PEAKS AT OLD LARAMIE TRAIL, THE

An administrative relicensure survey was completed on 7/6/26. No deficiencies were cited.

A licensure complaint, prompted by #CO38094, was completed on 4/13/26. A deficiency was cited.

Based on interview and record review, the residence failed to establish a fall management program which included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting three (#3, #4 and #5) of three sampled residents who sustained injuries from falls. Specifically, Resident #4, was observed on 4/13/26 at 10:15 a.m. with two black eyes and significant bruising throughout her face, as a result from multiple falls incurred in less than a one month period, all of which resulted in injury. On 3/18/26, Resident #4 had an unwitnessed fall, which resulted in a bruise and redness to her left knee. On 4/5/26 Resident #4 was walking by the activities room and tripped over her own feet, which resulted in a subdural hematoma (dangerous collection of blood between the brain's surface and its outer covering (dura). Resident #4 sustained an additional fall on 4/10/26, which resulted in Resident #4 striking the left side of her forehead on the floor. A care plan for Resident #4, dated 4/13/26, failed to reveal documentation of implemented fall interventions for the aforementioned falls. Specifically Resident #5, admitted to the residence on 8/1/25, had three falls between 1/26 and 4/26. One of the falls resulted in bruising and another fall resulted with hospitalization. Furthermore, a care plan dated 4/13/26 read the resident was independent with mobility. The care plan failed to reveal the resident had fall interventions implemented. Findings include:I.ObservationOn 4/13/26 at 10:42 a.m., Resident #4 had two black eyes and facial bruising covering a significant portion of her face. 2. Resident #4 was admitted to the residence on 12/3/25 with a diagnosis of dementia. An incident report (IR) dated 3/18/26, categorized as an unwitnessed fall, read in part, caregiver found resident sitting on the floor in the living room. The IR further read the resident sustained a bruise to her left knee as result of the fall. An IR dated 4/5/26, categorized as a witnessed fall, read in part, as per caregiver, resident fell while she was walking by the activities room and had an open area above her right eye. The IR further read the resident sustained no injury, however, a progress note dated 4/5/26 at 1:45 p.m. read in part, "resident fell down after lunch and they took her to the hospital." A second progress note dated 4/5/26 at 6:00 p.m. documented in part, "resident came back from hospital ..... She has a subdural hematoma."An IR dated 4/10/26, categorized as a witnessed fall, read in part, the resident fell, striking the left side of her forehead on the floor. The IR further read the resident sustained a lump and bruise on the upper left side between eyebrow and the forehead as a result from the fall. .A care plan, dated 4/13/26, read in part, Resident #4 was independent with mobility. The care plan failed to reveal fall interventions that were implemented or an individualized approach necessary to address fall risk related to deficits in strength and balance. 3. InterviewOn 4/13/26 at approximately 10:45 a.m., Staff #1 said Resident #4 had several falls lately along with an increase in wandering into other resident rooms. Staff #1 was not aware any fall interventions were implemented for Resident #4. Staff #1 said they (staff) were encouraged to keep all the residents in the commons area so they could keep a better eye on them. Staff #1 said she was made aware of any resident fall either during cross over shift report or if she was off for a few days, she would read the progress notes in the electronic health record. She said there were never fall interventions implemented for any of the residents who had falls. She said fall interventions were something staff could benefit from. On 4/13/26 at approximately 1:45 p.m., the memory care coordinator (MCC) said she was aware of which residents in the secure environment were at risk for falls. The MCC said she thought Resident #4 and Resident #5 had interventions in place. Upon review of the care plans, the MCC acknowledged no interventions were noted in Resident #3, Resident #4 or Resident #5's care plans. The MCC said the wellness director was responsible for initiating the interventions and updating the care plans. On 9/16/25 at approximately 2:00 p.m. the wellness director (WD) said the residence did not have a process in place for updating care plans with fall interventions. The WD said this was not done for any of the residents in the secure environment. She could not recall any resident currently having fall interventions implemented outside of staff supervision. The WD was aware the residence needed to implement a fall management plan but was not sure how to go about documenting the interventions on a care plan. The WD said she would talk to the executive director in order to get this done right away. On 9/16/25 at approximately 2:40 p.m. the administrator said he knew the residence failed by not updating resident care plans with fall interventions. He said the new software program the residence was switching to would allow for a fall management program to be carried over and documented on the resident care plans. He said this would be the first time the residence could properly document any interventions for a fall. The administrator was going to work with the WD to get this started immediately. Similar deficient practice was revealed for Resident #3 and Resident #5.

A revisit survey was completed on 9/30/24 for all previous deficiencies cited on 6/20/24. 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 revisit survey was completed on 9/30/24 for all previous deficiencies cited on 6/20/24. The facility is in compliance with all deficiencies that were cited.

A complaint revisit was completed on 6/20/24 for all previous deficiencies cited on 7/5/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 6/14/23 and the Chapter VII regulations were implemented on 11/15/23.

A relicensure survey with complaint #CO34336 was completed on 6/20/24. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to ensure each staff member completed orientation relevant to their specific duties, affecting 68 current residents. Findings include:1. ObservationOn 6/19/24 from approximately 7:15 a.m. to 4:30 p.m., Staff #20 provided care and services to residents. 2. Record Review On 6/19/24 at 11:02 a.m., staff records for Staff #17-#22 revealed that they were hired on 6/14/24, 3/15/24, 3/29/24, 5/23/24, 6/5/24 and 2/20/24, respectively. Staff records for Staff #17-#22 included no documentation that the residence provided orientation or training prior to providing care or services to residents. The June 2024 staff schedule revealed Staff #18 worked on 6/3, 6/4, 6/6, 6/7, 6/8, 6/10, 6/11, 6/13, 6/14, 6/15, 6/17, 6/18, 6/20, 6/21, and 6/22.3. Interviews On 6/19/24 at 1:55 p.m., the business office manager stated staff did not have any training prior to providing care and services to residents and was unable to provide documentation of training for Staff #17-#22. On 6/20/24 at approximately 7:30 a.m., Staff #20 stated she had not received any training prior to working with residents and could not give any specific information as to what was taught prior to onboarding. On 6/20/24 at 8:55 a.m., the administrator stated he was aware the above staff did not have the required training prior to providing care and services for residents.

Based on interview and record review, the residence failed to ensure that each staff member met the dementia training requirements, affecting 27 current residents residing in the secure environment. Findings include:On 6/19/24 at approximately 11:02 a.m., personnel files for Staff #17-#22 were provided by the administrator and revealed no documentation that the direct care staff members met the dementia training requirements. On 6/19/24 at 11:02 a.m., staff records revealed Staff #17-#22 were hired on 6/14/24, 3/15/24, 3/29/24, 5/23/24, 6/5/24 and 2/20/24, respectively. Staff #18 worked on 6/3, 6/4, 6/6, 6/7, 6/8, 6/10, 6/11, 6/13, 6/14, 6/15, 6/17, 6/18, 6/20, 6/21, and 6/22/24. On 6/20/24 at 7:15 a.m., Staff #20 stated that the residence did not provide her with training that met the dementia training requirements. On 6/20/24 at 8:55 a.m., the administrator acknowledged the above staff did not have dementia training as required.

Based on interview and record review the residence failed to ensure there was at least one staff member onsite at all times with current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization affecting 68 current residents. Findings include:1. Record Review On 6/19/24 at 8:55 a.m., CPR certifications were provided by the administrator. However, the CPR certifications revealed that Staff #17, #18, #20, #21 and #23 did not have certifications from a nationally recognized organization. The May and June 2024 staff schedules and CPR certifications revealed the residence failed to ensure that there was at least one staff member with current certification in CPR from a nationally recognized organization on the third shift (10:00 p.m. to 6:00 a.m.) on 5/25/24, 6/1/24, 6/8/24 and 6/15/24. 2. Interviews On 6/19/24 at 9:00 a.m, when requesting additional staff schedules, the business office manager stated they were aware of the requirement to ensure that at least one staff member certified in CPR during each shift. On 6/19/20 at 8:55a.m, the administrator stated he expected all staff to be CPR certified and that each shift should have at least one staff member that was certified from a nationally recognized organization. He also acknowledged that the residence consistently scheduled shifts without ensuring there was a staff member onsite with current CPR certification from a nationally recognized organization.

Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting four of four sample residents (#23, #29-#31) whose medications were administered. Findings include:On 6/19/24 from approximately 7:30 a.m. to 8:30 a.m., during medication administration, the following was observed:Staff #9 prepared medications for Resident #29. Staff #9 did not perform any hand hygiene. Staff #9 touched medication containers, keys, a pen, computer keyboard, computer mouse, binder and the door handle to the medication room. Staff #9 then administered medications to Resident #29 and did not perform hand hygiene afterwards. Staff #9 prepared medications for Resident #30. Staff #9 touched the medication cup with her left index finger. At 7:43 a.m., Staff #9 touched her hair with her left hand, touched a door handle and Resident #30's wheelchair handles. Staff #9 donned a pair of gloves and provided a treatment to Resident #30. Staff #9 doffed the gloves and did not perform hand hygiene. Staff #9 prepared and administered medications to two more residents (#23 and #31) and touched keys, computer, computer mouse, pen, binder, medication containers, door handles and her nose. Staff #9 completed no hand hygiene until 8:18 a.m., after administering Resident #32's medications. On 6/19/24 at 8:23 a.m., Staff #9 stated she had hand hygiene training and was trained to wash her hands when her hands were soiled, after resident contact or after providing resident care. She added she had not washed her hands after removing her gloves because her hands were not soiled. Staff #9 said she should have washed her hands after she removed her gloves. On 6/20/24 at approximately 9:00 a.m., the administrator said he expected QMAPs to wash their hands after providing medication administration to each resident and acknowledged that Staff #9 should have performed more hand hygiene when she administered medications to residents.

Based on observation and interview, the residence failed to ensure residents had independent access to drinks at all times, affecting 27 current residents residing in the secure environment. Findings include:On 6/19/24 at 7:22 a.m., 10:17 a.m. , and 11:32 a.m., there was a water container in the small kitchen area on the inside of a small "C" shaped counter; however, there were no cups in the surrounding area to ensure that residents in the secure environment had independent access to drinks at all times. On 6/20/24 from approximately 7:15 a.m. to 10:00 a.m., there was a water container in the small kitchen area on the inside of the same counter; however, there were no cups in the surrounding area to ensure that residents in the secure environment had independent access to drinks at all times. On 6/20/23 at 8:55a.m., the administrator stated he expected there to be water and cups available for residents in the secure environment to have independent access to drinks at all times. The administrator said that the dietary manager was not aware it was his responsibility to ensure residents had water and cups available.

Based on interview and record review, the residence failed to ensure resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affected a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs, affecting one current resident (#25) and one former resident (#32) who resided in the secure environment. (Cross-reference S3040)Findings Include:1. Resident #25 was admitted to the unsecure portion of the residence on 10/23/23. Resident #25 was later admitted to the secure environment of the residence in January 2024 e. An assessment in Resident #25's record, dated 1/15/24, read Resident #25 had drug seeking behavior and cognitive neglect. Progress notes were requested for Resident #25 from January 2024 to the onsite visit on 6/19/24. Staff documented no progress notes in Resident #25's record that included any out of the ordinary event or issue that affected Resident #25's behaviors or cognition around the time Resident #25 was moved from the unsecure portion of the residence to the secure environment in January 2024. On 6/19/24 at 7:33 a.m., Staff #9 said the residence moved Resident #25 to the secure environment from the unsecure portion of the residence because he left the water running in his room and he was drug dependent. Staff #9 was unaware when Resident #25 was transferred to the secure environment. On 6/19/24 at 11:46 a.m., Staff #24 stated the residence moved Resident #25 to the secure environment from the unsecure portion of the residence two months prior to the onsite visit because of drug abuse. On 6/19/24 at 3:37 p.m, Resident #25 said the residence moved him to the secure environment because he accidentally left the water running in his apartment. Resident #25 said he met and discussed moving from the secure environment with the administrator two weeks prior to the onsite visit and had a care conference on 6/17/24.2. During the onsite visits on 6/19 and 6/20/24, similar deficient practice was found for Former Resident #32.3. InterviewOn 6/20/24 at approximately 9:00 a.m., the administrator acknowledged the staff should have documented in progress notes all out of the ordinary events or issues that affected Resident #25 and Former Resident #32's physical, behavioral and cognitive functioning related to the need to be transferred from the unsecure portion of the residence to the secure environment.

Based on observation, interview and record review, the residence failed to ensure that no individual was required move into a secure environment against their will unless legal authority for the admission of the individual has been established by guardianship, court order, medical durable power of attorney, health care proxy, affecting one current resident (#25). (Cross-reference S2230)Findings Include:1. Resident #25 was admitted to the unsecure portion of the residence on 10/23/23. Resident #25 was admitted to the secure portion of the residence in January 2024.a. Record ReviewAn assessment for Resident #25's record, dated 10/17/23, read Resident #25 did not require assistance with grooming, dressing, bathing, transfers, escorts, laundry or toileting. The assessment read Resident #25 was not at risk for elopement. A practitioner's assessment for Resident #25, dated 10/20/23, read Resident #25 had a history of substance abuse and was able to drink alcohol, was depressed and wandered but did not require constant medical supervision. Another practitioner's assessment for Resident #25, dated 1/15/24, read Resident #25 had drug seeking behavior, cognitive neglect, was not allowed to drink alcohol, was confused/disoriented due to intoxication, required constant supervision for any undocumented substance use and cognitive deficiencies. Additionally, Resident #25 "has had acute decline in cognition, potentially substance abuse related, will require controlled environment to prevent him taking any non-prescribed agents and repeat of cognitive testing after a wash out period."A practitioner's progress note for Resident #25, dated 6/10/24, read: "The pressing issue for him today is that he wants to look at transferring back to the ALF (assisted living facility) side of the building. We recapped prior events which did include that he had multiple documented events of appearing altered with considerations for both alcohol and THC, that resulted in him leaving a sink on in his room which started to leak into rooms under him ... he has not required any assistance with ADLs, and has not been documented to have any disruptive or harmful behaviors. The last time this event was looked into it appears that there would have been fees associated with moving either back to the (residence) or to another building so he seemingly dropped the issue, but with management in the form of a head nurse and director for the building (Resident #25) does want this topic readdressed ... I did stress that to have my support in moving back to the building, he would be required to sign a contract stating he would not use any mind altering substances [even legal agents such as alcohol or THC (tetrahydrocannabinol)] and would only take his medications ..."The record for Resident #25 did not reveal any court order, guardianship or power of attorney documentation that said he was required to reside in a secure environment. Additionally, there was no documentation in Resident #25's record to show any practitioner deemed mentally incapacitated to make decisions regarding care and services. b. ObservationResident #25 resided in the secure environment of the residence throughout the onsite visits on 6/19 and 6/20/24.c. InterviewsOn 6/19/24 at 7:33 a.m., Staff #9 said Resident #25 was not appropriate for admission to the secure environment. On 6/19/124 at 3:37 p.m., Resident #25 said the residence moved him to the secure environment because he left the water on in his room. He added he was told he would only be in the secure environment for a week. Resident #25 said when the administrator started working at the residence, he had a meeting with him a few weeks prior to the onsite visit and had a care conference on 6/17/24 to discuss his potential move back to the unsecure portion of the residence. Resident #25 said, "I feel like I'm in a small prison here" and wanted to move back to the unsecure portion of the residence. On 6/20/24 at 8:07 a.m., the administrator said he had a care conference on 6/17/24 with Resident #25 and his family member. He added that the residence would allow Resident #25 to move to the assisted living portion of the residence when a room became available. The administrator said there was no medical reason to keep Resident #25 in the secure environment because he was not a wandering risk and had never eloped. On 6/20/24 at 8:18 a.m., the health and wellness director (HWD) said Resident #25 had a history of alcohol and drug use and added when he was impaired he could not function in assisted living. She added the residence placed him in the secure environment for his safety and medication management. The HWD added the residence checked rooms to make sure stuff that should not be allowed was removed. On 6/20/24 at 8:32 a.m., the memory care director said the only reason Resident #25 was in the secure environment because he was abusing drugs. She added Resident #25 never eloped when he was in assisted living and he never wandered.

