WESTERN SLOPE MEMORY CARE

A licensure complaint, prompted by #CO42203, was conducted on 5/7/26. Two deficiencies were cited.

Based on interviews and record review, the residence failed to require staff members to document, before the end of their shift, any out-of-the-ordinary event or issues affecting one of four sample residents (#1). Findings include:1. Resident #1 was admitted to the residence on 4/15/26 with a diagnosis of Alzheimer ' s dementia. Progress notes of all out-of-the-ordinary events affecting Resident #1 were requested; however, there was no documentation in progress notes of the following:Confidential staff #1 was interviewed on 5/6/26 at 8:25 a.m. They said Resident #1 put a pair of earrings in her mouth and confidential staff #1 was afraid she would choke on the earrings or injure herself if the earrings were sharp. Confidential staff #1 said they informed management and nothing was done about it. Confidential staff #1 said it was an out-of-the-ordinary event for the resident. Staff #1 was interviewed on 5/6/26 at approximately 8:45 a.m. Staff #1 said Resident #1 put the jewelry in her mouth a couple of times and it was hard to get it out of her mouth. She said she believed they were earrings. Staff #1 said Resident #1 took the jewelry out of her mouth, threw the jewelry down the hallway and said "good luck finding them." Staff #1 said she should have documented the incident but did not. Staff #2 was interviewed on 5/7/26 at 9:05 a.m. Staff #2 said progress notes were supposed to be documented at the end of the shift by the qualified medication administration personnel (QMAPs). She said progress notes were documented when anything out-of-the-ordinary occurred or the resident had a major change in their baseline. She said she was not present for Resident #1 doing anything out-of-the-ordinary but if a resident was putting non-edible items in their mouth the QMAP needed to document it in a progress note so other staff were aware of it. The resident care coordinator (RCC) was interviewed on 5/7/26 at 9:35 a.m. The RCC said she was unaware of Resident #1 having pins, earrings or jewelry and did not know she placed them in her mouth. She said it should have been documented in an incident report because it was an out-of-the-ordinary event. She said she was not sure why the staff did not document a progress note or incident report when they saw Resident #1 with jewelry in her mouth.

Based on record review and interview, the residence failed to provide an enhanced care plan (ECP) affecting four of four (#1, #2, #3 and #4) residents who resided in the secured environment. Findings include:1. Residence policyThe Resident's Care Plan and Enhanced Care Plan policy, undated, was provided by the residential care coordinator (RCC) on 5/6/26 at 10:10 a.m. It read in pertinent part:"At the time of the resident's initial assessment, the resident/guardian along with applicable parties, will describe the wandering patterns and known behavioral expressions of the resident along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact. Care staff will contribute to additional approaches to be added to the care plan that have proven successful during direct care."The resident shall have continuous independent access to his/her room. If restricting unwanted visitation by other residents becomes necessary, the facility will provide a locking mechanism with the consent of the resident/guardian. The resident will receive a key to their room in addition to the care staff and maintenance department. This information will be documented in the care plan. "At the time of the resident's initial assessment, in conjunction with the resident/guardian, it will be determined to what extent of supervision and oversight is necessary by care staff to ensure the needs of the resident within the secured environment and secured outdoor area. This information will be documented in the care plan."At the time of the resident's initial assessment, it will be determined by the admissions staff and resident/guardian, along with applicable parties, what items for personal grooming and hygiene are safe to remain in the possession of the resident for self-care and which items must remain in a secured, lock storage. Items remaining in the possession of the resident must not be accessible to other residents. Should uninvited visitation occur, a locking mechanism will be installed with the consent of the resident/guardian. A key will remain with the resident as well as care staff and maintenance. This information will be documented in the care plan."2. Record ReviewResident #3 was admitted to the residence on 9/20/21 with a diagnosis of dementia, schizoaffective disorder and paranoid schizophrenia chronic condition with acute exacerbation. A service (care) plan, dated 3/15/25, read in part, keep hygiene supplies in a locked/secure box in [resident's] bathroom. 3. InterviewConfidential staff #1 was interviewed on 5/6/26 at 8:25 a.m. Confidential staff #1 said Resident #3 frequently refused to be toileted until he was soaked with urine and the behaviors were not dealt with by management. Staff #1 was interviewed on 5/6/26 at approximately 8:45 a.m. Staff #1 said Resident #3 frequently refused to be toileted until he was soaked with urine but the day before the survey was a good day and he allowed staff to assist him. The resident care coordinator (RCC) was interviewed on 5/7/26 at 9:35 a.m. The RCC said she was unaware the enhanced care plans were missing items according to their policy and state regulation. She said the residence's policy mirrored the regulation and the enhanced care plans needed to reflect their policy because they were a secured environment. The RCC said her nurse was going to go through all of the care plans to ensure they had what was missing from the four care plans that were looked at. The RCC agreed Resident #3's care plan did not have his wandering patterns, known behavioral expressions, protection from unwanted visitors, identification of the type and level of staff oversight, monitoring or accompaniment that the residence deemed necessary to meet his needs within the secured environment and secured outdoor environment. 3. Evidence revealed similar deficient practice for Residents #1, #2 and #4.

A licensure and complaint revisit was completed on 6/4/25 for all previous deficiencies cited on 7/11/24. The residence is in compliance with all regulations surveyed.

A licensure complaint revisit was completed on 6/4/25 for all previous deficiencies cited on 7/11/24. The residence is in compliance with all regulations surveyed.

A licensure and complaint revisit was completed on 7/11/24 for all previous deficiencies cited on 1/25/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 1/14/24. Tag S3060 was not cited in the previous event; however, the deficiency was included in the previous event's informational 9999 tag.

