GARDENS ON QUAIL

A licensure complaint, prompted by ##CO39060, was completed on 7/1/25. No deficiencies were cited.

A revisit survey was completed on 2/3/25 for all previous deficiencies cited on 10/1/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO37570, was completed on 10/1/24. Deficiencies were cited.

Based on interview and record review, the residence failed to investigate an allegation of abuse in accordance with the residence's written policy, affecting one sample resident (#2). The residence's abuse and neglect policy, dated 7/1/24, read that the residence completed the following steps when investigating an allegation of physical abuse: the residence described the investigative steps taken and attempted to have a conversation with the residents involved and made notes of the conversation. The residence included in the notes the residents' reactions and responses to the incident. The residence assessed the residents for injuries. The residence documented the conclusion of the investigation. The residence documented how the residence kept the residents safe while the investigation was conducted. The residence documented the actions the residence took with the alleged assailant. Documented interventions that were put in place to ensure there was not a repeated incident. Documentation of an investigation of physical abuse, dated 7/24/24, read in part: "(Resident #3) was agitated and began stating that she owned the building and began trying to force other residents out of their rooms. (Resident #3) would hit (caregiver) and QMAP [qualified medication administration person] when trying to redirect the resident away. The resident then entered the room of (Resident #2) and tried forcing (Resident #2) out of the room. (Resident #2) refused to leave and then was struck by (Resident #3). (Resident #2) was struck on the side of the head. No injuries were shown, and residents were separated. (Resident #3) pushed (Resident #2) back into her room, (Resident #3) then used her right hand to punch the left side of (Resident #2) twice." However, the investigation did not contain the following: How the residence kept the residents safe while the residence conducted the investigation. A description of the investigative steps taken. The residence's documentation of conversations with the residents, residents' reactions, and responses to the incident. A documented assessment of the residents for injuries. Documentation of the conclusion of the investigation. Documentation of the actions that the residence took with the alleged assailant. Documentation of the interventions that were put in place to ensure there was not a repeated incident. On 10/1/24 at 7:53 a.m., Staff #1 stated that Resident #3 had a history of becoming physically aggressive with others, and there was one instance where she struck a staff member and broke a lamp. On 10/1/24 at 2:10 p.m., Staff #3 and #4 affirmed that Resident #3 struck Resident #2 on one occasion; however, they were unaware of the outcome of the incident as Resident #3 had a one-on-one caregiver for supervision at that point in time and they were unsure of other measures taken to address the incident. On 10/1/24 at approximately 2:30 p.m., the administrator stated that since Resident #2 was not assessed by the nurse or interviewed, the residence did not conduct a thorough investigation of the abuse allegation.

Based on observation, record review and interviews the residence failed to ensure resident care plans include how residents will have continuous independent access to their room, along with the residence plan to protect residents from unwanted visitation by other residents, affecting five sample residents (#1-#5) who resided in a secure environment (SE). (Cross-reference S1410). Findings include:1. Residence PolicyThe residence's Enhanced Resident Care Plan policy, dated 1/1/24, read in part, each resident of the secure environment will have an enhanced resident care plan. The enhanced care plan for each resident in a secure environment shall include a description of how the resident will have continuous independent access to his or her individual room and include the plan to protect the resident from unwanted visitation by other residents. 2. Resident #1 was admitted to the residence on 5/30/24 with a diagnosis including dementia. On 10/1/24 at 2:00 p.m., Resident #7 opened the door to another resident's room, looked inside, closed the door, and opened and closed the door again and walked away. An incident report, dated 6/4/24, read in part, Resident #1 stated she was hit by another resident. Resident #1 stated another resident was lying in her bed and she was hit by the other resident when she attempted to get the resident out of her bed. The care plan, dated 7/11/24, failed to include how the residence was ensuring residents had continuous independent access to their individual room and a plan to protect the residents from unwanted visitation by other residents. 3. Resident #3 was admitted to the residence on 6/7/24 with a diagnosis including dementia. An incident report, dated 7/24/24, read in part, Resident #3 forced other residents out of their rooms. Resident #3 entered room #126 and tried forcing that resident out of their room. The care plan, with an activation date of 6/24/24, failed to include how the residence was ensuring residents had continuous independent access to their individual room and a plan to protect the residents from unwanted visitation by other residents. Additionally, a similar deficiency was found for residents #2, #4, and #5.4. InterviewsOn 10/1/24 at 2:00 p.m., Staff #3 stated there were two residents who consistently went into rooms not belonging to them and Resident #7 was one of the two. Staff #3 stated that staff were responsible for monitoring residents and using redirection when residents in the SE attempted entering rooms not belonging to them. Staff #3 stated resident rooms on the SE remained unlocked at all times and none of the residents had been provided personal keys to lock their rooms. On 10/1/24 at approximately 2:30 p.m., the administrator stated she was not aware of the requirement to include how the residence ensured residents had continuous independent access to their individual rooms and a plan to protect the residents from unwanted visitation by other residents in the enhanced care plan. She added that it made sense as some residents as some residents wandered and entered residents' rooms which led to negative interactions between residents. On 10/1/24 at 2:59 p.m., the regional memory care director (RMCD) stated she was assisting in developing the enhanced resident care plans. The RMCD stated residents who were identified for extensive wandering were checked on by staff every 30 minutes to determine location. The RMCD stated visual deterrents such as stop signs in resident doorways or black tape on the floor had been discussed with various families who ultimately declined. The RMCD stated the families declining of visual deterrents was not documented. The RMCD stated none of the residents residing in the SE were provided the opportunity for locking the doors to their personal rooms.