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 Each administrator shall have completed 40 hours of administrator training before assuming an administrator position. Individuals appointed as an interim administrator shall have completed 40 hours of administrator training within 30 days of appointment. Written proof regarding the successful completion of such training program shall be maintained in the administrator ' s personnel file. The 40 hours shall be met by one of the following:7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following items:( C ) Orientation and training, including first aid and CPR certification, if applicable;8.8 Each assisted living residence shall place in a visible location a list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times. The list shall be kept up to date and indicate by staff person whether the certification is in first aid or CPR or both. 13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements: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. 14.30 The assisted living residence shall maintain a record on a separate sheet for each resident receiving a controlled substance which contains the name of the controlled substance, strength and dosage, date and time administered, resident name, name of authorized practitioner, and the quantity of the controlled substance remaining. 12.17 The assisted living residence shall ensure that it has trained staff available to evaluate residents who have fallen or are otherwise unable to independently get up off the floor and provide lift assistance when determined appropriate instead of relying on emergency medical responders. 25.22 The assisted living residence shall meet the requirements of Part 13.10 regarding the internal grievance and complaint resolution process. In addition, the assisted living residence shall hold regular meetings to allow residents, their family members, friends, and representatives to provide mutual support and share concerns and/or recommendations about the care and services within each separate secure environment.

A licensure revisit was completed on 6/20/24 for all previous deficiencies cited on 7/5/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 11/15/23.

Based on observation and interview, the residence failed to ensure residents had independent access to drinks at all times, affecting 27 current residents residing in the secure environment. This deficiency was cited previously during a state relicensure survey 7/5/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 6/19/24 at 7:22 a.m., 10:17 a.m. , and 11:32 a.m., there was a water container in the small kitchen area on the inside of a small "C" shaped counter; however, there were no cups in the surrounding area to ensure that residents in the secure environment had independent access to drinks at all times. On 6/20/24 from approximately 7:15 a.m. to 10:00 a.m., there was a water container in the small kitchen area on the inside of the same counter; however, there were no cups in the surrounding area to ensure that residents in the secure environment had independent access to drinks at all times. On 6/20/23 at 8:55a.m., the administrator stated he expected there to be water and cups available for residents in the secure environment to have independent access to drinks at all times. The administrator said the reason the deficiency was recited was because the dietary manager was not aware it was his responsibility to ensure residents had water and cups available.

A licensure complaint, prompted by #CO30524, was completed on 7/5/23. Deficiences were cited.

Based on interview and record review, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting 72 current residents. Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (I) Completing, maintaining, and submitting all reports and records required by the Department.b. Chapter VII regulations governing assisted living residences, part 12.8, requires that the comprehensive assessment shall be documented in writing and kept in the resident's health information record.c. Chapter VII regulations governing assisted living residences, part 18.8, requires that resident records shall contain, but not be limited to, the following items:(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.(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.d. A Resident Records Policy, dated 7/1/21, read in part: "the (residence) will maintain resident records in an organized manner ... (and) provide documentation when a surveyor requests."2. Record Review and InterviewsOn 7/5/23 at 9:20 a.m., a complete resident record for Resident #22 including progress notes and hospital discharge documentation, dated November-December 2022 and April-July 2023, was requested. Progress notes, dated from May-July 2023, were requested for Residents #2-#4, #8 and #20. Personnel files for Staff #14-#16 were also requested. The acting administrator (AA) was requested to provide all documentation by 10:15 a.m. The AA stated she was unsure she would be able to provide all requested documents since the residence was between electronic health systems since a new management company took over in April 2023. The AA stated she tried to had to obtain electronic access to their previous electronic health record system and locate all the requested documents since she did not have access since the change occurred in April 2023. On 7/5/23 at 10:32 a.m., paper resident records for Residents #2-#4, #8, #20 and #22 were provided; however, the records did not include assessments, care plans or progress notes. Complete resident records and personnel files were requested a second time. On 7/5/23 at 10:51 a.m. personnel files for Staff #14-#16 were provided. On 7/5/23 at 11:00 a.m., the resident care director stated she would need to retrieve progress notes, assessments and care plans for the sample residents and obtain records from the residence's previous electronic health system. She said this was the reason that complete resident records had not yet been provided. On 7/5/23 at 11:45 a.m., care plans, progress notes, and assessments for Residents #2, #3 and #22 were provided. Care plans, assessments and progress notes for Residents #4, #8 and #20 were not provided. Hospital discharge summaries were not provided for Resident #22. On 7/5/23 at 12:01 p.m., care plans, assessments and progress notes were requested for Residents #4, #8 and #20 and hospital discharge summaries for Resident #22. On 7/5/23 at 12:15 p.m., approximately three hours after resident records were initially requested, the residence provided progress notes, care plans and assessments for Residents #4, #8 and #20. On 7/5/23 at 12:30 p.m., the residence provided hospital discharge summaries for Resident #22. On 7/5/23 at 2:00 p.m. progress notes for Resident #4, #8 and #20, dated 7/1/23 to 7/5/23, were provided. The memory care director (MCD) stated the residence was currently transitioning from one electronic health system to another. She stated, therefore, progress notes for July 2023 were located in a hand-written binder. The MCD stated she had not thought to provide all progress notes which included July 2023. On 7/5/23 at 4:08 p.m., the AA stated she had difficulty providing documents upon request due to the residence's current transition from one electronic health system to another. The AA stated she was aware of the requirement to provide documentation upon request. She stated the residence thinned resident records every six months and she had difficulty locating the thinned resident record for Resident #22 which included the hospital discharge summaries. She stated this was the reason she had not provided the thinned resident record until 12:30 p.m.

Based on record review and interview, the administrator failed to be responsible for the overall day-to-day operation of the assisted living residence and managing day-to-day delivery of services, affecting 72 current residents. 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. A review of the department database on 7/5/23 read the administrator of record had been at the residence since 3/18/19. The acting administrator (AA) was not listed in the database. On 7/5/23 at 7:00 a.m., Staff #4 stated that he was unaware of who was responsible for the day-to-day operations of the residence since the administrator of record had left employment. He stated he thought it was the resident care director (RCD). On 7/5/23 at 7:33 a.m., the RCD stated the AA was responsible for the day-to-day operations of the residence, and assumed her position at the residence seven or eight weeks prior to the onsite visit. The RCD stated the administrator of record ended employment at the residence almost a year prior. On 7/5/23 at 8:42 a.m., the AA stated she was responsible for the day-to-day operations of the residence. On 7/5/23 at 4:08 p.m., the AA stated the administrator of record had been left employment at the residence one year ago and that she herself had assumed the role as the interim administrator on 5/15/23 after the former AA was terminated. The AA stated her contract ended on 7/15/23, at which point she hoped to be hired as the new executive director (administrator of record). The AA stated she was not fully aware of the requirements for this regulation

