with a pelvic fracture and shortly after being admitted fell and refractured her pelvis. She confirmed the care plan should have been updated when she was readmitted to the residence on 1/5/24 and again after the fall on 1/20/24. 3. Resident #3 was admitted to the residence on 8/21/23 with diagnoses of hypertension, dementia,atrial fibrillation, arthritis, cardiomyopathy and myocardial infarction. An assessment for Resident #3, dated 8/21/23, read in part, Resident #3 was unsteady, had fallen in the past 12 months with no pattern to his falls. Resident #3 used a wheelchair and a walker depending on his mood. Staff were to retrieve his walker, when he forgot. An incident report, dated 9/16/23, read in part, Resident #3 had an unwitnessed fall with injury. A care plan for Resident #3, dated 9/17/23, read in part, the resident had an unwitnessed fall with injury in the common area. External hospice provided a wheelchair, staff were to encourage the resident when weak or experienced an unsteady gait to utilize it. Klonopin was discontinued and Seroquel was started. An updated assessment for Resident #3, dated 12/26/23, read in part, Resident ambulates with a four wheel walker, required reminders to use it, has an unsteady gait and has not fallen since 9/20/23. An incident report, dated 1/2/24, read in part, Resident #3 had an unwitnessed fall resulting in a black eye. The incident report further read contributing factors to the fall was the resident was unable to sleep at night. A practitioner's visit dated 1/3/24, read in part, Resident #3 had an unwitnessed fall resulting in a black eye. A third updated assessment dated, 1/4/24, read in part, Resident #3 used a cane and walked with a slow steady gait. It further read he had not had any falls in the past quarter. However, there was no evidence in the record for Resident #3 which read the care plan was updated after the fall with injury on 1/2/24 with individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication. On 1/23/24, Resident #3 was observed walking around the residence without a walker or wheelchair during the following times: 7:55 a.m., 8:10 a.m., approximately 8:20 a.m., 8:41 a.m. and approximately 9:15 a.m. On 1/23/24 at 6:08 p.m., the assisted living director stated care plans should have been updated when there was a change in condition such as a fall or hospitalization. She stated the care plans for Resident #1 and #3 were the responsibility of the former memory care director as she only updated care plans for assisted living residents. On 1/23/24 at 6:44 p.m., the administrator stated she had just become aware that care plans had not been updated for residents with falls. The administrator confirmed that Resident #1 and #3 should have had care plan updates to include individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication.