A revisit survey was completed on 9/13/24 for all previous deficiencies cited on 6/12/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint prompted by #CO36049 and #CO36112 was completed on 6/12/24. Deficiences were cited.

Based on observation, record review, and interview, the residence failed to ensure the resident agreement did not relieve the residence of compliance with any requirement under state regulation, affecting 26 residents that resided in the secure environment (SE). Findings include:1. Reference and Residence Policya. The residence's undated resident agreement read in part, "The resident is responsible for any personal hygiene products and any paper goods ..."However, the resident agreement was written to relieve the residence from compliance with Chapter VII regulation, part 22.23.b. Chapter VII regulations governing assisted living residences, part 22.23, requires that each assisted living residence shall provide toilet paper in each resident bathroom, except where a resident has a specific preference and agrees to supply it. 2. ObservationsPhoto evidence revealed Resident #1's toilet paper roll was empty on the following dates:12/23/23 and 1/9, 1/22, 1/27, 2/9, 2/19, 3/7, 3/15, 4/2, 4/12, 4/27, 5/31 and 6/7/24. 3. InterviewOn 6/12/24 at 3:03 p.m., the administrator stated according to the resident agreement, the residents were responsible for providing their own toilet paper. However, she stated when the resident resided in the SE, it was the family member's responsibility to provide the resident with toilet paper. The administrator stated she was unaware of the state regulation that required the residence to provide toilet paper in each resident bathroom; therefore, she was also unaware that the resident agreement contradicted the state regulation.

Based on observation, record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting 26 current residents that resided in the secure environment. Findings include:1. Residence PolicyThe residence's Unanticipated Illness and Serious Injury policy, dated September 2019, read in part: "In the event that an individual resident experiences an unanticipated illness or injury, emergency care will be provided ... the community notifies a resident's emergency contact person, the primary care provider, and the appropriate case managers when an unanticipated illness (or) serious injury ... occurs." However, the policy failed to include how the residence would identify, investigate and document injuries of unknown origin. 2. Resident #1 was admitted to the residence on 10/21/22 with diagnoses including dementia. A photograph, dated 10/25/23, revealed bruising between the ring and pinky finger on the top of Resident #1's hand. A progress note, dated 10/25/23 at 2:20 p.m., read Staff #4 noticed a bruise on Resident #1's left hand when helping her shower. The progress note further read Staff #4 notified the health and wellness director (HWD). There was no documentation that an investigation was completed for the injury of unknown origin. 3. InterviewsOn 6/11/24 at 11:49 a.m., the legal representative for Resident #1 stated that in October 2023, Resident #1 was found to have a bruise on her hand; however, due to Resident #1's dementia, she was unable to recall what had happened. The legal representative further stated that once Staff #4 made the HWD aware of the bruise, both Staff #4 and the caregiver that came in during the evening shift reported to the legal representative that no one (not even the HWD) investigated the injury. On 6/12/24 at 2:15 p.m., the HWD stated because Resident #1 was ambulatory in her room she could bruise easily. The HWD acknowledged she was unsure how Resident #1 sustained the bruise, and thought she only needed to investigate severe injuries of unknown origin and not bruises or skin tears. On 6/12/24 at 3:03 p.m., the administrator stated she and the HWD were responsible for investigating injuries of unknown origin. She stated a small bruise on an ambulatory resident in the secure environment (SE) did not warrant an investigation for the injury of unknown origin, so they did not complete an investigation. The administrator stated residents in the SE frequently sustained bruises and minor injuries, but she nor the HWD investigated how these injuries occurred. The administrator acknowledged this applied to residents who were incapable of remembering what occurred.

Based on observation, interview, and record review, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting three of five residents (#1-#3). Findings include: 1. Residence Policy The residence's undated Medication Administration policy read in part, "Prescription and non-prescription medications must be administered by a qualified medication administration person (QMAP) only upon written order of an authorized practitioner." 2. Resident #2 was admitted to the residence on 3/10/23 with diagnoses including eye disease (dry eye) and insomnia.a. LatanoprostA written practitioner's order, dated 3/27/24, directed the residence to administer latanoprost 0.005% eye drops one drop in each eye at bedtime. However, the March through May 2024 medication administration records (MARs) read the residence failed to administer the medication because it was unavailable on the following dates: 3/1-3/2/243/5-3/6/243/8/244/14/244/24/245/7/245/13/24The residence failed to administer a total of nine doses. b. Acetaminophen Written practitioner's orders, dated 1/26/24, 3/27/24, and 5/23/24, directed the residence to administer acetaminophen 325 mg two tablets three times daily. However, the February through June 2024 MARs read the residence administered two tablets pro re nata (PRN) every six hours. The residence failed to administer a total of 151 doses. On 6/12/24 at 2:30 p.m., the health and wellness director (HWD) stated Resident #2 was currently admitted to and external hospice provider (EHP) and complied with their written orders, not the primary practitioner's orders. She stated the EHP discontinued the scheduled acetaminophen order and changed it to PRN and had not communicated that with the resident's primary practitioner. The HWD stated she was unable to provide the EHP's written orders. c. Phosphatidylcholine A written practitioner's order, dated 4/15/24, directed the residence to administer Phosphatidylcholine 40% one capsule daily. However, the May 2024 MAR read on 5/14/24 and 5/22/24, the residence failed to administer the medication because it was unavailable, for a total of two doses.d. ColaceA written practitioner's order, dated 4/15/24, directed the residence to administer Colace 100 mg two capsules daily. However, the April 2024 through June 2024 MARs directed the residence to administer three capsules daily. On 6/12/14 at 2:30 p.m., the HWD stated she was unaware that the resident's practitioner provided a written order directing the residence to administer Colace 100 mg two tablets (instead of three) on 4/15/24. She stated that she and three other resident coordinators were responsible for transcribing the orders to the MARs but was unsure who had received the written order. The HWD stated she expected the residence to transcribe written practitioner orders onto the MAR accurately in order to ensure compliance. e. Senna A written practitioner's order, dated 3/27/24, directed the residence to administer Senna 8.6-50 mg two tablets daily, However, the April 2024 through June 2024 MARs read the residence failed to administer the medication because it was unavailable on 4/1/24, 4/2/24, 5/29/25, and 6/8/24.3. InterviewOn 6/12/24 at 3:00 p.m., the administrator stated a majority of the medications were refilled by the pharmacy automatically, but the QMAPs were responsible for ordering medications when they were low in number. She stated some families ordered medications from outside pharmacies and brought the medications to the residence. The administrator stated she expected staff to administer medications as ordered. The investigation revealed evidence that the residence failed to comply with practitioner's orders for Residents #1 and #3.