Based on record review and interview, the residence failed to establish a fall management program which included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting four of six sample residents who resided in the secure environment (#4, #8, #20 and #22). Specifically, Resident #22 had documented falls on 11/20/22, 12/3/23, 12/28/22 and 5/31/23 resulting in no injury. The residence failed to update Resident #22's care plan to include individual approaches necessary to address the resident's fall risk since 9/22/20. Subsequently, Resident #22 sustained a fall on 6/26/23 and was not admitted to the hospital until 6/28/23 after pain for two days. Upon admission Resident #22 was discovered to have multiple right rib fractures due to her fall. Specifically, Resident #4 had diagnoses that included osteopenia. Resident #4 had a documented fall on 5/31/23 without injury. The residence failed to update Resident #4's care plan to include individual approaches necessary to address the resident's fall risk since 2/8/23. Subsequently, Resident #4 sustained a fall on 6/1/23 with a bump on her head and a fall on 7/2/23 with a skin tear on her right elbow. Findings include:1. Residence policyThe residence's Fall Risk Reduction policy, dated 7/1/21, read in part: "the residence is to update each resident's service plan with interventions after falls with or without injury."2. Resident #22 was admitted to the residence on 10/25/19 with a diagnosis of dementia.a. Record ReviewA grievance submitted by the family member of Resident #22, dated 11/21/22, read that Resident #22 called her family member at 2:00 a.m. on 11/19/22 to get off the floor and was unable to get help due to residence staff not answering the phone. Incident reports and progress notes for Resident #22 from November-December 2022 and May-July 2023 were reviewed and hospital documentation revealed the following: On 11/20/22, a progress note read Resident #22 was found on the floor with no injuries, and at 2:45 a.m., the resident's family member called to let staff know she was on the floor. She was last checked at 12:30 a.m. On 12/3/22, an incident report read the resident was found on the floor in her bedroom laying on her left side. Although the incident report read the resident did not hit her head and there were "No injuries", it further read the resident complained of hip pain. On 12/28/22, a progress note read Resident #22 was found on the floor with no injuries. The family member of Resident #22 agreed to send Resident #22 to the hospital for further observation due to ongoing hip pain. On 12/30/22, a progress note read Resident #22 came back from the hospital. A hospital discharge summary, dated 12/230/22, revealed Resident #22 had no injuries and was found to have influenza and a urinary tract infection (UTI). The residence's care plan for Resident #22, dated 3/14/23, read that Resident #22 was a fall risk, staff were to ensure pathways were free of clutter, observe for use of assistive device, observe for adequate lighting, and ensure proper footwear. The care plan read fall interventions were last updated on 9/22/20 and did not mention the resident had a fall mat and did not include the resident did not like to be awoken at night. On 5/31/23, a progress note read Resident #22 was found on the floor next to her bed with no injuries. The residence's assessment for Resident #22, dated 6/20/23, read that Resident #22 was a fall risk and was independent with transfers. On 6/26/23, an incident report read Resident #22 was found on the floor next to her bed and had pain between ribs. On 6/27/23, a progress note read Resident #22 was restless and complaining of pain. On 6/28/23, a progress note read Resident #22 was still complaining of pain. A hospital admission summary, dated 6/28/23, read that Resident #22 was admitted to the hospital with chest pain and was found to have sustained multiple right rib fractures after a fall. The residence's care plan for Resident #22, dated 7/5/23 and the day of the onsite investigation, read the same as the care plan from 3/14/23. The residence did not update the care plan for Resident #22 to include that Resident #22 used a wheelchair. Although the care plan read fall interventions were last updated on 9/22/20 and included fall interventions, the residence did not consider any individualized variances in fall prevention interventions to address her fall risk related to deficits in strength and balance after any of Resident #22's falls on 11/2022, 12/3/22, 12/28/22 and 5/31/23. On 7/5/23 at 12:30 p.m. a log with hourly rounding on Resident #22 was provided.b. InterviewsOn 7/5/23 at 7:27 a.m., the memory care director (MCD) stated that Resident #22 was still in the hospital and had been there since the end of June 2023. The MCD stated Resident #22 fell and experienced pain from her stomach area and was found to have four broken ribs. On 7/5/23 at 8:22 a.m., Staff #9 stated that Resident #22 had a fall the Monday prior to the onsite investigation, and stated she frequently fell. She stated the resident had a wheelchair for mobility and a fall mat in her room. She stated the resident was able to transfer independently and only struggled with mobility for long distances. Staff #9 stated that Resident #22 required two-hour safety checks. On 7/5/23 at 9:38 a.m., Staff #2 stated that Resident #22 had a wheelchair; however, was independent with transfers and frequently refused assistance since she preferred to ambulate and take care of her continence needs independently. Staff #2 stated most of Resident #22's falls had been in her room when the resident was tired and tried to get out of bed or go to the bathroom. On 7/5/23 at 11:00 a.m., the MCD stated that the care plan for Resident #22 was last updated 9/22/20 for her falls, since the 7/5/23 date was just the day it was printed. The MCD stated they did fall risk assessments after each fall; however, was unaware the care plan needed to be updated with individualized interventions. On 7/5/23 at 12:21 p.m. Staff #5 stated Resident #22 required two hour checks. Staff #5 stated she was on shift when Resident #22 fell on 11/20/22. Staff #5 stated she had last conducted a safety check on Resident #22 at 12:30 a.m.; however, she further stated Resident #22 did not like to be awoken at night. Staff #5 stated she was made aware that Resident #22 had fallen when her family member came to the residence at 2:00 a.m. On 7/5/23 at 12:30 p.m., the acting administrator (AA) stated that staff were to provide hourly safety checks on Resident #22.3. Resident #4 was admitted to the residence on 5/26/22 with diagnoses including osteopenia and dementia.a. Record ReviewThe residence's care plan for Resident #4, dated 3/23/23, read that Resident #4 had a wheelchair, was a fall risk, required one person assistance with transfers, and staff were to ensure she had proper footwear and assistance with ambulation due to poor safety awareness. The care plan read that fall interventions were last updated on 2/8/23. A progress note, dated 5/31/23, read Resident #4 was found was found on the floor by Staff #9 and did not hit her head. A progress note, dated 6/1/23 at 3:15 a.m., read Resident #4 was found on the floor in front of her bed with a large bump on her head. Staff waited on the external hospice provider to come to the residence to assess her. A progress note, dated 6/1/23 at 1:37 p.m., read Resident #4 was in bed all day due to her fall. The residence's assessment for Resident #4, dated 6/14/23, read that Resident #4 was a fall risk and required one person assistance with transfers. A hand written observation note, dated 7/2/23, read that Resident #4 was found on the floor with a small skin tear on her right elbow. The residence's care plan for Resident #4, dated 7/5/23 the day of the onsite investigation, read the same as the care plan dated 3/23/23. Although the care plan read fall interventions were last updated on 2/8/23 and included fall interventions, the residence did not consider any individualized variances in fall prevention interventions to address her fall risk related to deficits in strength and balance after Resident #4's falls on 5/31/23, 6/1/23 and 7/2/23.b. InterviewsOn 7/5/23 at 2:21 p.m., Staff #9 stated that Resident #4 used a wheelchair and staff were to monitor her throughout the day for falls in the residence's dining and activities area. On 7/5/23 at 2:31 p.m., Resident #4's family member stated Resident #4 liked to be independent with activities of daily living (ADLs), had a wheelchair, and was on external hospice services since January 2023. Resident #4's family member further stated that staff monitored Resident #4 in the main areas of the secure environment for her falls. On 7/5/23 a 2:40 p.m., the external hospice provider for Resident #4 stated Resident #4 had a wheelchair and was treated by external hospice for a skin tear from a fall she sustained on 7/2/23. The provider stated the resident had a history of falls and had assessed the resident for admission to external hospice services in December 2022.4. Resident #20 was admitted to the residence on 3/28/22 with a diagnosis of dementia. On 5/2/23, a progress note read in part that Resident #20 hit his head and was found on the floor. External hospice came to evaluate. On 5/12/23, a progress note read in part, Resident #20 tried to get out of his chair and it flipped to the ground. Resident #20 sustained red marks on the left side of his body. The residence's assessment for Resident #20, dated 6/20/23, read Resident #20 was a fall risk and did not have assistive devices. The residence's care plan for Resident #20, dated 7/5/23 the day of the onsite investigation, read Resident #20 required a clutter free environment, staff to observe for adequate lighting and proper footwear. Although the care plan read that fall interventions were last updated on 2/8/23 and included interventions, the residence did not consider any individualized variances in fall prevention interventions after Resident #20's falls on 5/2 and 5/12/23. b. InterviewsOn 7/5/23 at 2:19 p.m., Staff #9 stated she was not aware of any fall interventions that were in place for Resident #20. She stated the resident was unable to stay in one place for long, liked to wander around the residence, and was difficult to redirect. Staff #9 stated that Resident #20 had a wheelchair and seldom used it since he was not able to accept direction or recommendation to use it. On 7/5/23 at 2:28 p.m., Resident #20's family member stated she was unaware what fall interventions the residence had in place for the resident, other than a wheelchair. 5. Resident #8 was admitted to the residence on 9/29/22, with a diagnosis of dementia.a. Record ReviewThe residence's assessment for Resident #8, dated 4/21/23, read that Resident #8 had frequent falls and was independent with transfers. A progress note, dated 5/29/23, read Resident #8 had an unwitnessed fall in the dining area. No injuries were noted. The residence's care plan, dated 6/2/23, read Resident #8 required a clutter free environment, staff were to encourage use of a walker, and staff to observe for adequate lighting and footwear. The care plan read that fall interventions were last updated after a fall on 4/10/23. A progress note, dated 6/6/23, read Resident #8 was found on the floor in her room. No injuries were noted and staff assisted her back to bed. The residence's care plan, dated 7/5/23 the day of the onsite investigation, read the same as the care plan from 6/2/23. Although the care plan read fall interventions were last updated after a fall on 4/10/23 and included interventions, the residence did not consider any individualized variances in fall prevention interventions to address her fall risk related to deficits in strength and balance after Resident #8's falls on 5/29 and 6/6/23. Further, the care plan did not address mobility of the resident. b. InterviewsOn 7/5/23 at 2:21 p.m., Staff #9 stated Resident #8 had a walker and staff were to ensure her room was free of clutter and rugs that she could trip over. On 7/5/23 at 2:48 p.m., Resident #8's family member stated that Resident #8 used a walker. Resident #8's family member was unaware of any other interventions since they were not provided with family management education and materials when Resident #8 was admitted to the residence. 6. Management InterviewsOn 7/5/23 at 11:00 a.m., the MCD stated that she was responsible for updating care plans of Residents #4, #8, #20 and #22 who resided in the secure environment. The MCD stated the care plans dated the day of the onsite investigation were printed today. She stated the last update to the care plans for fall interventions was the date documented in the fall interventions section. The MCD stated she conducted fall risk assessments after each fall; however, was unaware the care plan needed to be updated with individualized interventions since she had just started as the MCD in May 2023. On 7/5/23 at 4:08 p.m., the AA stated the MCD was responsible for updating care plans in the secure environment and should have updated the care plans for Residents #4, #8, #20 and #22 after each fall. The AA stated she was unsure why care plans were not updated after each fall for the above residents to include individualized interventions or why families were not provided with fall management education materials.