Based on observation, interview and record review the residence failed to comply with authorized practitioner's orders associated with medication administration affecting four of four sample residents (#1-#4). Findings include:1. Residence Policy and Referencea. The residence's Medication Systems policy, dated 10/11/23, read in part: Medications were required to have been administered according to practitioner's orders appropriate. b. According to Mayo Clinic, for patients taking the extended release tablet, if the tablet has a groove in it, you can break it into two pieces along the groove. Then swallow the pieces whole, do not crush or chew the medication. Guaifenesin (oral route) 2/1/2024. Retrieved from https://www.mayoclinic.org/drugs-supplements/guaifenesin-oral-route/proper-use/drg-20068720.2. Resident #3 was admitted to the residence on 8/21/23 with diagnoses of dementia and arthritis.a. SeroquelA written practitioner's order, dated 10/19/23, directed the residence to administer Seroquel 100 mg twice daily. However, the January 2024 medication administration record (MAR) read the medication was not administered from 1/1 evening dose through 1/3/23 evening dose as the medication was not in stock. Additionally, the MAR further read Seroquel 75 mg was administered twice daily instead of 100 mg twice daily from 1/11 evening dose through 1/23/24 morning for a total of 29 missed doses. b. AcetaminophenA written practitioner's order, dated 9/27/23, directed the residence to administer acetaminophen 1000 mg three times daily. However, the December 2023 MAR read the medication was not administered on 12/16/23 at 5:00 p.m., because the prior dose of the medication was administered late and there was not enough time in between doses to administer the medication. c. Morphine SulfateA written practitioner's order, dated 10/18/23, directed the residence to administer morphine sulfate 0.5 ml four times daily. However, the December 2023 MAR read the medication was not administered on 12/16/23 at 4:00 p.m., as the prior medication was administered late and there was not enough time in between doses to administer the medication. 2. Resident #1 was admitted to the residence on 12/7/23 with diagnoses of Alzheimer's disease.a. CefdinirA written practitioner's order, dated 1/17/24, directed the residence to administer cefdinir 300 mg twice daily for three days. However, the January 2024 MAR read the medication was not administered on 1/20/23 as the resident was out of the residence for a total of one missed dose. b. BisacodylA written practitioner's order, dated 1/20/24, directed the residence to administer bisacodyl 5 mg for an impacted stool once daily. However, the January 2024 MAR read the medication was not administered on 1/21 and 1/22/24 for a total of two missed doses. c. Guaifenesin A written practitioner's order, dated 1/17/24, directed the residence to administer guaifenesin 1200 mg extended release twice daily for seven days. During morning medication pass on 1/23/24 at approximately 9:00 a.m., Staff #1 crushed the medication and administered it to the resident in yogurt. He subsequently stated the medication was too large of a pill for the resident to swallow so he crushed it for her.. 3. Similar deficient practice was noted for Residents #2 and #4. On 1/23/24 at 6:08 p.m., the regional nurse consultant stated she was aware residents had been going without medications. The regional nurse consultant stated she had seen the missed medication reports and was following up with the residence daily regarding the problems. On 1/23/24 at 6:44 p.m., the administrator stated she was not aware of the non-compliance with medications for Residents #1 and #3. She stated she was made aware of the issue for Resident #2. The administrator stated that she should have been made aware of the non-compliance with medications. The administrator stated the registered nurse manager was supposed to have been checking all of the medications, orders and ensuring compliance with medications. The administrator further stated Staff #1 should have not crushed Resident #3's medication as the order did not direct the staff to crush.

Based on observation, interview and record review, the residence failed to ensure that qualified administration persons applied nationally recognized protocols for basic infection control prevention when preparing and administering medications affecting four of six residents in the secure environment (#1, #3, #6, #7). (Cross-reference Q2320). Findings include:1. Residence PolicyThe residence's medication administration policy, dated 10/11/23, read in part, the residence would establish and maintain a safe system for staff to administer medications. 2. ObservationsOn 1/23/24 from 8:14 a.m through 8:49 a.m., the following was observed during morning medication pass in the residence's secure environment: Staff #1, without washing or sanitizing his hands, donned gloves, touched the medication cart, the computer, his keys and touched the rim of the medication cup with his gloved hands. Staff #1 then prepared medications for Resident #3. He subsequently entered the room for the resident and touched Resident #3, guided him to his couch to sit and brought his walker to him. Staff #3 gave the resident his medicated water and then took the cup back to the medication cart and refilled the cup with water handing it to Resident #3. Staff #3 then took the medication cup and disposed of it in the trash. Without doffing his gloves or sanitizing Staff #1 then touched the computer, documented on the controlled substance log and took out another medication cup grasping by the rim, dispensed medications for Resident #6, he then touched the cart, closed the computer and adjusted his face mask, touched the dining room table, took out a glass of water and administered the medication to Resident #6. Resident #6 gave the staff the medication cup back and Staff #1 subsequently threw it away. Without doffing his gloves or sanitizing Staff #1 then touched the computer, mask, staff radio and grabbed the rim of the medication cup. The staff subsequently left the area to obtain a refrigerated medication. Upon arrival the staff brought hand sanitizer, doffed his gloves, and sanitized his hands. Staff #1, then with his bare hands used the medication cup from above, dispensed medication into the cup and used two fingers to grab the Flouragen capsule on two separate occasions, emptied the capsule into a bag. Then he retrieved a second capsule from the medication cup and poured it into the bag. Staff #1 subsequently poured the contents of the bag into a second medication cup. He then crushed the remainder of Resident #7's medications and combined all of the medications. He then sanitized his hands, threw away the other cup, touched his mask and poured yogurt into the medication cup, retrieved a cup of water and administered the medications. Staff #1 then switched his surgical mask to a N-95 mask and prepared medications for Resident #1. Staff #1 with his bare hands took out the guaifenesin and placed it in a plastic bag crushing the medication. Staff #1 subsequently administered the crushed medication in yogurt to the resident. 3. InterviewsOn 1/23/24 at 9:23 a.m., Staff #1 stated he was trained on proper medication administration and infection control techniques and further stated "We got trained to use gloves and to change gloves or sanitize hands in between each resident ... I know I didn't change my gloves in between each resident." On 1/23/24 at 6:13 p.m., the regional nurse consultant confirmed the medication pass was not sanitary and stated the staff member should have doffed his gloves and sanitized between residents. On 1/23/24 at 6:44 p.m., the administrator stated the staff member should have sanitized between residents and donned new gloves.