Based on observation, record review, and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting four of four sample residents (#9, #10, #13, #14) who experienced falls. (Cross-reference S3074, S1326)This deficiency was cited previously during a state licensure survey 1/25/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #9 fell on 6/1/24 at 3:00 p.m., 6/1/24 at 5:00 p.m., 6/22/24 at 9:30 p.m., 6/22/24 at 4:49 p.m., and 6/27/24 at 9:10 a.m., and the residence failed to update the resident's care plan with new individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication. Subsequently, the resident fell on 7/3/24 and was diagnosed with a fractured left shoulder blade on 7/4/24. The resident had his arm in a sling, and his practitioner ordered him to keep his arm in the sling until he was seen by an orthopedic specialist. The residence failed to update the resident's care plan with new individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight or effects of medication, and the resident continued to be at risk for serious injury due to falls. Specifically, Resident #10 fell on 4/29/24 and sustained an injury to his face; he fell again on 5/1/24 and experienced pain and a limp. The resident fell again 5/21/24 and the residence failed to update the resident's care plan with new individualized approaches to address fall risk related to deficits in strength, balance, and eyesight, nor the effects of medication. Subsequently, on 5/26/24 he fell and sustained a hip fracture, and the residence again failed to update the resident's care plan with new approaches to address the resident ' s fall risk. The resident fell three times on 6/8/24, 6/9/24, and 6/10/24 and the residence implemented a chair alarm and placed his mattress on the floor on 6/8-6/10/24. However, the approaches were ineffective, and the resident fell on 6/14/24, 6/15/24, 6/20/24, twice on 7/5/24, and twice on 7/8/24. The resident ' s practitioner adjusted medication; however, the residence again did not update the resident's care plan with approaches to address the resident ' s fall risk, and the resident continued to be at risk of injury due to falls. These failures created an immediate jeopardy risk of falls with serious injury to two sample residents. On 7/10/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Residence PolicyThe residence ' s undated Falls Prevention and Management Program policy read in part: "The program focuses on reducing the residents ' falls and mitigating risks of falls through a resident focused (sic) approach that ensures that a resident ' s environment and social, physical, cognitive, and emotional strengths are supported. Initiate a written plan of care with (sic) 24 hours of admission based on resident ' s evaluated condition, fall history, needs, behaviors, and medications. If interventions have not been effective in reducing falls, initiate alternative approaches and update as necessary."2. Resident #9 was admitted to the residence on 4/30/24, with diagnoses including dementia. a. ObservationsOn 7/10/24 and 7/11/24, Resident #9 used a wheelchair for all ambulation. On 7/10/24 at 3:38 p.m., Resident #9 was lying on his mattress, which was elevated off of the floor by a bed frame, box spring, and mattress. The resident ' s feet and legs were protruding from the bed while his upper body was positioned on the bed. The residence placed no assistive devices nearby, did not change or lower his bed, nor implement other approaches toremove fall risk. b. Record ReviewFall audit reports for Resident #9 are read in part as follows:On 6/1/24 at 1:00 p.m., Resident #9 "was in activities, turned to sit in (a) chair and missed. No complaint of pain, able to stand." On 6/1/24 at 3:00 p.m., Resident #9 "was standing in activities, fall assessment done. Negative finding. High fall risk."On 6/22/24 at 9:30 p.m., Resident #9 "was observed on the floor in (his) room. (Staff provided) local care to (a) skin tear. (Resident #9 was) impulsive ..." On 6/22/24 at 4:49 p.m., "Res (a bystanding resident) observed [Resident #9] stand up and fall onto (his) back. Red area only on the back of (his)head."On 6/27/24 at 9:10 a.m., Resident #9 was "observed on (the) bathroom floor. (Staff) assessed (the resident with) negative findings." The resident's mentation/mobility (was at) baseline. On 7/3/24 at 3:40 p.m., Resident #9 was "observed lying on (his) back. No injury noted to (his) head. Mild crepitus (in his) left shoulder. Ice pack applied. Increased pain." On 7/7/24 at an undocumented time, Resident #9 sustained "swelling and contusions. (He was transported to the) emergency department (ED) for X-rays, positive nondisplaced left scapula fracture. Returned to (the residence). Obtained medications. Admitted to [an external hospice agency]." Incident reports (IR ' s) for Resident #9 read in part as follows:On 6/27/24, the resident was found on the floor beside the toilet wall holding his head. It was unknown if Resident #9 fell getting on or off the toilet. The resident had redness on his head. The resident had no safety awareness and was compulsive. The resident ' s fall risk level was at 27. A fall risk assessment form was attached to the IR which measured eight categories and rated the resident with an overall score. The categories included: regent fall history, ambulation/incontinence, mental status, vision, balance, blood pressure, medications, and predisposing conditions or disease. The bottom of the form read: "A total score of 10 or more indicated a resident ' at risk ' for falls." On 7/3/24, residence staff heard a crash and found Resident #9 on the floor, assisted him to sit up, and found no evidence of abrasions or contusions. Resident #9 complained about left shoulder pain. A palpable or audible grating or crunching sensation produced by motion was observed in the shoulder joint. On 7/4/24, the licensed practical nurse (LPN) learned about Resident #9 ' s fall that occurred on 7/3/24. Resident #9 complained of pain with any movement or touch to the left shoulder, which was ' very edematous ' compared to the right shoulder. The resident was moaning and holding his left shoulder. Once the health and wellness director (HWD) was informed of Resident #9 ' s status, they had him transported to the ED. Progress notes for Resident #9 read in part as follows:On 7/8/24, the HWD spoke to Resident #9 ' s daughter to learn he had a computed tomography (CT) scan scheduled for 7/10/24 at 7:00 a.m. before his appointment on 7/11/24 with his orthopedist. On 7/9/24, an unidentified staff member wrote that Resident #9 had been in a lot of pain and could not sit up to take pain medications, had a very dry mouth, and his fluid intake had decreased. On 7/10/24, Resident #9 returned to the residence with written practitioner's orders for pain medication. Resident #9 ' s had an upcoming scheduled appointment with the orthopedist on 7/11/24 at 10:00 a.m. The care plan, dated 6/30/24, had a handwritten note that read: "Uses cane and walker—frequently forgets," despite the resident ' s exclusive use of a wheelchair to ambulate. Additionally, the undated portions of the care plan read in part that the resident may have a physical therapy (PT) or occupational therapy (OT) consultation if it was appropriate and that the resident was unable to use the call light response system. The residence did not document the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication in the care plan. 3. InterviewsOn 7/10/24 at 2:32 p.m., a family member of Resident #9 stated that the residence planned to change the resident ' s bed to a hospital bed; however, the staff had not yet implemented this intervention. On 7/11/24 at 8:44 a.m., a representative from EPTA #2 stated Resident #9 demonstrated that he could not comprehend training and scored negatively on a cognitive test. The representative also confirmed that Resident #9 had not been admitted for external hospice services yet. On 7/11/24 at 9:17 a.m., the administrator stated that she acknowledged the residence had not identified the fall risks for Resident #9 until the date of the onsite investigation and stated that he could have fallen and significantly injured himself increasing the risk of death. In a later interview, at 11:30 a.m., the administrator stated that Resident #9 had received PT services; however, the resident did not have any ability to retain what he learned from PT, and therefore the PT was ineffective. She added the residence had not added any other approaches to the resident ' s care plan to mitigate his falls. On 7/11/24 at 09:55 a.m., the HWD confirmed that no approaches were put in place for Resident #9 to address fall management before the onsite investigation. She continued to say that she did not believe there were any other approaches that could be put in place to help mitigate falls for Resident #9 because "he is impulsive."On 7/11/24 at 11:30 a.m., the administrator stated that she thought this deficiency had been corrected but acknowledged that it had not been due to the Resident #9's current fall risks and the residence ' s failure to implement effective fall interventions when she learned that the staff interventions to mitigate falls were not effective. 4. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed two current residents at immediate jeopardy risk for falls with injury. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 7/10/24 at 5:22 p.m., the administrator submitted written evidence that read: "1) Resident #9 is with a 1:1 caregiver 24/7, until a higher level of care is found for him. Resident #9 will have his bed mattress put directly on the floor. Resident #10 was reviewed by the Hospice Medical Director, and changes to his medications were made related to his anxiety falling, he has not had a fall since these medication changes were made on 7/8/24. Pursue a wheelchair cushion for #6. These care plan interventions will be added for residents #9 and #10. (HWD) was educated that the interventions that are reviewed in Resident at Risk need to be put on the care plan. Fall assessment looking at medications, eye site, balance, continence and other comorbidities have been completed for all residents #9 and #6. 2) Audit the care plans for all the residents that have had a fall in the last 30 days and make sure that correct and appropriate interventions are implemented. 3) Audit all new falls for care plan interventions to ensure that they are appropriate for each resident and that a new intervention is added after each fall. After 30 days, will audit 5 fallsmonthly for three months until substantial compliance with falls interventions is ascertained by (quality management program). Will review multiple fallers weekly at Resident at Risk and ensure that they are appropriate forour level of care. Will add education to orientation for new staff. 4) Will educate all staff on fall prevention and intervention by 7/31/24. Will add education to orientation for new staff."However, the written evidence did not indicate the risk had been removed because the residence had not included implementation, auditing, and training timelines. The residence failed to identify the correct residents for some of the approaches, and the residence did not address how they would identify fall interventions to add to the care plans consistently. On 7/10/24 at 5:34 p.m., the administrator submitted written evidence that read in part that the residence implemented a one-on-one caregiver on 7/10/24 and correctly identified Resident #9 and #10. The evidence further read that the residence would identify individual fall interventions in the fall risk assessment. The residence would implement staff training on fall management for Residents #9 and #10 on 7/10/24. However, the written evidence did not indicate that the risk had been removed because it did include a timeline for when the residence planned to audit the care plans of residents who sustained falls within 30 days prior to the onsite investigation. On 7/10/24 at 5:55 p.m., the administrator submitted written evidence that read in pertinent part that on 7/12/24, the HWD planned to audit the care plans for all the residents who fell within 30 days of the onsite investigation to ensure the residence implemented correct and appropriate interventions. Additionally, after 30 days, the residence planned to audit five falls monthly for three months until substantial compliance with fall management was determined by the residence ' s fall management program measures. 5. Additionally, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance for Residents #9, #13, and #14.