Based on interview and record review, the residence failed to ensure the electronic medication administration records (eMARs) contained accurate information, affecting two of four sample residents whose medications were reviewed (#1 and #2). Findings include:1. Residence PolicyThe residence's undated Medication Administration policy read in part: "each qualified medication administration person (QMAP), nurse or practitioner must accurately document each medication administration or monitoring event at the time the event is completed for each resident."2. Resident #1 was admitted to the residence on 10/21/22 with a diagnosis of dementia.a. EscitalopramA written practitioner's order, dated 8/17/23, directed the residence to administer escitalopram 10 mg twice daily. However, the August through December 2023 eMARs directed the residence to administer escitalopram 10 mg two tablets twice daily or use two 5 mg tablets to equal 10 mg on 8/17 for the evening dose and on 12/18/23 for the morning dose. Additionally, the eMAR contained blank spaces for the evening doses on 10/15 and 12/3/23, for a total of two inaccurately documented doses. b. Artificial tearsA written practitioner's order, dated 8/31/23, directed the residence to administer artificial tears 0.2-1% one drop in each eye twice daily. However, the December 2023 eMAR contained blank spaces on 12/3/23 in the evening and 12/21/23 in the morning, for a total of two inaccurately documented doses. c. BuspironeA written practitioner's order, dated 10/12/23, directed the residence to administer buspirone 5 mg twice daily. However, the December 2023 eMAR contained a blank space on 12/3/23 in the evening, for a total of one inaccurately documented dose. d. NystatinA written practitioner's order, dated 11/28/23, directed the residence to administer nystatin 10000 units/gram twice daily. However, the December 2023 eMAR contained a blank space on 12/3/23 in the evening, for a total of one inaccurately documented dose. e. OlanzapineA written practitioner's order, dated 7/15/23, directed the residence to administer olanzapine 5 mg at bedtime. However, the October 2023 eMAR contained a blank space on 10/15/23, for a total of one inaccurately documented dose. f. AtorvastatinA written practitioner's order, dated 7/15/23, directed the residence to administer atorvastatin 40 mg daily. However, the October 2023 eMAR contained a blank space on 10/15/23, for a total of one inaccurately documented dose. 3. InterviewsOn 6/11/23 at 1:25 p.m., the health and wellness director (HWD) stated she realized the way she transcribed the escitalopram in the system read in a "confusing way;" however, she stated staff had been administering the medication as ordered with either two 5 mg tablets once in the morning and once in the evening, or one 10 mg tablet once in the morning and once in the evening. The HWD acknowledged she changed the directions for escitalopram on the eMAR to read as ordered on 12/18/23. On 6/12/24 at 2:15 p.m., the HWD stated that QMAPs should have placed their initials in the blank spaces on Resident #1's eMAR. She added that the residence had provided staff training on accurate documentation previously so she expected accurate documentation. On 6/12/24 at 3:03 p.m., the administrator stated she expected staff to provide accurate documentation on eMARs in accordance with practitioner orders, and she expected staff to document whether a medication was administered, refused or otherwise, instead of leaving blank spaces on the eMAR. 3. There was similar deficient practice for Resident #2.

A licensure complaint, prompted by #CO34930 and #CO35276, was completed on 5/9/24. No deficiencies were cited.

A complaint revisit was completed on 5/8/24 for all previous deficiencies cited on 3/27/23. The residence is in compliance with all regulations surveyed.

A revisit survey was completed on 3/27/23 for all previous deficiences cited on 9/20/22. The residence is in compliance with all regulations surveyed.

