HEALTHCARE RESORT OF COLORADO SPRINGS, THE

A revisit survey was completed on 6/16/25 for all previous deficiencies cited on 2/19/25. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO37408, was completed on 2/19/25. Deficiencies were cited.

Based on interviews and record review, the residence failed to ensure all staff members received orientation that included emergency response policies and procedures prior to providing any care or services to residents, affecting 23 current residents. 1. Record ReviewStaff training records revealed that Staff #1 was hired on 3/12/24, and completed Emergency Preparedness Training on 3/16/24 through online training. However, the training did not include all elements required by regulation, such as hands-on instruction on evacuation techniques or orientation to the residence's policies and procedures. Staff #2 was hired on 6/20/23, and completed Emergency Preparedness Training on 8/20/23 through online training. Similarly, this training did not cover critical emergency response procedures, including how to physically assist residents during an evacuation as listed in the residence's policy and procedures. 2. InterviewsOn 2/19/25 at 11:00 a.m., Staff #2 stated she had not received orientation on how to carry residents in an emergency and was unfamiliar with the policy. On 2/19/25 at 11:05 a.m., Staff #1 stated she had not received orientation on proper evacuation techniques or evacuation procedures. On 2/19/25 at 2:00 p.m., the wellness director stated that staff were expected to be familiar with the emergency policy and follow it. He stated "We throw a lot of training at employees and it might not 'stick'".

Based on observation, interview and record review, the residence failed to ensure its emergency policies addressed written instructions for when to evacuate the premises and the procedure for doing so, affecting ­­­­­23 current residents. Findings include:1. Residence policyThe Fire and Disaster Policy and Procedure was provided in a binder The table of contents did not match the contents of the book. There were no dividers, and all sections were labeled "Fire and Disaster Policy" including unrelated events such as hurricane and earthquake. Items related to fire response were scattered throughout the book such as identifying if the fire was small or major making it difficult to determine clear steps for an emergency evacuation. Fire and Disaster Policy/Procedure Policy (FDEP 19), revised November 27, was provided by the residence and read, and read in part: "Procedures: 1. Fire classes will be conducted in lieu of regularly scheduled fire drills. 2. Fire classes will include at a minimum: (D) Methods used to remove residents from the danger area." The policy included diagrams demonstrating how to carry residents safely. 2. Record ReviewStaff training records showed that Staff #1 was hired on 3/12/24, and completed Emergency Preparedness Training on 3/16/24. Staff #2 was hired on 6/20/23, and completed Emergency Preparedness Training on 8/20/23.3. InterviewsOn 2/19/25 at 7:30 a.m., Staff #2 stated that in the event of an evacuation, she would use the stair lift chair to assist residents unable to exit independently or seek assistance. She stated she had not been trained on how to use the stair lift chair. On 2/19/25 at 8:15 a.m., Staff #1 stated she would use the stair lift chair to assist residents but had only received verbal instructions and was unsure if she could use it safely, particularly for larger residents due to the lifting required. On 2/19/25 at 9:00 a.m., the maintenance director stated that he or the wellness director could operate the stair lift chair if needed. He also stated that staff were expected to carry residents manually if necessary during an emergency evacuation. On 2/19/25 at 9:03 a.m., the wellness director stated that in an emergency, staff were expected to manually carry residents unable to descend the stairs independently. However, she stated firstly residents would stay in their rooms to determine if evacuation was even necessary. On 2/19/25 at 11:00 a.m., Staff #2 confirmed she had not been trained on how to carry residents in an emergency. On 2/19/25 at 11:05 a.m., Staff #1 stated she had difficulty carrying anyone over 120 pounds and demonstrated a "baby carry" method with arms horizontally outstretched and stated she had not received orientation or training on proper evacuation techniques or how to carry residents. On 2/19/25 at 2:00 p.m., the wellness director stated the binder did not meet his expectations.

A revisit survey was completed on 9/19/23 for all previous deficiencies cited on 2/1/23. The facility is in compliance with all deficiencies that were cited.

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

A relicensure survey was completed on 2/1/23. Deficiencies were cited.