Based on observation and interview, the residence failed to ensure the residents' right to be free of restraint, affecting five of eight sample residents (#10-#12, #14, #15). (Cross-reference S1410)Findings include:1. Residence PolicyThe residence's undated Resident Rights policy read in part that residents had the right to be free of confinement and restraint. The residence's undated Restraint-Free Care policy read in part that, in most cases, the use of restraints was a form of neglect or abuse. The residence defined a restraint as a physical device, item, or practice that restricted a resident's freedom of movement. Restraints may be used to prevent a resident from scratching and touching areas of their bodies or to prevent the spread of infection. The residence must ensure that the residents had the right to be free from restraint. Restraints were inherently dangerous, specifically when applied to residents with cognitive impairment. Restraints often caused incontinence, decreased mobility, decreased independence, and often led to increased agitation. 2. ObservationsOn 7/10/24 at 9:16 a.m., Resident #11 wore a one-piece outfit with a zippered back. The zipper was inaccessible to the resident, so he pulled it at the front of the outfit and attempted to remove it. The resident moaned and continued to pull at the outfit until Staff #16 lowered the zipper. The resident removed the top of the outfit and stopped moaning. 3. Resident #11 was admitted to the residence on 1/12/24 with diagnoses including frontotemporal dementia, anxiety, blindness, and hemorrhagic telangiectasia disease. A care plan, dated 1/12/24, read in part that the resident had severe cognitive impairment, was legally blind, had chronic anxiety, and required staff to dress and undress him. The external hospice provider (EHP) care plan, dated 6/19/24, read in part that the resident demonstrated behavioral expressions, including urinating on the floor when the resident did not wear the outfit that he was unable to remove independently. 4. InterviewsOn 7/10/24 at 9:16 a.m., Staff #16 stated that Resident #11 had behavioral expressions that included urinating on the floor or on furniture and removing his incontinence product. She added that the staff ensured that the resident wore an outfit that only staff could fasten or unfasten, as the zipper was located on the backside of the outfit. The staff ensured that the resident wore an outfit that only staff could fasten or unfasten, as the zipper was located on the backside of the outfit. Staff #16 stated that the resident attempted to remove the outfit at times but was unsuccessful. She added that he was not permitted to remove the outfit independently to avoid the behavioral expressions. Staff #15 stated that staff were required to assist the resident with toileting every two hours; however, since the resident was unable to independently remove the outfit, he experienced bowel and bladder accidents when staff were unable to assist him in a timely fashion.. On 7/11/24 at 10:13 a.m., the health and wellness director (HWD) stated that the purpose of the outfit worn by Resident #11 was to prevent him from removing his clothing and urinating on the floor. She stated that the definition of a restraint included a device that impeded movement and independence. The HWD added she had not thought of the outfit as a restraint because the resident was admitted to the residence with it, and the resident's family member wanted him to wear it. She affirmed the resident was unable to remove it independently. On 7/11/24 at 11:41 a.m., the administrator stated that a restraint was a device that the resident was unable to remove and limited a resident's independence. She affirmed that the residence utilized clothing and devices such as chair and bed alarms, or leg rests, on residents; they were unable to remove or adjust the clothing and devices independently. The administrator affirmed the residents were unable to remove the devices which limited their mobility and independence. She added that she believed the residence was able to implement restraints when residents were admitted to the residence with them, in some cases, when a practitioner ordered the devices. 5. Additionally, the residence failed to ensure the resident right to be free of restraint for Residents #10, #12, #14, #15.

ased on record review and interview, the residence failed to investigate allegations of abuse of a resident, affecting one sample resident (#12). (Cross-reference S1326)This deficiency was cited previously during a state licensure survey on 1/25/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.1, defines abuse as any of the following acts or omissions:(A) The non-accidental infliction of bodily injury, serious bodily injury or death,(B) Confinement or restraint that is unreasonable under generally accepted caretaking standards, or(C) Subjection to sexual conduct or contact that is classified as a crime.b. The residence ' s undated Abuse/Neglect policy read in part that the initial response to allegations of abuse, mistreatment, involuntary seclusion, or misappropriation of property greatly affected the resident ' s feelings of safety and comfort. All cases of alleged abuse must be reported immediately to the administrator. The physician and family/representative should be notified immediately.c. The residence ' s undated Restraint-Free Care policy read in part that in most cases the use of restraints was a form of neglect or abuse. 2. Resident #12 was admitted to the residence on 12/20/23 with the diagnosis of dementia with behavioral disturbance. A progress note, dated 3/2/24, read in part that three unidentified staff members held down Resident #12 ' s hands and feet while they changed her clothing. The residence provided all abuse investigations from February 2024 to July 2024; however, the investigations did not include an investigation of the alleged abuse/restraint of Resident #12 on 3/2/24.3. InterviewsOn 7/11/24 at 10:21 a.m., the health and wellness director (HWD) stated that all allegations were reviewed right away and the administrator reviewed them within 72 hours. Regarding the incident on 3/2/24 with Resident #12, the HWD said she was not aware that this incident happened. She further stated that the residence should investigate the incident, but they did not. On 7/11/24 at 11:50 a.m., the administrator stated she was not aware of the incident on 3/2/24 with Resident #12; however, she had access to the progress note that detailed the incident. She added that the residence failed to investigate the incident. The administrator stated that based on the progress note, the staff applied a possible restraint that was unreasonable under generally accepted caretaking standards which fit within the definition of abuse, and that the residence should have investigated the allegation. She added that the residence did not correct this citation as the administrator was out of the residence and unaware of the incident.