A licensure revisit was completed on 7/5/23 for all previous deficiences cited on 12/13/22. Deficiences were cited.

Based on record review and interviews, the licensee failed to notify the department of a change in administrator, affecting 72 current residents. (Cross-reference Q512 and Q540)This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. ReferenceChapter II regulations governing assisted living residences, part 1.36, defines Letter of Intent as, the notification provided to the Department related to an application for a license, to make changes to an existing license, to make changes in services provided by the entity, or for any other business reason the Department requests. 2. Record ReviewOn 7/5/23, the department database read that the administrator of record had been at the residence since 3/18/19. The acting administrator (AA) was not listed in the database. On 7/5/23, a department representative sent an electronic communication that read that the residence had started three draft applications; however, had not submitted a change application that notified the department of the change in administrator since the administrator of record left employment at the residence. 2. InterviewsOn 7/5/23 at 7:00 a.m., Staff #4 stated he was unaware who the new administrator of the residence was and he was under the impression it was the resident care director (RCD). On 7/5/23 at 7:33 a.m., the RCD stated she was not the AA. The RCD stated the AA assumed her position at the residence seven or eight weeks prior to the onsite investigation, and the administrator of record ended employment at the residence almost a year prior. On 7/5/23 at 8:23 a.m., the AA stated she had worked at the residence since 5/15/23. She further stated that the administrator of record had ended employment at the residence one year ago. The AA stated the former AA had worked at the residence for a few months (October to December 2022). The AA stated she was unaware of who the former AA was after that. On 7/5/23 at 8:42 a.m., the business office director (BOD) stated that the administrator of record left the residence in July 2022. The BOD stated the former AA worked at the residence from October to December 2022 and the AA started working at the residence a couple months prior to the onsite investigation. On 7/5/23 at 4:08 p.m., the AA stated she was aware of the requirement to notify the department and there had been issues removing the administrator of record from the license since she was unable to get in touch with him. The AA further stated this deficiency had not been corrected since the former AA failed to submit the change application.

Based on interview and record review, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting 72 current residents. Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (I) Completing, maintaining, and submitting all reports and records required by the Department.b. Chapter VII regulations governing assisted living residences, part 12.8, requires that the comprehensive assessment shall be documented in writing and kept in the resident's health information record.c. Chapter VII regulations governing assisted living residences, part 18.8, requires that resident records shall contain, but not be limited to, the following items:(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.(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.d. A Resident Records Policy, dated 7/1/21, read in part: "the (residence) will maintain resident records in an organized manner ... (and) provide documentation when a surveyor requests."2. Record Review and InterviewsOn 7/5/23 at 9:20 a.m., a complete resident record for Resident #22 including progress notes and hospital discharge documentation, dated November-December 2022 and April-July 2023, was requested. Progress notes, dated from May-July 2023, were requested for Residents #2-#4, #8 and #20. Personnel files for Staff #14-#16 were also requested. The acting administrator (AA) was requested to provide all documentation by 10:15 a.m. The AA stated she was unsure she would be able to provide all requested documents since the residence was between electronic health systems since a new management company took over in April 2023. The AA stated she tried to had to obtain electronic access to their previous electronic health record system and locate all the requested documents since she did not have access since the change occurred in April 2023. On 7/5/23 at 10:32 a.m., paper resident records for Residents #2-#4, #8, #20 and #22 were provided; however, the records did not include assessments, care plans or progress notes. Complete resident records and personnel files were requested a second time. On 7/5/23 at 10:51 a.m. personnel files for Staff #14-#16 were provided. On 7/5/23 at 11:00 a.m., the resident care director stated she would need to retrieve progress notes, assessments and care plans for the sample residents and obtain records from the residence's previous electronic health system. She said this was the reason that complete resident records had not yet been provided. On 7/5/23 at 11:45 a.m., care plans, progress notes, and assessments for Residents #2, #3 and #22 were provided. Care plans, assessments and progress notes for Residents #4, #8 and #20 were not provided. Hospital discharge summaries were not provided for Resident #22. On 7/5/23 at 12:01 p.m., care plans, assessments and progress notes were requested for Residents #4, #8 and #20 and hospital discharge summaries for Resident #22. On 7/5/23 at 12:15 p.m., approximately three hours after resident records were initially requested, the residence provided progress notes, care plans and assessments for Residents #4, #8 and #20. On 7/5/23 at 12:30 p.m., the residence provided hospital discharge summaries for Resident #22. On 7/5/23 at 2:00 p.m. progress notes for Resident #4, #8 and #20, dated 7/1/23 to 7/5/23, were provided. The memory care director (MCD) stated the residence was currently transitioning from one electronic health system to another. She stated, therefore, progress notes for July 2023 were located in a hand-written binder. The MCD stated she had not thought to provide all progress notes which included July 2023. On 7/5/23 at 4:08 p.m., the AA stated she had difficulty providing documents upon request due to the residence's current transition from one electronic health system to another. The AA stated she was aware of the requirement to provide documentation upon request. She stated the residence thinned resident records every six months and she had difficulty locating the thinned resident record for Resident #22 which included the hospital discharge summaries. She stated this was the reason she had not provided the thinned resident record until 12:30 p.m.

