PALISADES AT BROADMOOR PARK, THE

A complaint revisit was completed on 6/6/24 for all previous deficiencies cited on 8/23/22. Deficiencies were cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 11/15/23.

Based on observation, interview, and record review, the residence failed to ensure that each staff member received initial orientation prior to providing any care or services to a resident for three of three sample staff (#17-#19), affecting 46 current residents. This deficiency was cited previously during a state licensure survey on 8/3/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. ObservationsOn 6/5/24 and 6/6/24 from 2:00 to 4:30 p.m., Staff #1 and #3 were being trained by Staff #5. On 6/5/24 and 6/6/24 from 2:00 to 4:00 p.m. Staff #2 was observed providing care services to residents. 2. Record Review Review of the personnel files for Staff #1-#3 revealed they were hired as qualified medication administration persons (QMAPs) on 6/3/24, 5/7/24, and 5/30/24, respectively. Their files contained documentation they had completed an initial orientation; however, the initial orientation did not include training on house rules, practitioner assessments, where to locate advance directives, or hand hygiene. The June 2024 staff schedule read Staff #18 worked 6/1-6/6/24.3. InterviewOn 6/5/24 at 11:39 a.m., the administrator stated she was aware that all new employees were required to complete orientation prior to providing care to residents. However, she was unaware that the orientation did not meet all of the requirements per state regulations. The administrator acknowledged the residence had been cited for orientation during the last onsite visit because at the time, they used contract staff who had not completed orientation prior to working with residents.

Based on observation, interview and record review, the residence failed to ensure each staff member completed training relevant to their specific duties and responsibilities prior to working independently for one of three sample residents (#18), affecting all current residents. This deficiency was cited previously during a state licensure survey on 8/23/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. ObservationsOn 6/5/24 and 6/6/24 from 2:00 to 4:00 p.m., Staff #2 was observed providing care to residents. 2. Record Review Review of the personnel files for Staff #2 revealed they were hired as qualified medication administration persons (QMAPs) on 5/7/24. However, there was no evidence that the residence trained Staff #2 on the overview of state regulatory oversight applicable to the assisted living residence, person-centered care, the role of and communication with external service providers, recognizing behavioral expression and management techniques, as appropriate for the population being served, how to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, as appropriate for the population being served, training related to fall prevention and ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobility, how to safely provide lift assistance, accompaniment, and transport of residents, maintenance of a clean, safe and healthy environment including appropriate cleaning techniques, food safety, and understanding the staff or volunteer's role in end of life care including hospice and palliative care. The June 2024 staff schedule read Staff #2 worked 6/1-6/6/243. Interview On 6/5/24 at 11:39 p.m., the administrator stated she was aware that all new employees were required to complete training prior to providing care to residents. However, she was unaware that the training did not meet all of the requirements per state regulations. The administrator acknowledged the residence had been cited for training during the last onsite visit, because at the time, they used contract staff who had not completed training prior to working with residents. She stated had she been made aware that the residence's training did not meet state requirements, the residence would have fixed the issue.

Based on observation, 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 one of two sample residents who fell (#8). This deficiency was cited previously during a state licensure survey on 8/23/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #8 was admitted to the residence on 6/17/21 with a diagnosis of osteoporosis. The residence's most recent care plan, dated 5/9/24, read the resident was at risk for falling and required escorts to meals and activities, limited outdoor time to 10-15 increments due to poor safety awareness, and required no assistive devices. Resident #8 sustained a fall on 5/26 which resulted in a right lower arm abrasion. The resident sustained additional falls on 6/2, which resulted in a skin tear to the left elbow, and on 6/4/24, which resulted in bruising on the right hand. However, the residence failed to updated Resident #8's care plan to include individualized interventions after the falls with injury on 5/26, 6/2 and 6/4/24. Findings include:1. Residence PolicyThe residence's fall management policy dated 12/1/23, read in part: "All residents are evaluated for fall risk and their service plan (care plan) will be updated accordingly ... each resident's service plan and fall risk evaluation will be reviewed and updated whenever a resident has ... two or more falls within 30 days (or) a fall with injury requiring medical intervention/treatment."2. Resident #8 was admitted to the residence on 6/17/21 with a diagnosis of osteoporosis. The residence's most current care plan for Resident #8, dated 5/9/24, read Resident #8 was at risk for falling, required escorts to meals and activities, limited outdoor time to 10-15 increments due to poor safety awareness, had one on one supervision from 11:00 a.m. to 7:00 p.m., and had no assistive devices. However, the care plan was not updated to include individualized interventions necessary to address fall risk. A progress note dated 5/26/24, read in part, Resident #8 was found on the floor on the patio, and her right lower arm had an abrasion that was bleeding. Resident #9's external hospice provider was made aware of the fall. A progress note dated 6/2/24, read in part, Resident #8 had a fall in her room and sustained a skin tear to her left elbow. A progress note dated 6/4/24, read in part, Resident #8 had a fall and sustained a bruise to her right hand. The residence's assessment for Resident #8 dated 6/5/24 (the day of the onsite investigation) read Resident #8 required coordination with her external hospice provider due to falls. On 6/6/24 at 7:49 a.m., contrary to the care plan dated 5/9/24, a wheelchair was observed next to Resident #8's bed. There were also signs posted on the walls in Resident #8's room that read: "please call for staff assistance."3. InterviewsOn 6/5/24 at 8:24 a.m., the memory care director (MCD) stated Resident #8 had an external service provider supervise Resident #8 from 11:00 a.m. to 7:00 p.m. due to behaviors and falls that occurred during that time. The MCD stated Resident #8 required reminders to notify staff she required assistance prior to getting out of bed and reminders to wear shoes. On 6/6/24 at 7:41 a.m., Staff #4 stated she was unaware of any fall interventions that were in place for Resident #8. On 6/6/24 at 7:49 a.m., Resident #8 stated she had sustained a few falls recently due to her forgetting to use her call pendant to notify staff she required assistance, and losing her balance. Resident #8 stated she used her wheelchair when she felt weaker, to assist her when ambulating to the dining room. On 6/6/24 at 11:45 a.m., the administrator stated the MCD and nurse were responsible forupdating care plans for residents in the secure environment. The administrator further stated that she would expect the care plan to be updated after each fall with individualized fall interventions. The administrator further stated she was unsure why the deficiency had not been corrected and was working hard at updating care plans, and believed it may have been an oversight.

A licensure complaint, prompted by #CO34932 was completed on 2/8/24. No deficiencies were cited.