Based on observation, record review, and interviews, the residence failed to ensure that each resident received proper administration and monitoring of medication, affecting three of four residents observed during medication administration (#2, #3, #4). Findings include: 1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences defines, in part 2.26, Medication administration as "assisting a person in the ingestion, application, inhalation, or, using universal precautions, rectal or vaginal insertion of medication, including prescription drugs, according to the legibly written or printed directions of the attending physician or other authorized practitioner, or as written on the prescription label, and making a written record thereof with regard to each medication administered, including the time and the amount taken ... "b. Chapter VII regulations governing assisted living residences defines, in part 2.27, Medication monitoring as"(A) Reminding the resident to take medication(s) at the time ordered by the authorized practitioner;(B) Handing to a resident a container or package of medication that was lawfully labeled previously by an authorized practitioner for the individual resident; (C) Visual observation of the resident to ensure compliance ..."c. The residence's Medication Administration policy, dated 3/7/16, read in part, "Staff will observe the resident swallowing the medications then initial the medication as given ..."2. Observations On 2/1/23 at approximately 8:00 a.m., Resident #3 was seated at the dining room table with a medication cup filled with medication and no staff were present to monitor ingestion. On 2/1/23 at 9:16 a.m., Staff #1 administered Resident #2's medication in the resident's room. Staff #1 placed the medication cup on Resident #2's table, turned around and walked out of the room. Staff #1 did not observe Resident #2's medication ingestion. On 2/1/23/ at 9:25 a.m., Staff #1 administered Resident #4's medication in the resident's room. Staff #1 placed the medication cup on Resident #4's television tray, turned around and walked out of the room. Staff #1 did not observe Resident #4's medication ingestion. 3. Record ReviewThe residence had a document titled "Qualified medication administration person (QMAP) medication pass worksheet. Two of the categories on the worksheet were; May leave medications in room and self-administer. Review of the QMAP medication pass worksheet read that Residents #3 and #4 were marked as may leave medications in their room; however, the self-administration boxes were blank. Both boxes for Resident #2 were blank. 4. InterviewsOn 2/1/23 at 10:53 a.m., Resident #2 stated staff left her medications for her to take and did not watch her ingest them. She stated staff left her medications with her all of the time. On 2/1/23 at 11:00 a.m., Resident #4 stated staff left her medications for her all of the time. She stated she knew what all of her medications were and that staff trusted her to take them. On 2/1/23 at 11:04 a.m., Staff #1 stated the residence had a sheet with the resident's names on it and whoever had a mark next to their name, staff were allowed to leave the medications with the resident and did not have to monitor ingestion. On 2/1/23 at 12:20 p.m., the wellness director (WD) stated the residence assessed the residents and if a resident was determined safe to leave their medications in the resident's rooms, it was included in their care plan and medication assessment, and was also indicated on the QMAP medication pass worksheet. He stated both Resident #3 and #4 were considered safe for staff to leave their medications in their rooms; however, Staff #1 should have monitored Resident #2 ingest her medication. The WD stated he was not aware a written practitioner order for self-administration was required and believed the residence assessment was all that was needed. On 2/1/23 at 12:50 p.m., the administrator stated Staff #1 should not have left Resident #2's medications in her room and should have monitored ingestion; however, thought it was okay for Resident #3 and #4.

Based on observation, record review and interview, the residence failed to ensure all over-the-counter (OTC) medications prescribed for administration were labeled or marked with the residents' full names, affecting three of three sample residents (#1-#3). Findings include: 1. Residence PolicyThe residence's Medication Administration policy, dated 3/17/16, revealed it did not address storage of OTC medications. 2. ObservationOn 2/1/23 at approximately 12:00 p.m., a medication cart audit revealed the following OTC medications were not labeled or marked with the individual's full name, as follows:Resident #1: a bottle of calcium carbonate antacid, a bottle of acetaminophen 325 mg, and Cetirizine 10 mg. Resident #2: a bottle of calcium carbonate antacid 500 mg. Resident #3: a bottle of acetaminophen 500 mg. 3. InterviewsOn 2/1/23 at approximately 12:50 p.m., the administrator and wellness director stated that OTC medications should have been labeled with the resident's name and date. The WD stated he was unaware the last name was required as well.

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