Based on record review and interviews, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one sample resident (#15). This deficiency was cited previously during a state licensure survey on 1/25/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. The residence ' s undated Administering Medication policy read in part that the residence was required to administer medications to the resident when ordered by an authorized practitioner. Resident #15 was admitted to the residence on 12/22/23 with diagnoses including depression and dementia. A written practitioner's order, dated 3/25/24, directed the residence to administer citalopram hydrobromide 20 mg once daily. However, the July 2024 medication administration record (MAR) read that the medication was not administered on 7/1-7/4 and 7/8-7/10/24, for a total of seven missed doses. A written practitioner's order, dated 3/25/24, directed the residence to administer quetiapine fumarate 25 mg twice daily. However, the July 2024 MAR read that the medication was not administered in the evening on 7/4 and 7/7 or in the morning on 7/8-7/10/24, for a total of five missed doses. On 7/10/24 at 7:35 a.m., Staff #15 stated that the residence Resident #15 did not administer citalopram or quetiapine to Resident #15 for several days as the residence was out of stock and waiting for the pharmacy to deliver the medications. On 7/11/24 at 10:41 a.m., the health and wellness director stated that when the residence failed to have the medication in stock, the residence failed to comply with the written practitioner ' s orders. On 7/11/24 at 12:27 p.m., the administrator stated that she was unaware that Resident #15 ' s citalopram and quetiapine were out of stock. She added that the resident used a different pharmacy and health system than other residents and that the pharmacy was mail-order. The administrator added that when the residence did not administer the medications to a resident then the residence failed to comply with the practitioner ' s orders. The administrator stated this issue was not corrected; however, the number of concerns was significantly reduced.

Based on record review and interview, the residence failed to ensure resident care plans contained a description of the residents' personal grooming and hygiene items that were determined safe for the resident to have in their possession for self-care and how those items were stored to prevent unauthorized access by other residents or behavioral expressions and staff approaches to protect the resident, affecting eight of eight sample residents (#2, #9, #10-#15). 1. Residence PolicyThe residence's undated Enhanced Care Plan policy read in part that the residence included items for personal grooming and hygiene that were safe to remain in the residents' possession and which items must remain in a secured locked storage unit. 2. ObservationOn 7/10/24 at 3:06 p.m., an unsecured hygiene product was on the counter of the resident's bathroom. 3. Record ReviewResident #15 was admitted to the residence on 12/22/23 with diagnoses including depression and dementia. Progress notes read in part:On 2/26/24, Resident #15 chewed on candy packaging. On 5/18/24, Resident #15 had a hygiene product bottle in her hand and some of the hygiene product in her mouth. A care plan, dated 12/22/23, did not contain information regarding which personal grooming and hygiene items were safe to remain in the resident's possession and which items must remain in a secured, locked storage. Further, the care plan did not include information about the resident's behavior of chewing items and the staff's approaches to keep the resident safe. 4. InterviewsOn 7/10/24 at 3:06 p.m., the health and wellness director (HWD) stated that Resident #15 had ingested the hygiene product that was unsecured on the resident's bathroom counter. She added that she instructed staff to remove all hygiene items from the resident's line of sight; however, the product was on the counter and visible to the resident. On 7/11/24 at 10:44 a.m., the HWD stated that Resident #15 ingested a hygiene product in the past and had a behavioral expression of chewing on non-food items. She added that she had verbally requested that staff keep hygiene products out of her line of sight; however, the residence did not include the information in the resident's care plan. The HWD affirmed that the residence had not included a description of personal grooming and hygiene items that were determined safe for self-care in any residents' care plans. She added she was unaware that the residence was required to include hygiene product access in the residents' care plans. On 7/11/24 at 12:28 p.m., the administrator stated she was unaware that Resident #15 had ingested a hygiene product. She added that she was not surprised to hear that the resident had ingested the product since the resident had a history of chewing on non-food items. The administrator stated that the residence should have included the resident's access to hygiene products in the care plan and that staff should have ensured that the hygiene products for Resident #15 were locked up. 5. Additionally, the residence failed to ensure resident care plans contained a description of the residents' personal hygiene items that were determined safe for them to have in their possession for self-care and how those items were stored to prevent unauthorized access by other residents for Residents #2, #9, #10-#14.

A licensure complaint, prompted by #CO36495, was completed on 7/11/24. Deficiencies were cited.