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

A licensure complaint prompted by #CO30634 and #CO31397, was completed on 3/27/23. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to ensure a comprehensive assessment was updated for residents whenever residents' conditions changed from baseline status, affecting one of five sample residents (#3). (Cross-reference Q1180). Findings include:1. Reference a. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items: (J) History and circumstances of recent falls and any known approaches to prevent future falls. 2. Resident #3 was admitted to the residence on 3/25/22, with diagnoses including dementia and arthritis. Resident #3 was admitted to external hospice on 3/9/23. On 3/27/23 at 9:37 a.m., a sign located on the door for Resident #3's read independent. On 3/27/23 between approximately 9:30 a.m. and 3:00 p.m., Resident #3 was observed laying in her bed. The residence's assessment for Resident #3, dated 10/28/22, read in part: "Resident is independent and does not require assistance with escorting with or without an assistive device ... and hospice not needed."However, the residence's care plan for Resident #3, dated 3/27/23 (the day of the onsite visit), read the resident had last been assessed on 10/28/22. The care plan conflicted with the 10/28/22 assessment as follows: Resident #3 required one hour checks by staff, had a high potential for falls, required two person transfer assistance, required full staff assistance for escorts and required a private caregiver between 4:00 and 10:00 p.m., Resident #3 required a tilted wheelchair. Progress notes revealed the following:On 3/4/23 Resident #3's private caregiver told the qualified medication administration person (QMAP), that Resident #3 required two person assistance with transfers. On 3/9/23 Resident #3 admitted to external hospice. On 3/13/23 Resident #3 was not able to bear weight and was crying when staff were trying to help her transfer and stand up. On 3/15/23 Resident #3's daughter requested foot pedals for her wheelchair. On 3/19/23 Resident #3 was having trouble walking; however, the resident continued to try and walk without assistance. On 3/20/23 Resident #3 attempted to rise from her wheelchair, and was pushing and pulling it to prevent staff from wheeling her around. On 3/22/23 two staff transferred Resident #3 into her wheelchair and wheeled and transferred her to the bedroom recliner. On 3/23/23 Resident #3 remained in bed and did not attempt to get up, however, the resident would lift her head and put it back down. On 3/24/23 Resident #3 wheeled around the residence in her tilted wheelchair. On 3/26/23 Resident #3 had slept in her tilted wheelchair all night. Implementation reports for Resident #3 read that Resident #3 had a private caregiver implemented from 2/23/23 to 3/4/23, and implemented for a second time from 3/24/23 to the day of the onsite visit. The private caregiver worked with the resident from 4:00 p.m.-10:00 p.m. daily. The report also read that Resident #3's wheelchair was approved to be delivered on 3/17/23. Residence incident reports for Resident #3 read she had six unwitnessed falls in one month in which no assessment was completed as follows: 2/21, 3/4, 3/15, 3/20, 3/21, and 3/22/23. 3. InterviewsOn 3/27/23 at 7:39 a.m., Staff #4 stated that Resident #3 had been in bed all shift and had not been walking around anymore. Staff #4 stated that external hospice provided services to Resident #3 daily, and staff conducted hourly safety checks. On 3/27/23 at 10:05 a.m., in a second interview Staff #4 stated that the last two shifts she had worked, Resident #3 had been in her bed or in her tilted wheelchair. However, Staff #4 stated that Resident #3 would try and put one foot out of her titled wheelchair and did not have the strength to stand up. On 3/27/23 at 12:51 p.m., an external hospice representative stated that Resident #3 was admitted to external hospice on 3/9/23, due to increased decline with agitation and exit seeking. The external hospice representative stated that the day of the onsite investigation, Resident #3's medications were discontinued since she was unable to take them and she stopped eating and drinking. The external hospice representative stated that Resident #3 had experienced multiple falls in March of 2023 and even had a tilted wheelchair that was delivered on 3/21/23. The external hospice stated Resident #3 had declined to where she was no longer able to safely ambulate independently without the use of a wheelchair. On 3/27/23 at 1:54 p.m., Resident #3's family member stated that Resident #3 had only had a wheelchair for three weeks prior to the onsite investigation, and before that was able to ambulate independently. Resident #3's family member stated that in the past three weeks, Resident #3 had experienced multiple falls due to her falling out of her wheelchair. On 3/27/23 at 2:32 p.m., the health and wellness director (HWD) stated that Resident #3 had been in bed since 3/24/23. The HWD stated that she and care coordinators at the residence conducted resident assessments; however, the HWD stated she had not completed a comprehensive assessment for Resident #3. She stated the resident had recent care changes and the residence was working with practitioners and external hospice for her care needs. On 3/27/23 at 3:18 p.m., the administrator stated that Resident #3 was actively passing on external hospice, which the administrator stated that Resident #3 would quickly change from being in the bed for extended periods of time to trying to get out of the bed. The administrator stated that she did not know why Resident #3 was not reassessed by the residence after her falls and her use of the wheelchair and admission to external hospice in March of 2023. The administrator stated there was a care conference for Resident #3 on 3/23/23, and acknowledged that Resident #3 should have had a comprehensive reassessment updated.