Based on interview and record review the residence failed to ensure the administrator and qualified medication administration supervisor audited the accuracy and completeness of the medication administration records affecting four of four sample residents (#1-#4). (Cross-reference Q1468). Findings include:The residence's Medications Systems policy, dated 10/11/23, read in part: Ongoing oversight of medication delivery would be provided through the residence's quality assurance section. The oversight consisted of routine medication administration record (MAR) audits and MAR to medication cart audits which focused on medication availability. On 1/23/24 quarterly medication audits were requested from the administrator and provided. However, the medication audits were not completed by the administrator and the qualified medication administration supervisor, they were completed by an external pharmacy. On 1/23/24 at 6:14 p.m., the regional nurse consultant stated she was aware of the regulation and agreed it needed to have been completed by the administrator and qualified medication administration supervisor. On 1/23/24 at 6:44 p.m., the administrator stated she was not aware of the regulation and therefore did not complete the audits.

Based on observation, interview, and record review, the residence failed to follow written procedures that addressed the transmission of communicable diseases affecting 36 current residents (Cross- reference S0001, S814, S1596). Findings include:1. Residence Policy and Referencesa. The residence's policy on infection control, dated 10/11/23, read in part: -Defined an outbreak as two or more persons present with the same group of symptoms in a time frame relatively the same for all. -If the residence suspects outbreak, staff must immediately after the outbreak is confirmed notify administrator, local health department(s), several others as well as inform the community visitors. -The residence was required to provide adequate notice at the main entrance and sustain notice until symptoms are resolved. -Instruct staff on universal precautions, maintain strict personal hygiene, use personal protective equipment, to deliver meals to those isolated due to symptoms during an outbreak and the initial delivery would be conducted by a staff member to the resident at their apartment door, staff to enter the apartment to deliver the meal, wear appropriate personal protective equipment (PPE), any carts used for delivery would be cleaned and disinfected before taking them back to the kitchen and the residence would record the ' outbreak ' on a reporting form. The residence's policy failed to identify all precautions when in an Respiratory Syncytial Virus (RSV) outbreak.b. According to the guidelines for prevention and control of RSV associated outbreaks in long-term care facilities 2023-2024 season from the Colorado Department of Public Health and Environment (CDPHE) required residences to:-Define suspected RSV outbreak as one resident with a positive test for RSV, among one or more other residents.-Defined a confirmed RSV outbreak as two or more positive cases.-Required the residence to complete an Outbreak Checklist. The checklist should have residents, staff, visitors, and surveillance requirements. -Symptomatic residents should be isolated to the affected unit for eight days after illness onset and 24 hours after they no longer have a fever or other symptoms (e.g., cough).-Do not wait for confirmation of illness to isolate, as ongoing transmission can occur during this time.-New admissions should be limited until the outbreak is over.-Cancel group activities until the outbreak is over (at least two incubation periods of 16 days). - Staff should be informed of RSV cases and implement infection control precautions.-Designate all staff to a certain unit/floor. Do not allow staff to work in both affected and unaffected units. Gowns and gloves should be changed between every resident treatment. -Staff should follow standard, contact, and droplet precautions for any resident with respiratory illness.-Encourage residents to wear a cloth face covering or facemask any time they leave their room or when staff enter their room to provide care.-Hospitalized residents with a history of confirmed or suspected RSV could be transferred back to the residence if acute symptoms were resolved or the accepting residence was able to maintain transmission-based precautions.- Ensure hand hygiene was performed in accordance with the centers of disease control recommendations and implement respiratory hygiene and cough etiquette strategies to reduce transmission of respiratory infections in the residence. - Encourage residents to limit visitors while they are infectious or symptomatic. -Alert visitors to the residence of the current outbreak, receive instruction about limiting touching surfaces and instructed to visit the resident room only to minimize time spent in other locations. -Conduct daily active surveillance for new illnesses among residents and staff until at least two incubation periods (16 days). -Monitor the progressions of the outbreak and report the outbreak to the local or state public health." -Report all suspected and confirmed RSV outbreaks to the local health. After comparing the residence policy on infection control to the CDPHE guidelines for prevention and control of RSV-associated outbreaks in long-term care facilities, the residence failed to have the following aspects in their policies for infection control:2. Failure to implement personal protective equipment (PPE), isolate and notify staff and visitors of an outbreak:On 1/23/24 at 7:00 a.m., upon entrance to the residence there were no signs posted regarding an outbreak. On 1/23/24 at 7:10 a.m., Staff #1 greeted the surveyors and stated the residence was experiencing an RSV outbreak. He further stated that staff in the secure environment were required to wear a mask as that was where the one resident (#8) resided that had tested positive. HeOn 