Based on record review and interview, the residence failed to ensure its quality management program (QMP) was reviewed annually, affecting 72 current residents. (Cross-reference Q540, Q262)This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 7/5/23 at 10:29 a.m., the acting administrator (AA) stated the last person that reviewed the residence's QMP was the administrator of record. She stated the former AA had refused to review the QMP. On 7/5/23 at 10:34 a.m., the residence provided the QMP that was implemented by the administrator of record. The documentation read the QMP was last reviewed on 3/23/21 with a target completion date of 5/11/21 for several items. Therefore, the residence's QMP was not reviewed annually as required. The members of the QMP team did not include the current acting administrator (AA). On 7/5/23 at 4:08 p.m., the AA stated she was aware of the requirement for the QMP to be reviewed annually and was aware of what needed to be included in a QMP. The AA stated there was currently no QMP in place since she had not had time to implement a QMP because she had just assumed her role on 5/15/23. The AA further stated the deficiency had not been corrected since the former AA did not review or implement it.

Based on record review and interview, the administrator failed to be responsible for the overall day-to-day operation of the assisted living residence and managing day-to-day delivery of services, affecting 72 current residents. (Cross-reference Q512 and Q262)This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. 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. A review of the department database on 7/5/23 read the administrator of record had been at the residence since 3/18/19. The acting administrator (AA) was not listed in the database. On 7/5/23 at 7:00 a.m., Staff #4 stated that he was unaware of who was responsible for the day-to-day operations of the residence since the administrator of record had left employment. He stated he thought it was the resident care director (RCD). On 7/5/23 at 7:33 a.m., the RCD stated the AA was responsible for the day-to-day operations of the residence, and assumed her position at the residence seven or eight weeks prior to the onsite visit. The RCD stated the administrator of record ended employment at the residence almost a year prior. On 7/5/23 at 8:42 a.m., the AA stated she was responsible for the day-to-day operations of the residence. On 7/5/23 at 4:08 p.m., the AA stated the administrator of record had been left employment at the residence one year ago and that she herself had assumed the role as the interim administrator on 5/15/23 after the former AA was terminated. The AA stated her contract ended on 7/15/23, at which point she hoped to be hired as the new executive director (administrator of record). The AA stated she was not fully aware of the requirements for this regulation and was unaware why this deficiency had not been corrected.

Based on record review and interview, the residence failed to ensure a name-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective employee for three of three sample staff (#10-#12) affecting 72 current residents. This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. ReferenceChapter VII regulations governing assisted living residences, part 2.45, defines "staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. 2. Record ReviewThe residence's current staff list revealed hire dates as follows:Staff #10: 5/17/23Staff #11: 6/14/23Staff #12: 5/25/23. The residence's June and July 2023 staff schedule was reviewed and revealed staff worked the following shifts: Staff #10: 2:00 p.m. to 10:00 p.m. on 6/1-6/3/23, 6/6-6/10/23, 6/13-6/17/23, 6/20-6/24/23, 6/27-7/1/23, 7/4/23 and 7/5/23. Staff #11: 2:00 p.m. to 10:00 p.m. on 6/20-6/22/23, 6/26-6/29/23, 7/2/23, 7/4/23 and 7/5/23. Staff #12: 6:00 a.m. to 2:00 p.m. on 6/3-6/5/23, 6/9-6/13/23, 6/17-6/19/23, 6/23-6/26/23 and 7/1-7/3/23. On 7/5/23, the personnel records for Staff #10-#12 each included documentation of criminal history record checks completed by a third-party background check agency. However, the residence had no evidence a criminal history record check was conducted by the CBI. On 7/5/23 at 3:06 p.m., the business office director (BOD) stated the residence began utilizing a a third-party background check company in May 2023. She stated the third-party background check company had conducted the criminal history record checks for Staff #10-#12 and she assumed the criminal history record checks included a name-based search by CBI. The BOD further stated she was not able to provide evidence the results from the third-party background check company included a criminal history record check through the CBI. On 7/5/23 at 3:24 p.m., the BOD stated in May 2023 the residence had started conducting background checks which included a CBI through a third-party background check company. However, she acknowledged when the residence switched management companies, she had assumed but not verified the third-party background check company included a criminal history record check through the CBI. On 7/5/23 at 4:08 p.m., the acting administrator (AA) stated the BOM was responsible for ensuring personnel files contained the required documentation. She stated she was aware of the requirement for a name-based search by CBI to be conducted. The AA further stated this deficiency had previously been corrected; however, with the management company change, it seemed that the new third-party background checks had not been conducted through the CBI.