Based on observation, record review and interviews, the residence failed to implement a fall management program, affecting two of two sample residents (#3, #8). (Cross-reference Q1146 and 1428). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.9, defines a "care plan" as a written description in lay terminology of the functional capabilities of an individual, the individual's need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual's needs. In order to deliver person-centered care, the care plan shall take into account the resident's preferences and desired outcomes. b. The residences' undated Fall Management Program policy, read in part: the residence shall "detail in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance and eyesight, or effects of medication as identified during the comprehensive resident assessment ... (and) provide staff training related to fall prevention as specified in Section 7.9(h) of Chapter 7."2. Resident #3 was admitted to the residence on 3/25/22, with diagnoses including dementia, arthritis, pain and anxiety. On 3/27/23 at 9:37 a.m., Resident #3 was located in her room on a scoop mattress. There was a tilted wheelchair was across the room in the bathroom. Fall mats were on both sides of Resident #3's bed, which was lowered to the floor. On 3/27/23 at approximately 4:08 p.m., Resident #3 slid out of her tilted chair while Staff #2 was present. Staff #2 was unable to catch her and Resident #3 landed on her buttocks and stated ow. Staff #2 placed a green foam noodle under Resident #3's buttocks, Staff #2 subsequently stated: "she had a fall, and she went down slowly but I could not stop it." Staff #8 went over and assisted with Staff #2 to lift Resident #3 off the floor. However, both staff were unable to list Resident #3. The resident started to moan as Staff #2 and Staff #8 tried to pull her up by her arms. Staff #1 arrived next and Staff #8 placed a gait belt around Resident #3. Staff #8 held the gait belt, while Staff #1 and #2 attempted to transfer Resident #3 into the wheelchair without success and verbalized "she is dead weight, we need lift assist." Staff #1 then asked the surveyor to help and hold the tilted chair still. Staff #1, #2 and #8 then transferred Resident #3 into a living room chair as Resident #3 moaned throughout the transfer. The residence's care plan for Resident #3, dated 3/27/23 (the day of the onsite investigation), read the resident required one hour checks by staff, had a high potential for falls, required two person assistance with transfers, had a private caregiver from 4:00 to 10:00 p.m. and used a tilted wheelchair. Although the care plan had been updated following the date of the onsite investigation, the care plan had not been updated following the 2/22, 3/4, 3/15, 3/20 or 3/21 and 3/22/23 falls. The care plan also did not include the individualized approach necessary to address fall risk related to deficits in strength, balance and eyesight, or effects of medication as identified during the comprehensive resident assessment from 10/28/22 to 3/27/23. Residence progress notes and incident reports for Resident #3 read she had six unwitnessed falls within a month as follows: A progress note for Resident #3, dated 2/22/23, read that Resident #3 was found on the floor next to her bathroom. No injuries were present. A progress note for Resident #3, dated 3/4/23, read that Resident #3 was scheduled with a personal caregiver from 4:00 p.m. to 11:00 p.m., contrary to what interviews revealed. During the shift the personal caregiver told residence staff that the resident required two person assistance with transfers and refused finish her shift. The personal caregiver left between 7:30 and 7:45 p.m.. At 8:19 p.m. Staff went to check on Resident #3 and saw her on the floor in front of her chair. A progress note for Resident #3, dated 3/15/23, read Resident #3 fell backwards in the living room and staff assisted the resident to the floor. A progress note for Resident #3, dated 3/17/23, read that external hospice was notified by the residence and requested floor mats and a tilted wheelchair due to her high fall risk. An incident report for Resident #3, dated 3/20/23, read that Resident #3 was found on the floor in the dining room, and was assisted back into her wheelchair. An incident report for Resident #3, dated 3/21/23, read that Resident #3 had an unwitnessed fall and was found in the common area on the foot of her wheelchair. No visible injuries. Ativan administered. A progress note for Resident #3, dated 3/22/23, read that Resident #3 had a fall and was able to get back into her chair with two-person transfer assistance. On 3/27/23 at approximately 10:40 a.m., Staff #7 stated that she had not received fall management training from the residence and was not aware what fall interventions Resident #3 had other than a fall mat. On 3/27/23 at 12:51 p.m., an external hospice representative for Resident #3 stated that Resident #3 had the tilted wheelchair, and fall mat put in place due to her falls throughout February and March 2023. On 3/27/23 at 3:18 p.m., the administrator confirmed Resident #6 had not sustained any injuries from her falls and stated the residence held a care conference on 3/23/23. She stated the wheelchair, scooped mattress, fall mats, and close medication management with Resident #3's practitioner were fall interventions. On 3/27/23 at 4:08 p.m., Staff #1 stated that she was unsure what Resident #3's fall interventions were and stated that the residence did not provide her with fall management training. On 3/27/23 at 5:25 p.m., Staff #2 stated that Resident #3 was resistant to transfers which was why it took three staff to transfer her into a chair when she fell on the day of the onsite survey. 3. Resident #5 was admitted to the residence on 1/3/22 with diagnoses including dementia and cerebrovascular accident. The residence's care plan for Resident #5, dated 3/27/23, read the resident required hands on assistance with transfer or changes in position. Further, it read Resident #5 required two hour checks by staff members to ensure his safety due to him being a high fall risk. The care plan had been updated following the 2/7/23 fall however; it had not been updated after the fall on 2/19/23. The residence's assessment for Resident #5, dated 3/22/23, read the resident required extensive, hands on assistance and had an assistive device for mobility and ambulation. Residence incident reports for Resident #5 read he had unwitnessed falls on 2/7/23, 2/19/23, and 3/27/23. The residence's 2/7/23 incident report for Resident #5 read he had an unwitnessed fall. The report read the care plan had been updated. The residence's 2/19/23 incident report for Resident #5 read he had an unwitnessed fall. The report read there was no need for the care plan to be updated following the fall. A residence progress note for Resident #5 read "Staff entered residents room for safety checks, when staff entered residents room, resident was on the floor on his back next to his bed. No c/o (complaint) of pain, no apparent injuries." On 3/27/23 at 11:32 a.m., the administrator sent an email which read, the residence had updated Resident #5's care plan following his fall on 2/7/23 and the care plan had not been updated following the fall on 2/19/23 (sic). On 3/27/23 at 2:04 p.m., Resident #6 stated Resident #5 fell quickly due to weakness in his legs and stated they had moved into the residence due to Resident #5's falls. On 3/27/23 at 2:41 p.m., the HWD stated the 3/27/23 fall was the first fall Resident #5 had while she was working at the residence. However, she stated she was aware Resident #5 was on two hour safety checks for falls. On 3/27/23 at approximately 3:50 p.m., theadministrator stated Resident #5's practitioner was working on what could be done to prevent falls. She stated she was not aware Resident #5's care plan had not been updated after his fall on 2/19/23 and stated at the time it was not updated, an interim nurse was responsible for updating resident care plans. On 3/27/23 at 3:50 p.m., the administrator stated the expectation was for resident care plans to be updated after a resident had a fall to reflection interventions to prevent future falls.