1/23/24 at 7:16 a.m., Staff #4 stated she was told a resident had RSV; however, she was unsure which resident. On 1/23/24 at 8:49 a.m., the assistant executive director (AED) stated the RSV outbreak started at the residence the day prior to the onsite visit and investigation. On 1/23/24 at 8:52 a.m., Staff #3 stated he was not aware the residence was in an RSV outbreak. On 1/23/24 at approximately 3:40 p.m., the RN manager stated she was the infection prevention person. She stated she was made aware of the first positive case of RSV on 1/12/24 (11 days prior to the onsite visit). She stated staff should wash their hands and wear a mask during the outbreak. On 1/23/24 at 7:16 a.m., Staff #4 was located in the residence's secure environment without any personal protective equipment. On 1/23/24 at 7:46 a.m., Staff #4 was assisting residents (#3, #7) In the dining room, no one was wearing PPE. On 1/23/24 at 7:51 a.m., Staff #3 entered the residence's secure environment without donning any PPE. On 1/23/24 at 7:57 a.m., Staff #1 entered the secure environment and prompted Staff #3 and #4 to don a mask. On 1/23/24 at 08:08 a.m., three residents were left alone in the dining room (#3, #6, #7) none were encouraged to wear PPE.At 8:39 a.m., Staff #3 and #4 wheeled Resident #1 to the dining room and placed her at the dining room table. Resident #1 coughed at the dining room table several times throughout the duration of her meal residents (#3, #6, #7) were present and eating Resident #1 was seated adjacent to Resident #3. On 1/23/24 at 8:49 a.m., the assistant executive director and the assisted living administrator arrived in the residence's secure environment and directed Staff #1, #3 and #4 to don N-95 masks. On 1/23/24 at 10:15 a.m., there was a sign posted at the residence's entrance informing visitors the residence was experiencing an RSV outbreak. On 1/23/24 at 11:53 a.m., during lunch Staff #1 and Staff #3 were in the dining room and stated two residents (#6, #7) were suspected of having RSV and were awaiting test results. On 1/23/24 during the twelve and a half hour onsite visit from 7:00 a.m. through 7:32 p.m., no staff, visitors or residents were observed in the assisted living portion of the residence wearing PPE. 3. Failure to Report OutbreakEmail correspondence on 1/23/24 at 1:30 p.m. with the department's communicable disease branch read the department had no record of the residence reporting an outbreak of RSV.Email correspondence on 1/23/24 at 1:43 p.m. read local health was not notified of the RSV outbreak. 4. RSV Positive Residentsa. Resident #1The record for Resident #1 revealed the resident tested positive for RSV on 1/11/24 and again on 1/20/24 as follows:A written practitioner's order, dated 1/11/24, read the resident was diagnosed with RSV. A written practitioner's order, dated 1/17/24, read in part: Staff requested Resident #1 be seen for a respiratory infection. Staff reported the resident had gone to the emergency department and was prescribed medications; however, the notes for the visit had not been received and the resident had been prescribed medications. A written emergency department summary, dated 1/20/24, read the resident was diagnosed with RSV.b. Resident #8On 1/23/24 at 7:23 a.m., Staff #1 stated Resident #8 had been sent to the emergency department one night prior and tested positive for RSV.A document of requested items read Resident #8's positive RSV test results were requested, the residence requested documentation from the family member; however, the residence had not received the documentation. On 1/23/24, at 2:37 p.m., the administrator stated she was aware Resident #1 had gone to the emergency department on 1/11/24. She stated she was not sure if she had been made aware of the positive RSV result, she was aware the resident had a cough. The administrator stated the regional nurse (RN) manager reviewed all incoming documentation and should have notified her that Resident #1 was positive for RSV on 1/11/24. The administrator stated she was not aware Resident #1 was positive for a second time on 1/20/24. The administrator further stated she became aware of Resident #8's positive test result on 1/22/24 and notified the regional nurse consultant. The administrator stated she was sent the RSV policy by the regional nurse consultant and told all staff to wear masks. On 1/23/24 at 3:44 p.m., the RN manager stated she became aware of Resident #1's positive RSV test result on 1/12/24. She stated that she hoped staff were sanitizing their hands and had worn masks; however, gave no such direction. The RN manager confirmed she was the infection control person for the residence; however, she stated she was not clear on her role as this was the first time she had worked in an assisted living residence. She said she was not sure if any other residents had been tested, and was not clear if residents should have been isolated. The RN manager added she thought a text had been sent out to staff on 1/22/24 regarding the latest positive result. The RN manager stated she had not put up any signage for the outbreak and stated she did not think it was necessary for the assisted living staff or visitors to wear masks as they did not go into the secure environment. However, the RN manager confirmed Staff #1 had been passing medications and working in both the assisted living and secure environment portions of the residence. On 1/23/24 at 6:13 p.m., the regional nurse consultant stated the RN manager was responsible for implementing the infection control program and the administrator was responsible for ensuring it had been implemented. The regional nurse consultant stated the RN manager should have notified local health of the outbreak and should have taken precautions. The regional nurse consultant stated she was aware there was not positing and when she arrived at the residence posted the outbreak sign on the entrance. She confirmed that the whole residence should have taken more precautions.