Based on observation, record review, and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting four of four sample residents (#9, #10, #13, #14) who experienced falls. (Cross-reference S3074, S1326)Specifically, Resident #9 fell on 6/1/24 at 3:00 p.m., 6/1/24 at 5:00 p.m., 6/22/24 at 9:30 p.m., 6/22/24 at 4:49 p.m., and 6/27/24 at 9:10 a.m., and the residence failed to update the resident's care plan with new individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication. Subsequently, the resident fell on 7/3/24 and was diagnosed with a fractured left shoulder blade on 7/4/24. The resident had his arm in a sling, and his practitioner ordered him to keep his arm in the sling until he was seen by an orthopedic specialist. The residence failed to update the resident's care plan with new individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight or effects of medication, and the resident continued to be at risk for serious injury due to falls. Specifically, Resident #10 fell on 4/29/24 and sustained an injury to his face; he fell again on 5/1/24 and experienced pain and a limp. The resident fell again 5/21/24 and the residence failed to update the resident's care plan with new individualized approaches to address fall risk related to deficits in strength, balance, and eyesight, nor the effects of medication. Subsequently, on 5/26/24 he fell and sustained a hip fracture, and the residence again failed to update the resident's care plan with new approaches to address the resident's fall risk. The resident fell three times on 6/8/24, 6/9/24, and 6/10/24 and the residence implemented a chair alarm and placed his mattress on the floor on 6/8-6/10/24. However, the approaches were ineffective, and the resident fell on 6/14/24, 6/15/24, 6/20/24, twice on 7/5/24, and twice on 7/8/24. The resident's practitioner adjusted medication; however, the residence again did not update the resident's care plan with approaches to address the resident's fall risk, and the resident continued to be at risk of injury due to falls. These failures created an immediate jeopardy risk of falls with serious injury to two sample residents. On 7/10/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Residence PolicyThe residence's undated Falls Prevention and Management Program policy read in part: "The program focuses on reducing the resident falls and mitigating risks of falls through a resident focused (sic) approach that ensures that a resident's environment and social, physical, cognitive, and emotional strengths are supported. Initiate a written plan of care with (sic) 24 hours of admission based on resident's evaluated condition, fall history, needs, behaviors, and medications. If interventions have not been effective in reducing falls, initiate alternative approaches and update as necessary."2. Resident #9 was admitted to the residence on 4/30/24, with diagnoses including dementia. a. ObservationsOn 7/10/24 and 7/11/24, Resident #9 used a wheelchair for all ambulation. On 7/10/24 at 3:38 p.m., Resident #9 was lying on his mattress, which was elevated off of the floor by a bed frame, box spring, and mattress. The resident's feet and legs were protruding from the bed while his upper body was positioned on the bed. The residence placed no assistive devices nearby, did not change or lower his bed, nor implement other approaches to remove fall risk. b. Record ReviewFall audit reports for Resident #9 are read in part as follows:On 6/1/24 at 1:00 p.m., Resident #9 "was in activities, turned to sit in (a) chair and missed. No complaint of pain, able to stand." On 6/1/24 at 3:00 p.m., Resident #9 "was standing in activities, fall assessment done. Negative finding. High fall risk."On 6/22/24 at 9:30 p.m., Resident #9 "was observed on the floor in (his) room. (Staff provided) local care to (a) skin tear. (Resident #9 was) impulsive ..." On 6/22/24 at 4:49 p.m., "Res (a bystanding resident) observed [Resident #9] stand up and fall onto (his) back. Red area only on the back of (his)head."On 6/27/24 at 9:10 a.m., Resident #9 was "observed on (the) bathroom floor. (Staff) assessed (the resident with) negative findings." The resident's mentation/mobility (was at) baseline. On 7/3/24 at 3:40 p.m., Resident #9 was "observed lying on (his) back. No injury noted to (his) head. Mild crepitus (in his) left shoulder. Ice pack applied. Increased pain." On 7/7/24 at an undocumented time, Resident #9 sustained "swelling and contusions. (He was transported to the) emergency department (ED) for X-rays, positive nondisplaced left scapula fracture. Returned to (the residence). Obtained medications. Admitted to [an external hospice agency]." Incident reports (IRs) for Resident #9 read in part as follows:On 6/27/24, the resident was found on the floor beside the toilet wall holding his head. It was unknown if Resident #9 fell getting on or off the toilet. The resident had redness on his head. The resident had no safety awareness and was compulsive. The resident's fall risk level was at 27. A fall risk assessment form was attached to the IR which measured eight categories and rated the resident with an overall score. The categories included: regent fall history, ambulation/incontinence, mental status, vision, balance, blood pressure, medications, and predisposing conditions or disease. The bottom of the form read: "A total score of 10 or more indicated a resident 'at risk' for falls." On 7/3/24, residence staff heard a crash and found Resident #9 on the floor, assisted him to sit up, and found no evidence of abrasions or contusions. Resident #9 complained about left shoulder pain. A palpable or audible grating or crunching sensation produced by motion was observed in the shoulder joint. On 7/4/24, the licensed practical nurse (LPN) learned about Resident #9's fall that occurred on 7/3/24. Resident #9 complained of pain with any movement or touch to the left shoulder, which was "very edematous" compared to the right shoulder. The resident was moaning and holding his left shoulder. Once the health and wellness director (HWD) was informed of Resident #9's status, they had him transported to the ED. Progress notes for Resident #9 read in part as follows:On 7/8/24, the HWD spoke to Resident #9's family member to learn he had a computed tomography (CT) scan scheduled for 7/10/24 at 7:00 a.m. before his appointment on 7/11/24 with his orthopedist. On 7/9/24, an unidentified staff member wrote that Resident #9 had been in a lot of pain and could not sit up to take pain medications, had a very dry mouth, and his fluid intake had decreased. On 7/10/24, Resident #9 returned to the residence with written practitioner's orders for pain medication. Resident #9's had an upcoming scheduled appointment with the orthopedist on 7/11/24 at 10:00 a.m. The care plan, dated 6/30/24, had a handwritten note that read: "Uses cane and walker-frequently forgets," despite the resident's exclusive use of a wheelchair to ambulate. Additionally, the undated portions of the care plan read in part that the resident may have a physical therapy (PT) or occupational therapy (OT) consultation if it was appropriate and that the resident was unable to use the call light response system. The residence did not document the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication in the care plan. 3. InterviewsOn 7/10/24 at 2:32 p.m., a family member of Resident #9 stated that the residence planned to change the resident's bed to a hospital bed; however, the staff had not yet implemented this intervention. On 7/11/24 at 8:44 a.m., a representative from EPTA #2 stated Resident #9 demonstrated that he could not comprehend training and scored negatively on a cognitive test. The representative also confirmed that Resident #9 had not been admitted for external hospice services yet. On 7/11/24 at 9:17 a.m., the administrator stated that she acknowledged the residence had not identified the fall risks for Resident #9 until the date of the onsite investigation and stated that he could have fallen and significantly injured himself increasing the risk of death. In a later interview, at 11:30 a.m., the administrator stated that Resident #9 had received PT services; however, the resident did not have any ability to retain what he learned from PT, and therefore the PT was ineffective. She added the residence had not added any other approaches to the resident's care plan to mitigate his falls. On 7/11/24 at 09:55 a.m., the HWD confirmed that no approaches were put in place for Resident #9 to address fall management before the onsite investigation. She continued to say that she did not believe there were any other approaches that could be put in place to help mitigate falls for Resident #9 because "he is impulsive."On 7/11/24 at 11:30 a.m., the administrator stated that she thought this deficiency had been corrected but acknowledged that it had not been due to the Resident #9's current fall risks and the residence's failure to implement effective fall interventions when she learned that the staff interventions to mitigate falls were not effective. 4. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed two current residents at immediate jeopardy risk for falls with injury. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 7/10/24 at 5:22 p.m., the administrator submitted written evidence that read: "1) Resident #9 is with a 1:1 caregiver 24/7, until a higher level of care is found for him. Resident #9 will have his bed mattress put directly on the floor. Resident #10 was reviewed by the Hospice Medical Director, and changes to his medications were made related to his anxiety falling, he has not had a fall since these medication changes were made on 7/8/24. Pursue a wheelchair cushion for #6. These care plan interventions will be added for residents #9 and #10. (HWD) was educated that the interventions that are reviewed in Resident at Risk need to be put on the care plan. Fall assessment looking at medications, eye site, balance, continence and other comorbidities have been completed for all residents #9 and #6. 2) Audit the care plans for all the residents that have had a fall in the last 30 days and make sure that correct and appropriate interventions are implemented. 3) Audit all new falls for care plan interventions to ensure that they are appropriate for each resident and that a new intervention is added after each fall. After 30 days, will audit 5 fallsmonthly for three months until substantial compliance with falls interventions is ascertained by (quality management program). Will review multiple fallers weekly at Resident at Risk and ensure that they are appropriate forour level of care. Will add education to orientation for new staff. 4) Will educate all staff on fall prevention and intervention by 7/31/24. Will add education to orientation for new staff."However, the written evidence did not indicate the risk had been removed because the residence had not included implementation, auditing, and training timelines. The residence failed to identify the correct residents for some of the approaches, and the residence did not address how they would identify fall interventions to add to the care plans consistently. On 7/10/24 at 5:34 p.m., the administrator submitted written evidence that read in part that the residence implemented a one-on-one caregiver on 7/10/24 and correctly identified Resident #9 and #10. The evidence further read that the residence would identify individual fall interventions in the fall risk assessment. The residence would implement staff training on fall management for Residents #9 and #10 on 7/10/24. However, the written evidence did not indicate that the risk had been removed because it did include a timeline for when the residence planned to audit the care plans of residents who sustained falls within 30 days prior to the onsite investigation. On 7/10/24 at 5:55 p.m., the administrator submitted written evidence that read in pertinent part that on 7/12/24, the HWD planned to audit the care plans for all the residents who fell within 30 days of the onsite investigation to ensure the residence implemented correct and appropriate interventions. Additionally, after 30 days, the residence planned to audit five falls monthly for three months until substantial compliance with fall management was determined by the residence's fall management program measures. 5. Additionally, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance for Residents #9, #13, and #14.