Based on observation, interview and record review, the residence failed to ensure the residents had the right to be free from restraint affecting one current resident (#3). (Cross-reference Q1180, Q1146, Q1428 and Q2960)Specifically, on 3/19/23, Resident #3 was found by her hospice nurse in the dining room of the secured environment in distress attempting to get out of her wheelchair. However, Resident #3 was unable to get out of her wheelchair as staff buckled the resident in the chair with a seatbelt. External hospice informed staff that they were restraining the resident and directed them to unbuckle the seatbelt. Resident #3 once the restraint was released became relieved and stood up. However, after the incident on 3/19/23 was investigated, and Staff #1-#6 who were the staff on the day of the incident were retrained on restraints, Resident #3 was observed being verbally and physically restrained the day of the onsite survey on 3/27/23. Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.42, defines restraint as any method or device used to involuntarily limit freedom of movement including, but not limited to, bodily physical force, mechanical devices, chemicals, or confinement.b. Chapter VII regulations governing assisted living residences, requires in part 12.9, that the comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status.c. The residence's undated Resident Rights Policy, read in part: "(residents have) the right to live free from ...restraint and involuntary confinement, except as allowed by the secure environment requirements."2. Resident #3 was admitted to the residence on 3/25/22, with diagnoses including dementia, arthritis, pain and anxiety. On 3/24/23 Resident #3 was agitated and was trying to climb out of bed. On 3/25/23 Resident #3 kept trying to climb out of bed and was unable to be calmed easily. On 3/27/23 at 9:37 a.m., Resident #3 was located in her room on a scoop mattress and a tilted wheelchair was across the room in the bathroom. Resident #3 was unable to respond to the surveyor. On 3/27/23 at approximately 4:15 p.m., Resident #3 attempted to stand up out of a green chair in the living room, and Staff #1 told Resident #3 to "sit back down." Resident #3 then sat back down as directed. The residence's assessment for Resident #3, dated 10/28/22, read that Resident #3 was frequently disoriented and exhibited wandering behaviors that could require verbal prompts and redirection. An external hospice note, dated 3/18/23, read the residence "requested a tilted wheelchair so they could lean the patient back so she can not get out of her chair. (The external hospice nurse wrote) this would be considered a restraint." An external hospice note, dated 3/19/23, read that Resident #3 was "found in distress sitting with a female caregiver attempting to get out but cannot because (the residence) was buckled in. (The external hospice nurse informed) the caregiver they cannot buckle her in (her wheelchair) because it is a restraint. The residence caregiver immediately unbuckled the resident and she got out of the wheelchair. (The resident) was immediately relieved and began to wander when released. The Health and Wellness Director (HWD) was notified and said that the resident should receive another way to treat her anxiety and agitation going forward. The HWD came to the conclusion in coordination with external hospice, that PRN (as needed) Zyprexa would work best. The hospice nurse administered a PRN Zyprexa and staff were provided education on how to take care of dementia (residents)."A progress note, dated 3/25/23, read that "evening shift attempted to put (Resident #3) in bed, but she kept trying to climb out. They put her back in her tilted wheelchair. (Resident #3) at this time is very agitated, trying to climb out. (Staff are) unable to calm her down. PRN Ativan 0.5 mg given."An occurrence, dated 3/19/23 contained six statements that, read that Staff #2 and Staff #5 put Resident #3 in her recliner after she kept trying to get out of her bed and Resident #3 expressed notable agitation. Staff #2 and Staff #5 then placed Resident #3 in her wheelchair. The wheelchair had a seatbelt on it and Staff #2 placed the seatbelt on Resident #3 because she thought it was there to prevent Resident #3's falls and was not aware it was a restraint. Upon shift change Staff #4 and #5 were sitting with Resident #3. Another investigation note revealed that Staff #1 had informed Staff #3 to replace Resident #3's seatbelt due to her agitation around 3:30 p.m. so Staff #3 had fastened the seat belt. Staff #6 also stated she was not aware that Resident #3 could not have a seatbelt on her. An investigation note from 3/19/23 read that at 3:34 p.m., an external hospice provider said they did not provide wheelchairs with seat belts and it must have been a wheelchair from another resident and was accidentally pulled for delivery because they never ordered (Resident #3) a wheelchair with a seatbelt. 3. InterviewsOn 3/27/23 at 9:38 a.m., Staff #4 stated that Resident #3 had only had her tilted wheelchair for a week, and had another wheelchair prior that was taken away for having a seatbelt on it. Staff #4 stated that she had never seen the seatbelt used on Resident #3. On 3/27/23 at approximately 10:58 a.m., Staff #7 stated that she had not received training on restraints from the residence. On 3/27/23 at 12:51 p.m., an external hospice representative stated that Resident #3 was found by the external hospice nurse buckled into her wheelchair with a seatbelt. The external hospice nurse educated the staff there on how that was considered a restraint and staff could not prevent Resident #3 from trying to get up. The external hospice representative stated that on 3/21/23, Resident #3 was ordered a new reclining chair and staff had requested it, wanting to tilt her back in the chair so she could not get up, and staff were educated that they could not use it for that purpose because hospice could not clinically restrain. The external hospice representative also stated that she had received a call on 3/25/23 from residence staff to administered as needed Ativan to Resident #3 since she would not calm down, and also received numerous calls on 3/20/23 for staff to administer Resident #3's as needed Ativan or Clonazepam. The hospice representative stated that she was not aware if staff were using Resident #3's as needed medication to sedate her so she would not get up out of her chair or bed. However, the hospice representative acknowledged that if staff were using the PRN medication for Resident #3 trying to get out of the bed or chair that would be considered a restraint. On 3/27/23 at 1:54 p.m., Resident #3's family member stated that she was notified that on 3/19/23 Resident #3 was buckled into her wheelchair and discussed with the staff involved termination. Resident #3's family member stated that Resident #3 had just gotten a wheelchair because of her decline in condition three weeks prior to the onsite survey, and had gotten the tilted wheelchair on 3/21/23 that was harder for Resident #3 to slide out of. Resident #3's family member stated that Resident #3 could not verbalize her needs. On 3/27/23 at 2:29 p.m., the HWD stated that Staff #2 and Staff #3 were the staff members who physically restrained Resident #3 on 3/19/23 to a transport wheelchair that was accidentally delivered to Resident #3. The HWD stated that she did not know if all staff received training on restraints since she had just started working at the residence three weeks prior to the onsite survey. The HWD stated she found out about an incident on 3/24/23 where Resident #3 was reclined backwards in her tilted wheelchair, however, did not know the name of the staff member who did it. The HWD stated that she did not know of any other instances of restraintfor Resident #3. On 3/27/23 at 2:45 p.m., Staff #2 stated that she had not worked with Resident #3 before 3/19/23, and when Staff #5 asked Staff #2 for assistance transferring Resident #3 out of bed, Staff #2 grabbed a wheelchair. Staff #2 stated she thought it was okay to buckle her in it so she did. Staff #2 stated that she did not know the seatbelt was a restraint since she was not trained by the residence on restraints. On 3/27/23 at 3:18 p.m. the administrator stated that she had reported and did a full investigation and education about Resident #3's restraint on 3/19/23 and discovered there was no negative intent by the staff who snapped the seatbelt, who were Staff #2 and Staff #3. The administrator stated that Staff #3 self terminated. On 3/27/23 at 3:50 p.m., the administrator stated that the incident with Resident #3 on 3/19/23 was considered a form of restraint, and confirmed a restraint was a violation of resident rights. On 3/27/23 at approximately 4:08 p.m., Staff #1 stated that she administered as needed medications to Resident #3 whenever she exhibited anxious behaviors as directed by hospice, since Resident #3 was unable to request as needed medications. Staff #1 stated that she had just given Resident #3 as needed 0.5 mg Ativan at 4:03 p.m., right before she fell "because (Resident #3) was anxious and trying to get out of her tilted wheelchair." Staff #1 also stated that she had not been trained on restraints and was unaware of all the types of restraints beyond physical restraints. On 3/27/23 at 4:08 p.m., the HWD stated that Resident #3's as needed medication was administered for her agitation, anxiety, and exit-seeking. The HWD stated that she did not have anything to do with the order of Resident #3's scoop mattress and believed it was provided by Resident #3's hospice. The HWD stated that she did not think it was keeping her from getting out of the bed and was like that for comfort.