Based on record review and interview, the residence failed to establish a fall management program which included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting four of six sample residents who resided in the secure environment (#4, #8, #20 and #22). This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #22 had documented falls on 11/20/22, 12/3/23, 12/28/22 and 5/31/23 resulting in no injury. The residence failed to update Resident #22's care plan to include individual approaches necessary to address the resident's fall risk since 9/22/20. Subsequently, Resident #22 sustained a fall on 6/26/23 and was not admitted to the hospital until 6/28/23 after pain for two days. Upon admission Resident #22 was discovered to have multiple right rib fractures due to her fall. Specifically, Resident #4 had diagnoses that included osteopenia. Resident #4 had a documented fall on 5/31/23 without injury. The residence failed to update Resident #4's care plan to include individual approaches necessary to address the resident's fall risk since 2/8/23. Subsequently, Resident #4 sustained a fall on 6/1/23 with a bump on her head and a fall on 7/2/23 with a skin tear on her right elbow. Findings include:1. Residence policyThe residence's Fall Risk Reduction policy, dated 7/1/21, read in part: "the residence is to update each resident's service plan with interventions after falls with or without injury."2. Resident #22 was admitted to the residence on 10/25/19 with a diagnosis of dementia.a. Record ReviewA grievance submitted by the family member of Resident #22, dated 11/21/22, read that Resident #22 called her family member at 2:00 a.m. on 11/19/22 to get off the floor and was unable to get help due to residence staff not answering the phone. Incident reports and progress notes for Resident #22 from November-December 2022 and May-July 2023 were reviewed and hospital documentation revealed the following: On 11/20/22, a progress note read Resident #22 was found on the floor with no injuries, and at 2:45 a.m., the resident's family member called to let staff know she was on the floor. She was last checked at 12:30 a.m. On 12/3/22, an incident report read the resident was found on the floor in her bedroom laying on her left side. Although the incident report read the resident did not hit her head and there were "No injuries", it further read the resident complained of hip pain. On 12/28/22, a progress note read Resident #22 was found on the floor with no injuries. The family member of Resident #22 agreed to send Resident #22 to the hospital for further observation due to ongoing hip pain. On 12/30/22, a progress note read Resident #22 came back from the hospital. A hospital discharge summary, dated 12/230/22, revealed Resident #22 had no injuries and was found to have influenza and a urinary tract infection (UTI). The residence's care plan for Resident #22, dated 3/14/23, read that Resident #22 was a fall risk, staff were to ensure pathways were free of clutter, observe for use of assistive device, observe for adequate lighting, and ensure proper footwear. The care plan read fall interventions were last updated on 9/22/20 and did not mention the resident had a fall mat and did not include the resident did not like to be awoken at night. On 5/31/23, a progress note read Resident #22 was found on the floor next to her bed with no injuries. The residence's assessment for Resident #22, dated 6/20/23, read that Resident #22 was a fall risk and was independent with transfers. On 6/26/23, an incident report read Resident #22 was found on the floor next to her bed and had pain between ribs. On 6/27/23, a progress note read Resident #22 was restless and complaining of pain. On 6/28/23, a progress note read Resident #22 was still complaining of pain. A hospital admission summary, dated 6/28/23, read that Resident #22 was admitted to the hospital with chest pain and was found to have sustained multiple right rib fractures after a fall. The residence's care plan for Resident #22, dated 7/5/23 and the day of the onsite investigation, read the same as the care plan from 3/14/23. The residence did not update the care plan for Resident #22 to include that Resident #22 used a wheelchair. Although the care plan read fall interventions were last updated on 9/22/20 and included fall interventions, the residence did not consider any individualized variances in fall prevention interventions to address her fall risk related to deficits in strength and balance after any of Resident #22's falls on 11/2022, 12/3/22, 12/28/22 and 5/31/23. On 7/5/23 at 12:30 p.m. a log with hourly rounding on Resident #22 was provided.b. InterviewsOn 7/5/23 at 7:27 a.m., the memory care director (MCD) stated that Resident #22 was still in the hospital and had been there since the end of June 2023. The MCD stated Resident #22 fell and experienced pain from her stomach area and was found to have four broken ribs. On 7/5/23 at 8:22 a.m., Staff #9 stated that Resident #22 had a fall the Monday prior to the onsite investigation, and stated she frequently fell. She stated the resident had a wheelchair for mobility and a fall mat in her room. She stated the resident was able to transfer independently and only struggled with mobility for long distances. Staff #9 stated that Resident #22 required two-hour safety checks. On 7/5/23 at 9:38 a.m., Staff #2 stated that Resident #22 had a wheelchair; however, was independent with transfers and frequently refused assistance since she preferred to ambulate and take care of her continence needs independently. Staff #2 stated most of Resident #22's falls had been in her room when the resident was tired and tried to get out of bed or go to the bathroom. On 7/5/23 at 11:00 a.m., the MCD stated that the care plan for Resident #22 was last updated 9/22/20 for her falls, since the 7/5/23 date was just the day it was printed. The MCD stated they did fall risk assessments after each fall; however, was unaware the care plan needed to be updated with individualized interventions. On 7/5/23 at 12:21 p.m. Staff #5 stated Resident #22 required two hour checks. Staff #5 stated she was on shift when Resident #22 fell on 11/20/22. Staff #5 stated she had last conducted a safety check on Resident #22 at 12:30 a.m.; however, she further stated Resident #22 did not like to be awoken at night. Staff #5 stated she was made aware that Resident #22 had fallen when her family member came to the residence at 2:00 a.m. On 7/5/23 at 12:30 p.m., the acting administrator (AA) stated that staff were to provide hourly safety checks on Resident #22.3. Resident #4 was admitted to the residence on 5/26/22 with diagnoses including osteopenia and dementia.a. Record ReviewThe residence's care plan for Resident #4, dated 3/23/23, read that Resident #4 had a wheelchair, was a fall risk, required one person assistance with transfers, and staff were to ensure she had proper footwear and assistance with ambulation due to poor safety awareness. The care plan read that fall interventions were last updated on 2/8/23. A progress note, dated 5/31/23, read Resident #4 was found was found on the floor by Staff #9 and did not hit her head. A progress note, dated 6/1/23 at 3:15 a.m., read Resident #4 was found on the floor in front of her bed with a large bump on her head. Staff waited on the external hospice provider to come to the residence to assess her. A progress note, dated 6/1/23 at 1:37 p.m., read Resident #4 was in bed all day due to her fall. The residence's assessment for Resident #4, dated 6/14/23, read that Resident #4 was a fall risk and required one person assistance with transfers. A hand written observation note, dated 7/2/23, read that Resident #4 was found on the floor with a small skin tear on her right elbow. The residence's care plan for Resident #4, dated 7/5/23 the day of the onsite investigation, read the same as the care plan dated 3/23/23. Although the care plan read fall interventions were last updated on 2/8/23 and included fall interventions, the residence did not consider any individualized variances in fall prevention interventions to address her fall risk related to deficits in strength and balance after Resident #4's falls on 5/31/23, 6/1/23 and 7/2/23.b. InterviewsOn 7/5/23 at 2:21 p.m., Staff #9 stated that Resident #4 used a wheelchair and staff were to monitor her throughout the day for falls in the residence's dining and activities area. On 7/5/23 at 2:31 p.m., Resident #4's family member stated Resident #4 liked to be independent with activities of daily living (ADLs), had a wheelchair, and was on external hospice services since January 2023. Resident #4's family member further stated that staff monitored Resident #4 in the main areas of the secure environment for her falls. On 7/5/23 a 2:40 p.m., the external hospice provider for Resident #4 stated Resident #4 had a wheelchair and was treated by external hospice for a skin tear from a fall she sustained on 7/2/23. The provider stated the resident had a history of falls and had assessed the resident for admission to external hospice services in December 2022.4. Resident #20 was admitted to the residence on 3/28/22 with a diagnosis of dementia. On 5/2/23, a progress note read in part that Resident #20 hit his head and was found on the floor. External hospice came to evaluate. On 5/12/23, a progress note read in part, Resident #20 tried to get out of his chair and it flipped to the ground. Resident #20 sustained red marks on the left side of his body. The residence's assessment for Resident #20, dated 6/20/23, read Resident #20 was a fall risk and did not have assistive devices. The residence's care plan for Resident #20, dated 7/5/23 the day of the onsite investigation, read Resident #20 required a clutter free environment, staff to observe for adequate lighting and proper footwear. Although the care plan read that fall interventions were last updated on 2/8/23 and included interventions, the residence did not consider any individualized variances in fall prevention interventions after Resident #20's falls on 5/2 and 5/12/23. b. InterviewsOn 7/5/23 at 2:19 p.m., Staff #9 stated she was not aware of any fall interventions that were in place for Resident #20. She stated the resident was unable to stay in one place for long, liked to wander around the residence, and was difficult to redirect. Staff #9 stated that Resident #20 had a wheelchair and seldom used it since he was not able to accept direction or recommendation to use it. On 7/5/23 at 2:28 p.m., Resident #20's family member stated she was unaware what fall interventions the residence had in place for the resident, other than a wheelchair. 5. Resident #8 was admitted to the residence on 9/29/22, with a diagnosis of dementia.a. Record ReviewThe residence's assessment for Resident #8, dated 4/21/23, read that Resident #8 had frequent falls and was independent with transfers. A progress note, dated 5/29/23, read Resident #8 had an unwitnessed fall in the dining area. No injuries were noted. The residence's care plan, dated 6/2/23, read Resident #8 required a clutter free environment, staff were to encourage use of a walker, and staff to observe for adequate lighting and footwear. The care plan read that fall interventions were last updated after a fall on 4/10/23. A progress note, dated 6/6/23, read Resident #8 was found on the floor in her room. No injuries were noted and staff assisted her back to bed. The residence's care plan, dated 7/5/23 the day of the onsite investigation, read the same as the care plan from 6/2/23. Although the care plan read fall interventions were last updated after a fall on 4/10/23 and included interventions, the residence did not consider any individualized variances in fall prevention interventions to address her fall risk related to deficits in strength and balance after Resident #8's falls on 5/29 and 6/6/23. Further, the care plan did not address mobility of the resident. b. InterviewsOn 7/5/23 at 2:21 p.m., Staff #9 stated Resident #8 had a walker and staff were to ensure her room was free of clutter and rugs that she could trip over. On 7/5/23 at 2:48 p.m., Resident #8's family member stated that Resident #8 used a walker. Resident #8's family member was unaware of any other interventions since they were not provided with family management education and materials when Resident #8 was admitted to the residence. 6. Management InterviewsOn 7/5/23 at 11:00 a.m., the MCD stated that she was responsible for updating care plans of Residents #4, #8, #20 and #22 who resided in the secure environment. The MCD stated the care plans dated the day of the onsite investigation were printed today. She stated the last update to the care plans for fall interventions was the date documented in the fall interventions section. The MCD stated she conducted fall risk assessments after each fall; however, was unaware the care plan needed to be updated with individualized interventions since she had just started as the MCD in May 2023. On 7/5/23 at 4:08 p.m., the AA stated the MCD was responsible for updating care plans in the secure environment and should have updated the care plans for Residents #4, #8, #20 and #22 after each fall. The AA stated she was unsure why care plans were not updated after each fall for the above residents to include individualized interventions or why families were not provided with fall management education materials. The AA stated she was unsure why this deficiency had not been corrected.