Based on observation and interview, the residence failed to ensure the residents' right to be free of restraint, affecting five of eight sample residents (#10-#12, #14, #15). (Cross-reference S1410)Findings include:1. Residence PolicyThe residence's undated Resident Rights policy read in part that residents had the right to be free of confinement and restraint. The residence's undated Restraint-Free Care policy read in part that, in most cases, the use of restraints was a form of neglect or abuse. The residence defined a restraint as a physical device, item, or practice that restricted a resident's freedom of movement. Restraints may be used to prevent a resident from scratching and touching areas of their bodies or to prevent the spread of infection. The residence must ensure that the residents had the right to be free from restraint. Restraints were inherently dangerous, specifically when applied to residents with cognitive impairment. Restraints often caused incontinence, decreased mobility, decreased independence, and often led to increased agitation. 2. ObservationsOn 7/10/24 at 9:16 a.m., Resident #11 wore a one-piece outfit with a zippered back. The zipper was inaccessible to the resident, so he pulled it at the front of the outfit and attempted to remove it. The resident moaned and continued to pull at the outfit until Staff #16 lowered the zipper. The resident removed the top of the outfit and stopped moaning. 3. Resident #11 was admitted to the residence on 1/12/24 with diagnoses including frontotemporal dementia, anxiety, blindness, and hemorrhagic telangiectasia disease. A care plan, dated 1/12/24, read in part that the resident had severe cognitive impairment, was legally blind, had chronic anxiety, and required staff to dress and undress him. The external hospice provider (EHP) care plan, dated 6/19/24, read in part that the resident demonstrated behavioral expressions, including urinating on the floor when the resident did not wear the outfit that he was unable to remove independently. 4. InterviewsOn 7/10/24 at 9:16 a.m., Staff #16 stated that Resident #11 had behavioral expressions that included urinating on the floor or on furniture and removing his incontinence product. She added that the staff ensured that the resident wore an outfit that only staff could fasten or unfasten, as the zipper was located on the backside of the outfit. The staff ensured that the resident wore an outfit that only staff could fasten or unfasten, as the zipper was located on the backside of the outfit. Staff #16 stated that the resident attempted to remove the outfit at times but was unsuccessful. She added that he was not permitted to remove the outfit independently to avoid the behavioral expressions. Staff #15 stated that staff were required to assist the resident with toileting every two hours; however, since the resident was unable to independently remove the outfit, he experienced bowel and bladder accidents when staff were unable to assist him in a timely fashion.. On 7/11/24 at 10:13 a.m., the health and wellness director (HWD) stated that the purpose of the outfit worn by Resident #11 was to prevent him from removing his clothing and urinating on the floor. She stated that the definition of a restraint included a device that impeded movement and independence. The HWD added she had not thought of the outfit as a restraint because the resident was admitted to the residence with it, and the resident's family member wanted him to wear it. She affirmed the resident was unable to remove it independently. On 7/11/24 at 11:41 a.m., the administrator stated that a restraint was a device that the resident was unable to remove and limited a resident's independence. She affirmed that the residence utilized clothing and devices such as chair and bed alarms, or leg rests, on residents; they were unable to remove or adjust the clothing and devices independently. The administrator affirmed the residents were unable to remove the devices which limited their mobility and independence. She added that she believed the residence was able to implement restraints when residents were admitted to the residence with them, in some cases, when a practitioner ordered the devices. 5. Additionally, the residence failed to ensure the resident right to be free of restraint for Residents #10, #12, #14, #15.

Based on record review and interview, the residence failed to investigate allegations of abuse of a resident, affecting one sample resident (#12). (Cross-reference S1326)Findings include: 1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.1, defines abuse as any of the following acts or omissions:(A) The non-accidental infliction of bodily injury, serious bodily injury or death,(B) Confinement or restraint that is unreasonable under generally accepted caretaking standards, or(C) Subjection to sexual conduct or contact that is classified as a crime.b. The residence's undated Abuse/Neglect policy read in part that the initial response to allegations of abuse, mistreatment, involuntary seclusion, or misappropriation of property greatly affected the resident's feelings of safety and comfort. All cases of alleged abuse must be reported immediately to the administrator. The physician and family/representative should be notified immediately.c. The residence's undated Restraint-Free Care policy read in part that in most cases the use of restraints was a form of neglect or abuse. 2. Resident #12 was admitted to the residence on 12/20/23 with the diagnosis of dementia with behavioral disturbance. A progress note, dated 3/2/24, read in part that three unidentified staff members held down Resident #12's hands and feet while they changed her clothing. The residence provided all abuse investigations from February 2024 to July 2024; however, the investigations did not include an investigation of the alleged abuse/restraint of Resident #12 on 3/2/24.3. InterviewsOn 7/11/24 at 10:21 a.m., the health and wellness director (HWD) stated that all allegations were reviewed right away and the administrator reviewed them within 72 hours. Regarding the incident on 3/2/24 with Resident #12, the HWD said she was not aware that this incident happened. She further stated that the residence should investigate the incident, but they did not. On 7/11/24 at 11:50 a.m., the administrator stated she was not aware of the incident on 3/2/24 with Resident #12; however, she had access to the progress note that detailed the incident. She added that the residence failed to investigate the incident. The administrator stated that based on the progress note, the staff applied a possible restraint that was unreasonable under generally accepted caretaking standards which fit within the definition of abuse, and that the residence should have investigated the allegation.

Based on record review and interview, the residence failed to ensure resident care plans contained a description of the residents' personal grooming and hygiene items that were determined safe for the resident to have in their possession for self-care and how those items were stored to prevent unauthorized access by other residents or behavioral expressions and staff approaches to protect the resident, affecting eight of eight sample residents (#2, #9, #10-#15). 1. Residence PolicyThe residence's undated Enhanced Care Plan policy read in part that the residence included items for personal grooming and hygiene that were safe to remain in the residents' possession and which items must remain in a secured locked storage unit. 2. ObservationOn 7/10/24 at 3:06 p.m., an unsecured hygiene product was on the counter of the resident's bathroom. 3. Record ReviewResident #15 was admitted to the residence on 12/22/23 with diagnoses including depression and dementia. Progress notes read in part:On 2/26/24, Resident #15 chewed on candy packaging. On 5/18/24, Resident #15 had a hygiene product bottle in her hand and some of the hygiene product in her mouth. A care plan, dated 12/22/23, did not contain information regarding which personal grooming and hygiene items were safe to remain in the resident's possession and which items must remain in a secured, locked storage. Further, the care plan did not include information about the resident's behavior of chewing items and the staff's approaches to keep the resident safe. 4. InterviewsOn 7/10/24 at 3:06 p.m., the health and wellness director (HWD) stated that Resident #15 had ingested the hygiene product that was unsecured on the resident's bathroom counter. She added that she instructed staff to remove all hygiene items from the resident's line of sight; however, the product was on the counter and visible to the resident. On 7/11/24 at 10:44 a.m., the HWD stated that Resident #15 ingested a hygiene product in the past and had a behavioral expression of chewing on non-food items. She added that she had verbally requested that staff keep hygiene products out of her line of sight; however, the residence did not include the information in the resident's care plan. The HWD affirmed that the residence had not included a description of personal grooming and hygiene items that were determined safe for self-care in any residents' care plans. She added she was unaware that the residence was required to include hygiene product access in the residents' care plans. On 7/11/24 at 12:28 p.m., the administrator stated she was unaware that Resident #15 had ingested a hygiene product. She added that she was not surprised to hear that the resident had ingested the product since the resident had a history of chewing on non-food items. The administrator stated that the residence should have included the resident's access to hygiene products in the care plan and that staff should have ensured that the hygiene products for Resident #15 were locked up. 5. Additionally, the residence failed to ensure resident care plans contained a description of the residents' personal hygiene items that were determined safe for them to have in their possession for self-care and how those items were stored to prevent unauthorized access by other residents for Residents #2, #9, #10-#14.