Based on interviews and record reviews, the residence failed to ensure the qualified medication administration personnel (QMAP) did not perform decision making regarding PRN or "as needed" medication administration or administer medications for the purpose of restraint, affecting one sample resident (#3) in the secured environment who was administered PRN medication when unable to request it. (Cross-reference Q1180, Q1312, Q1146 and Q2960)Findings include:1. References and Residence Policya. The residence's undated medication policy, read in part: "medication may not be administered by a qualified medication administration person on a PRN or as needed basis except where the resident understands the purpose of the medication and is capable of voluntarily requesting the medication."b. Chapter VII regulations governing assisted living residences, require in part 14.9, that no medication shall be administered by a qualified medication administration person on a pro re nata (PRN) or "as needed" basis except: (B) Where the resident understands the purpose of the medication, is capable of voluntarily requesting the medication, and the assisted living residence has documentation from an authorized practitioner that the use of such medication in this manner is appropriate 2. Resident #3 was admitted to the residence on 3/25/22, with diagnoses including dementia, arthritis, pain and anxiety. A written practitioner's order, dated 3/9/23, directed the residence to administer one 0.5 mg tablet of Clonazepam as needed for agitation. The March 2023 electronic medication administration record (eMAR) read that Clonazepam was administered by a qualified medication administration person (QMAP) on 3/11/23 and 3/18/23. A written practitioner's order, dated 3/22/23, directed the residence to administer 0.5 mg of Ativan every two hours as needed for agitation. The March 2023 eMAR read that Ativan was administered four times 3/22-3/25/23 by Staff #1 and Staff #9 .On 3/27/23 at 11:42 p.m., Staff #4 stated that she administered PRN medication under the external hospice nurse's direction, however did not remember the last time she had given it or for what reason. On 3/27/23 at at 12:51 p.m., an external hospice representative stated that residence staff administer as needed medications to Resident #3 after telephoning the external hospice representative. The external hospice representative stated that she had received a telephone call on 3/25/23 from a residence QMAP to administer PRN Ativan to Resident #3 since she would not calm down, and further stated she received numerous telephone calls on 3/20/23 for a residence QMAP to administer Resident #3's as needed Ativan or Clonazepam. The external hospice representative stated that she was not aware if staff were using Resident #3's PRN medication to sedate her so she would not get up out of her chair or bed. However, the external hospice representative acknowledged that if staff were using the PRN medication for Resident #3 trying to get out of the bed or chair that would be considered a restraint. On 3/27/23 at 1:54 p.m., Resident #3's family member stated that Resident #3 could not verbalize her needs; however, the resident showed other forms of expression through her agitation and facial expressions. On 3/27/23 at approximately 3:18 p.m., the administrator stated that Resident #3 could not verbalize her needs. The administrator stated that she was aware it was a requirement that staff could not administer as needed medications if a resident could not request it; however, she thought it was okay if it was under the direction of the external hospice nurse with nurse assessment. On 3/27/23 at approximately 4:08 p.m., Staff #1 stated that she administered as needed medications to Resident #3 whenever she exhibited anxious behaviors as directed by the external hospice nurse, since Resident #3 was unable to request as needed medications. Staff #1 stated that she had just administered Resident #3 as needed 0.5 mg Ativan at 4:03 p.m. right before she fell "because (Resident #3) was anxious and trying to get out of her tilted wheelchair."