Based on observation and interview, the residence failed to ensure grounds were maintained to protect residents from hazards affecting six current residents in the secure environment. Findings include:According to weather underground that last measurable precipitation that occurred at the residence's location was on 1/15/24 (seven days prior to the onsite visit). Retrieved from https://www.wunderground.com/history/daily/us/co/denver/KDEN/date/2024-1-15 During an environmental tour on 1/23/24 at approximately 8:15 a.m., the secure outdoor courtyard contained the following hazard: The sidewalk leading to the sitting area was covered with ice and snow and was slick to walk on. On 1/23/24 at 11:51 p.m., Resident #9 was observed attempting to walk through the secure outdoor courtyard. On 1/23/24 at 6:44 p.m., the administrator stated all pathways in the secure outdoor courtyard should have been cleared. She stated it was her and the maintenance director's responsibility to ensure pathways were clear and safe.

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 7.6.5 Effective January 1, 2019, an administrator training program shall meet all of the following requirements: (A) The program or program components are conducted by an accredited college, university, or vocational school; or an organization, association, corporation, group or agency with specific expertise in the provision of residential care and services, and (B) The curriculum includes at least 40 actual hours, 20 of which shall focus on applicable state regulations. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner.(A) The medication administration record shall reflect the name, strength, dosage and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration and the signature or initial of the person administering the medication.(B) As part of the medication administration record, the assisted living residence shall maintain 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.(C) Each qualified medication administration person, nurse or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.(D) Each qualified medication administration person, nurse or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals and resident reported responses to medications. 18.8 Resident records shall contain, but not be limited to, the following items:(A) Face Sheet, (B) Practitioner order, (C) Individualized resident care plan, (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition along with the action taken by staff to address that resident ' s changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. (E) Medication Administration Record, (F) Documentation of on-going services provided by external service providers including, but not limited to, family members, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants and caregivers; (G) Advance directives, if applicable, with extra copies; and (H) Final disposition of resident including, if applicable, date, time and circumstances of a resident ' s death along with the name of the person to whom the body is released.