Based on observation, record review, and interview, the residence failed to train each staff member on each resident's care plan prior to the staff member working with the resident, affecting one sample resident (#9). (Cross-reference S1080)Specifically, Resident #9 sustained a fractured left shoulder blade after falling on 7/3/24. The residence failed to train Staff #10, #15, and #17 on how to transfer the resident with a fractured left shoulder blade. Subsequently, the resident called out in pain, moaned, and said "ow" several times while Staff #10, #15, and #17 transferred him. Resident #9's hands were shaking during this process.a. ObservationsOn 7/11/24 at 8:22 a.m., Staff #10, #15, and #17 attempted to transfer the resident. The resident called out in pain and moaned several times. Staff #10 grabbed Resident #9's left arm and pulled him into an upright sitting position on his bed before Staff #15 placed a gait belt around the resident's waist, after which Resident #9 stated, "Ow that hurt me." Staff #10 told him she was going to slide Resident #9's feet over to another position and as she did the resident moaned in pain again. When she slid him over, Resident #9 laid back onto the bed. Staff #10 and #15 asked the resident to sit back up. Staff #10 was positioned near Resident #9's left foot, grabbed his left arm, and pulled as Staff #15 grabbed Resident #9's right arm and pulled him into an upright position. Staff #17 positioned herself behind Resident #9 on his bed and provided minimal support to Resident #9's back as he moaned. As they got him in an upright position, his hands were shaking. Staff #20 and #15 counted to three and pulled on Resident #9's respective arms until he was in a standing position, after which Resident #9 moaned in pain again. Staff #17 brought the wheelchair over to Resident #9, who was initially hesitant to sit in the wheelchair. After being asked and encouraged to sit down three times he sat. Staff #10 stated, "do you know how long it's been since I've been on the floor?" As Staff #15 got the right footrest in position and attempted to place Resident #9's leg in it, the resident stated, "Ow my leg." The staff encouraged him to bend his leg to put it on the footrest. b. Record ReviewResident #10 was admitted to the residence on 4/30/24, with diagnoses including dementia. Incident reports read in part:On 7/4/24, the licensed practical nurse (LPN) had learned about the fall that occurred on 7/3/24. Resident #9 complained about pain with any movement or touch to his left shoulder and stated that the left shoulder was very "edematous" compared to the right shoulder. "Resident was moaning and holding his left shoulder." On 7/7/24, "Non displaced fracture of left scapula. Has a referral to orthopedist. "The residence failed to provide documentation that staff was trained on how to properly and safely transfer the injured resident after the fractured scapula was diagnosed on 7/4/24 and before the date of the onsite investigation. A hospital discharge note dated 7/4/24, read in part Resident #9 had fractured his left shoulder blade. It also read that Resident #9 was to keep his arm in his sling until he was evaluated by an orthopedic specialist. c. InterviewsOn 7/11/24 at 7:50 a.m., Staff #14 stated that staff were split into specific sections when scheduled, the Blue and Gold Hall. He clarified that the Gold Hall has lower acuity and the Blue Hall has more intense or higher acuity cases. On 7/11/24 at 8:02 a.m., Staff #17 stated she had volunteered to come in at 3:00 a.m. to provide 1:1 supervision for Resident #9. She stated no one provided training on what Resident #10 was allowed or not allowed to do, and she only was instructed to call other staff when he needed help since she was not trained. She stated she was not sure if Resident #9 was a one, two or three person transfer. On 7/11/24 at 8:10 a.m., Staff #15 arrived in the room and stated that she was not trained on whether Resident #9 requireda one, two or three person transfer. She guessed he required a two person and maybe even a three person transfer. On 7/11/24 at 8:26 a.m., Staff #10 clarified that when she asked, "Do you know how long it's been since she worked on the floor?" she meant that she had been promoted two weeks prior to the onsite investigation and was now in charge of ordering supplies and monitoring the courtyard. She stated she did not work in the hall on which Resident #9 lived. On 7/11/24 at 8:26 a.m., the administrator confirmed that the training she provided Staff #10, #15, and #17 did not include how to safely transfer Resident #9, most specifically Staff #10, #15 and #17. On 7/11/24 at 12:31 p.m., the administrator confirmed that Staff #17 had just started working at the residence on 7/10/24 and had not completed all of her training. She also confirmed that Staff #10, #15 and #17 were not trained on how to transfer Resident #9 but should have been.

A licensure complaint, prompted by #CO35239 was completed on 3/19/24. No deficiencies were cited.

A revisit survey was completed on 6/27/23 for all previous deficiencies cited on 4/19/23. No deficiencies were cited.

A licensure complaint, prompted by #CO31669, was completed on 4/19/23. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one sample resident (#5). Findings include:1. Reference and Residence Policya. According to the Occurrence Reporting Manual, dated May 2018, "Any occurrence involving neglect of a patient or resident ... is a reportable occurrence." One of the defining elements to require reporting an occurrence of neglect included when a staff member intentionally failed to follow standard of practice and or residence policy with significant potential for harm. It is the allegation of the event, not the outcome of the provider's investigation, which made it reportable.b. The residence's undated abuse and neglect investigation policy read in part that the residence reported all allegations of abuse and neglect to the Department within 24 hours. 2. Record ReviewDocumentation of an investigation regarding allegations of neglect initiated on 3/31/23 revealed that a family member of Resident #5 alleged the residence neglected the resident. On 4/19/23 at approximately 9:00 a.m., a review of the Department's database revealed the residence failed to report the allegation of neglect to the Department as an occurrence. 3. InterviewsOn 4/19/23 at 9:21 a.m., the administrator acknowledged she did not report the allegation of the neglect of Resident #5 to the department as an occurrence. She stated she was not aware of the requirement to report any allegations of abuse or neglect to the department unless their investigation determined it was substantiated. On 4/19/23 at 10:02 a.m., a department representative confirmed that the residence should have reported the allegation of neglect involving Resident #5 to the Department as an occurrence, as it was the allegation of the event, not the outcome of the residence's investigation, which made it reportable.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 26 current residents. Findings include:1. ReferencesThe COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/22/23,required residences to:-Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month) and (period two, defined as days 15-31 of each month). Multiple reports within the same reporting period will overwrite previous reporting and does not meet requirements for future reporting periods.-Assign at least one staff member to oversee the infection prevention and control (IPC) within the residence and to complete the Colorado RCF Infection Prevention Training using COTRAIN within two weeks of the assignment of duties and each calendar year thereafter. This information must be reported in EMResource and remain updated. 2. EMResourceOn 4/19/23 at 9:29 a.m., a review of the residence's EMResource details revealed the last date the residence reported updated information was on 1/4/23. It read that Former Administrator #1 was the contact for the residence and was the staff member in charge of the residence's IPC program. Further, it listed there were 21 current residents; however, there were 26 during the onsite. 3. RCF Infection Prevention TrainingOn 4/19/23 at 10:04 a.m., documentation of the Colorado RCF Infection Prevention Training using COTRAIN for any staff was requested, but not provided. 4. InterviewOn 4/19/23 at 12:48 p.m., the administrator stated that Former Administrator #2 (who also currently worked at the residence's corporate office, located in another state) informed her that, as of 2/22/23, the residence was no longer required to complete EMResource at all nor assign a staff member to oversee an IPC program. She stated this was the reason the residence did not meet the requirements.