Based on observation and interviews, the residence failed to ensure residents had independent access to drinks at all times, affecting 29 current residents residing in the secure environment. This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 7/5/23 during the onsite visit from approximately 7:30 a.m. to 8:30 a.m., there was an empty side table with cups available; however, there was no pitcher of water available to ensure that residents in the secure environment had independent access to drinks at all times. However, staff did provide residents with drinks at breakfast time at around 8:00 a.m. On 7/5/23 at 8:13 a.m., Staff #7 stated kitchen staff should have placed a water pitcher on the empty table where the cups were located at 7:30 a.m. Staff #7 stated that drinks were provided throughout the day and the last time liquids were served to residents was at 7:30 p.m. the previous evening. Staff #7 stated staff did not serve liquids to residents during the overnight shift from 7:30 p.m. to 7:30 a.m. unless they asked for it. Staff #7 confirmed the residence did not provide residents with independent access to drinks during the overnight shift. On 7/5/23 at 4:08 p.m., the acting administrator (AA) stated she was aware of the requirement that residents in the secure environment had independent access to drinks at all times. She stated she was unaware why the deficiency had not been corrected. On 7/5/23 at 4:25 p.m., the memory care director (MCD) stated she was unaware residents hade independent access to drinks at all times. The MCD stated kitchen staff remove the water pitcher in the evening at 7:30 p.m. and put it back in the morning at 7:30 a.m.

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 and other residents with whom they have contact, affecting two of two sample residents with behavioral expressions (#8 and #20). This deficiency was cited previously during a state licensure survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. 1. Residence PolicyThe residence's Resident Assessment and Service Plan policy, dated 1/9/21, read in part that the service plan (care plan) for the residents should contain behavioral expressions. 2. Resident #8 was admitted to the residence on 9/29/22 with a diagnosis of dementia with behavioral disturbance. Progress notes for Resident #8, read in part as as follows: On 2/28/23, Resident #8 swatted in front of the face of another unknown resident. On 4/25/23, Resident #8 was easily agitated. On 5/16/23, Resident #8 has been agitated after family member visits and yelled at staff and other residents. On 5/29/23, Resident #8 tried to push the exit door to leave and was very aggressive about it. On 5/30/23, Resident #8 scratched staff and hit her family member and Resident #23 and #24. Local law enforcement was called and all parties notified. On 6/1/23, Resident #8 yelled at her family member. On 6/5/23, Resident #8 tried to open other residents' doors. When the qualified medication administration person (QMAP) intervened, the resident hit the QMAP in the face. On 6/8/23, Resident #8 was exit-seeking and agitated the first half of the evening. The residence's most current assessment for Resident #8, dated 4/21/23, read the resident exhibited physical and verbal aggression behavior towards others. Additionally, the assessment read Resident #8 expressed agitation and anxiety. The residence's most current care plan for Resident #8, dated 4/21/23, read that Resident #8 became agitated, especially after her family member left the residence. The care plan read staff were to redirect the resident by never saying "no" to her, providing reassurance that she was safe, assisting her to her room, informing her that her family member would return soon, and offer her a coffee. The care plan also read if none of the approaches worked, staff were to notify the family member. However, the care plan did not specify that Resident #8 had exit-seeking and verbally and physically aggressive behaviors, and contained no description of individualized approaches to be implemented by staff to protect the resident and other residents with whom they had contact. On 7/5/23 at 2:21 p.m., Staff #9 stated that Resident #8 was more verbally aggressive than physically aggressive and used profanity when she was upset. Staff #9 stated that Resident #8 liked companionship and had increased aggression when she was alone. Staff #9 stated that Resident #8 had recently been physically aggressive toward other staff. She stated the resident had expressed physically aggressive toward other residents once previously on 5/30/23; however, it was only a tap to their shoulder and was not a hit. Staff #9 stated that Resident #8 required redirection and distraction such as activity engagement to help her calm down. On 7/5/23 at 4:08 p.m., the acting administrator (AA) stated she was unaware why the care plan for Resident #8 did not include that she was verbally and physically aggressive and had exit-seeking behaviors. She stated she was not aware of the requirement for enhanced care plans to include known behavioral expression and how to keep the resident and other residents safe. On 7/5/23 at 4:39 p.m., the memory care director (MCD) acknowledged that Resident #8 had expressed exit-seeking behaviors, and verbally and physically aggressive behaviors in the past. The MCD acknowledged the incident that occurred on 5/30/23 and said it was deemed a behavioral episode over an altercation. She stated no other residents had ever been injured by the resident and that was the first time something like that had occurred. 3. Resident #20 was admitted to the residence on 3/28/22 with a diagnosis of dementia. Progress notes for Resident #20, read in part as as follows:On 2/2/23, Resident #20 hit Staff #13 and threw chairs and other items in the dining area, tried hitting other residents around him and yelled aloud. Local law enforcement was called. On 2/3/23, Resident #20 yelled profanities at other residents and staff. On 2/25/23, Resident #20 yelled profanities at Staff #9 during medication pass and chased Staff #9 out of his room after he took his medication. Resident #20 then threw a chair in the west dining area and when Staff #9 ran over to see what happened, Resident #20 swung at Staff #9 and grabbed her arm leaving a scratch mark. The resident care director (RCD) intervened, and Resident #20 hit her back and twisted her wrist. Local law enforcement were called due to inability to calm Resident #20 down. The residence's most current assessment for Resident #20, dated 6/14/23, read that the resident had no physically or verbally aggressive behavior. The residence's most current care plan for Resident #20, dated 4/28/23, read that Resident #20 became agitated, at times, so it was helpful for staff to take him on a walk, guide him to his room and tell him that his family member would be there shortly. The care plan also read if none of the approaches worked, to notify the QMAP who would then contact the external hospice provider. However, the care plan did not specify that Resident #20 had verbally and physically aggressive behaviors and contained no description of individualized approaches to be implemented by staff to protect the resident and other residents with whom they had contact. On 7/5/23 at 9:41 a.m., Staff #2 stated that Resident #20 became verbally and physically aggressive toward staff and two staff members should go together whenever care was provided to Resident #20. Staff #2 stated that Resident #20 responded well to a calm voice when speaking to him. On 7/5/23 at 2:19 p.m., Staff #9 stated that the incident in February 2023 caused bruising on her arm. Staff #9 stated Resident #20 exhibited moments of physical and verbal aggression and staff should stand back at least six feet at all times after providing care. Staff #9 stated staff should provide the resident with redirection, or walk away and approach him once he became calm. On 7/5/23 at 4:08 p.m., the acting administrator stated she was unaware of the reason the care plan for Resident #20 did not include that he was verbally and physically aggressive. On 7/5/23 at 4:39 p.m., the MCD acknowledged that Resident #20 had expressed verbally and physically aggressive behaviors in the past. 4. InterviewsOn 7/5/23 at 4:08 p.m., the AA stated she was not aware of the requirement for enhanced care plans to include known behavioral expressions and how to keep the resident and other residents safe. The AA stated she was unsure why this deficiency had not been corrected. On 7/5/23 at 4:39 p.m., the MCD stated she was aware of the requirement for enhanced care plan to include known behavioral expressions and how to keep other residents safe. She stated she had thought including agitation as the behavior for Resident #8 and #20 on the care plan was sufficient.

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 2.2.3.6. Applicants must show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements as set forth in section 26-3.1-111, C.R.S.