A licensure complaint, prompted by #CO30369 and #CO30556, was completed on 6/28/23. Deficiencies were cited.

Based on record review and interview, the residence failed to notify the department of a change in administrator, at least 30 calendar days in advance, affecting 39 current residents. (Cross-reference Q0540) Findings include: On 6/28/23, the department's database read the administrator of record was the current administrator of the residence. The residence's staff roster read the acting administrator was the administrator of the residence. On 6/28/23 at 7:50 a.m., Staff #4 stated the administrator of record was the residence's interim administrator. He added the acting administrator was the residence's administrator. On 6/28/23 at approximately 8:00 a.m., the regional nurse stated the resident's administrator was the acting administrator. She added she was unsure when the administrator of record had resigned from the residence, but stated the acting administrator had been at the residence since May 2023. On 6/28/23 at 8:12 a.m., Staff #2 stated the administrator of record was only a temporary administrator. She added the acting administrator was the administrator of the residence. On 6/28/23 at 8:53 a.m., a department representative confirmed the residence had not submitted notification for a change in administrator at the residence. On 6/28/23 at 9:34 a.m., the acting administrator stated she began at the residence in May 2023. On 6/28/23 at 2:25 p.m., the acting administrator stated her first official day as the administrator of the residence was 4/26/23. She added she was aware she was not in the department's system as the administrator of the residence. Further, she stated when she began working at the residence at the end of April 2023, corporate stated they would submit the name change to the department, but stated they never changed it.

Based on observation, record review and interview, the residence failed to ensure the administrator was responsible for the residence's day-to-day operations, affecting 39 current residents. (Cross-reference B0260) Findings include: Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management and maintenance of the assisted living residence. The term "administrator" is synonymous with "operator" as that term is used in Title 25, Article 27, Part 1. On 6/28/23 at approximately 7:30 a.m., upon entrance to the residence, Staff #4 was asked to notify the administrator of record the surveyor had arrived. Staff #4 notified the acting administrator. The residence's staff roster read the acting administrator was the administrator of the residence. The residence's resident council meeting minutes, dated 5/2/23, read the acting administrator's role was "to satisfy the current residents ... hiring for many positions, beginning to build her team, and to share her vision for this place with them." On 6/28/23 at 7:50 a.m., Staff #4 stated the acting administrator was responsible for the day-to-day operations at the residence. On 6/28/23 at 2:25 p.m., the acting administrator stated her first official day as the administrator of the residence was 4/26/23. She added, she was responsible for the day-to-day operations at the residence. The acting administrator stated the administrator of record was never the administrator at the residence, and stated she had only been an interim administrator. Further, the acting administrator stated when the administrator of record was the interim, she (the acting administrator) was responsible for the day-to-day operations at the residence.

Based on record review and interview, the residence failed to ensure records of former residents were complete and maintained for three years, affecting three of three former residents (#4-#6). Findings include:1. Reference Chapter VII regulations governing assisted living residences, part 18.8, requires resident records shall contain, but not be limited to, the following items: (A) Face Sheet; (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. 2. Record Review On 6/28/23 at 9:47 a.m., the record for Former Residents #4-#6 were requested. On 6/28/23 at approximately 11:00 a.m., the residence's records for Former Resident #4-#6 were provided. The residence's records were missing the following items: Former Resident #4's file did not contain a face sheet. Former Resident #5's file did not contain a care plan. Former Resident #6's file did not contain progress notes. 3. Interviews On 6/28/23 at 1:43 p.m., the acting administrator stated when she began employment at the residence, they had been disposing of resident records, although she advised them not to. She added because of the disposal, she could not find the progress notes for Resident #6. The acting administrator stated the residence did not have a care plan for Resident #5. On 6/28/23 at 2:38 p.m., the acting administrator stated she was aware the residence was required to maintain complete resident records for three years after the resident was no longer in the residence. She added as of the day of the onsite visit (6/28/23), she was aware of the missing records for Resident #4-#6.

A licensure revisit was completed on 6/28/23 for the previous deficiency cited on 3/28/22. The residence is in compliance with all regulations surveyed.

A revisit survey was completed on 4/25/23 for all previous deficiencies cited on 6/16/22. 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

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