Based on record review and interview, the residence failed to ensure resident care plans contained a description of the resident's known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident, affecting one of one sample residents (#3) who resided in the secure environment. (Cross-reference Q1146, Q1312 and Q1428). Findings include:1. Residence PolicyThe residence's undated Enhanced Resident Care Plan policy, read in part: "The care plan for each resident residing in the secure memory care will include a description of the resident's wandering patterns and known behavioral expressions, along with the individualized approaches to be implemented by staff to protect the resident."2. Resident #3 was admitted to the residence on 3/25/22, with a diagnosis of dementia. February and March 2023 Progress notes for Resident #3, read as follows:On 2/2/23 Resident #3 tried to escape multiple times and was combative and crying. On 2/5/23 Resident #3 had been crying on and off, entering other resident's rooms and trying to escape. On 2/11/23 Resident #3 was exit seeking most of the shift and was agitated and aggressive. On 2/12/23 Resident #3 was exiting seeking; however the resident calmed down when staff assisted her to her room and provided a snack. On 2/13/23 Resident #3 was exit seeking and difficult to redirect. On 2/15/23 Resident #3 was aggressive with care staff and showed increased exit seeking and agitation. On 2/18/23 Resident #3 was in another resident's room and Resident #3 was squeezing that resident's hand and she was saying "ow ow."On 2/22/23 Resident #3 had been in and out of her room crying and wandering around. On 2/23/23 Resident #3 had a care conference to discuss a private caregiver to support her one on one. On 3/3/23 Resident #3 had been hard to redirect and tried to go out the exit and cursing at staff. On 3/9/23 Resident #3 had been walking around for three hours straight and was crying and aggressive. On 3/18/23 Resident #3 was agitated and trying to kick the caregiver. On 3/21/23 Resident #3 was exit seeking and hits and punches the locked door. On 3/24/23 Resident #3 was agitated and was trying to climb out of bed. On 3/25/23 Resident #3 kept trying to climb out of bed and was unable to be calmed easily. The residence's most recent assessment for Resident #3, dated 10/28/22, read in part: "Resident wanders and has a history or current disruptive, aggressive, and inappropriate behavior, either verbally or physically improper that may require professional consultation or staff training."The residence's care plan for Resident #3, updated 3/27/23 (the day of the onsite investigation), read the resident would become agitated and combative and required intervention and behavior management. However, the care plan contained no specific behavioral expressions or individualized approaches to be implemented by staff to protect the resident and the other residents. 3. InterviewsOn 3/27/23 at 8:52 a.m., Staff #4 stated that when Resident #3 is more alert and she wanders. On 3/27/23 at 1:47 p.m., Staff #2 stated that Resident #3 exhibits aggression and crying as well as wandering. Staff #2 stated that to redirect Resident #3 it helped her to say her family member would come back and bring her dog. Staff #2 stated that when she was aggressive she guided her to her room and would give Resident #3 her stuffed dog. On 3/27/23 at 1:54 p.m., Resident #3's family member stated that Resident #3 had a private caregiver and was unable to be verbally redirected, so staff supplement by offering Resident #3 snacks, attempted to have her listen to music, or bring her her stuffed dog. Resident #3's family member stated that she was not aware of any specific behavioral interventions in place for Resident #3. On 3/27/23 at 2:29 p.m., the Health and Wellness Director (HWD) stated that Resident #3 was agitated and would exit seek. She stated she had asked external hospice for direction on administration ofas needed medications for Resident #3's behaviors. On 3/27/23 at 3:18 p.m., the administrator stated that Resident #3 could not communicate what she needed and would get frustrated with staff which comes across with her crying and needing redirection. The administrator stated that staff use stuffed animals to help with her behaviors. The administrator stated that historically staff would hold Resident #3's hand and sing and dance, play balloon volleyball and pray with her. The administrator stated that she was not aware why the above interventions were not listed in the residence's care plan for Resident #3, since they have had numerous conversations on ways to help her. The administrator stated that nurses were responsible for updating care plans and acknowledged it should have been done and should include behavioral expressions and interventions.