A second initial licensure survey with complaint #CO30525 was completed on 1/25/23. Deficiencies were cited.

Based on interview and record review, the residence personnel failed to report suspected caretaker abuse of an at-risk resident to law enforcement within 24 hours of discovery, affecting one of seven sample residents (#1). (Cross-reference Q1312, Q1360, Q1362)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.1, defines abuse as the non-accidental infliction of bodily injury, serious bodily injury or death and confinement or restraint that is unreasonable under generally accepted caretaking standards.b. Chapter VII regulations governing assisted living residences, part 2.7, defines At-risk person as any person who is 70 years of age or older.c. Chapter VII regulations governing assisted living residences, part 2.28, defines mistreatment as abuse, caretaker neglect, or exploitation.d. The residence's undated posted resident rights, read, in part, "The right not to be sexually, verbally, physically or emotionally abused, humiliated, intimidated, or punished."2. Resident #1 was admitted to the residence on 9/1/22 with diagnoses including dementia with behavioral disturbance. Resident #1 was 86 years old. Internal investigation notes in Resident #1's record, dated 12/9/22, revealed the following:An incident report, written by Staff #4, dated 12/9/22 at 10:00 a.m., read that Resident #1 had bruising to her forehead, both arms and legs. Additionally, Resident #1 had reopened a skin tear to her arm. The description of the incident read, in part, "Walked into shower to see if help was needed. Found (Resident #1) in shower hitting, kicking, biting, pinching staff and stating she was being bruised. I tried to calm (Resident #1) down, we all finished (Resident #1's) shower." The people notified were an outside agency representative on 12/11/22 by family, local law enforcement on 12/12/22 and adult protective services (APS) on 12/12/22. Local law enforcement was not notified within 24 hours of the incident, as required. An incident report, written by an unknown staff member, dated 12/9/22 at 12:00 p.m., read Resident #1 had bruising on both her left and right forearms from her wrist to her elbow as well as small bruising up higher on her arm. A faded bruise with a bump was noticed on the right side of her forehead. An unsigned handwritten timeline, written by the previous administrator, dated 12/14/22, read, that Resident #1 had a shower on 12/9/22 at approximately 10:00 a.m. and Staff #8 reported Resident #1 had bruises at 12:00 p.m. Staff #3 was spoken to on 12/9/22 at 6:37 p.m. and stated Resident #1 did not want to shower but staff finally were able to get her into the shower and Resident #1 started screaming so Staff #4 assisted and held Resident #1's arms so Resident #1 was not able to hit the staff during the shower. Skin tear noticed on Resident #1's right forearm. Resident #1 stated to Staff #3, "look at what they did to me." The writer asked Staff #3 to write a written statement. An undated hand written statement by Staff #3 read that Staff #3 and Staff #8 entered Resident #1's room, undressed her and walked her to the shower. Staff #8 guided Resident #1 to the shower and Resident #1 started kicking, fighting and screaming real loud and Staff #4 heard this from the hallway and entered Resident #1's room to assist. When Staff #4 entered Resident #1's room Resident #1 started to get physical and Staff #4 was holding Resident #1's hands and arms and tried to calm her down while Staff #8 washed her body and hair. After the shower, staff tried to dress Resident #1 but she refused and said she would pick out her own outfit. When Resident #1 picked out her own outfit she refused to put it on so Staff #4 and Staff #8 grabbed a dress and dressed Resident #1 while she was refusing. Staff #3 noticed blood on Resident #1's right forearm. Afterwards Resident #1 was not in a good mood. A handwritten statement by Staff #4, dated 12/12/22, read that she heard screaming comingout of Resident #1's room and asked if the staff needed help. Resident #1 screamed expletives and that she was going to get staff in trouble for hurting her. Resident #1 had bruises on her arms, forehead and inner leg. Resident #1 tried to bite Staff #8 and swung her arms at Staff #3. Resident #1 screamed she was being hurt. Resident #1 had soap in her eye so Staff #4 grabbed the shower head and Staff #8 rinsed her off and Resident #1 began hitting Staff #4. Resident #1 hit the shower head out of #8's hand, which caused a skin tear to Resident #1's arm. Resident #1 fought with Staff #4 and Staff #8 when they dressed her. An external law enforcement report, dated 12/12/22, read that on 12/12/22, a local law enforcement officer was dispatched to telephone the former administrator regarding injuries to a resident at (The Residence). The former administrator filed a mandatory report on 12/12/22 for the incident that involved Resident #1 on 12/9/22.3. InterviewsOn 1/24/23 at 9:25 a.m., a local law enforcement officer stated the local police department was first made aware of the mandatory report on 12/12/22. On 1/24/23 at 10:34 a.m., a family member of Resident #1 stated she was notified by the medication supervisor (MS) on 12/9/22 about a bruises on Resident #1's shoulder and head. She added she was told that Resident #1 probably hit her head on a door and the bruises were healing. The family member said she would come the following day on Saturday 12/10/22 to check on Resident #1. She added that the wellness director (WD) telephoned her in the morning on 12/10/22 at 8:10 a.m. to let her know that Resident #1 had been abused in the shower and that staff were fired and that the WD notified local law enforcement, an outside agency representative, and the Department. She added, the WD made comments about how the residence was, "getting rid of all bad staff." The family member stated that Resident #1 may have been combative in the past but, it "doesn't give them the right to assault her (Resident #1)."On 1/24/23 at 12:22 p.m., an adult protection worker stated their department received notification on 12/12/22 from the residence of an abuse allegation on 12/9/22. On 1/24/23 at 2:23 p.m., the WD stated on 12/9/22 Resident #1's shower was not handled correctly and that two staff member helped Resident #1 in the shower. She added, Resident #1 "Started tussling with QMAPs (qualified medication administration persons)." She added one staff member held her hands and the other staff tried to get the shampoo out of Resident #1's hair. The WD said she was not in the building when the incident happened and, "Was told the shower was not handled correctly." The WD stated she notified local law enforcement, contrary to other statements and written evidence proven otherwise. When the surveyor mentioned the evidence that pointed to the contrary, the WD stated she may have mixed up the stories. She added the former administrator informed her that she would handle the situation. On 1/24/23 at 3:21 p.m., the MS stated, "Unknown if APS, police report, and the state (were notified). I believe she (former administrator) did it on Monday (12/12/22)." On 1/25/23 at 7:30 a.m., Staff #3 stated during Resident #1's shower Staff #4 and #8 were forceful with Resident #1. Staff #3 said Staff #4 restrained Resident #1's wrists or arms because Resident #1 was hitting and kicking staff. Staff #3 noticed a skin tear on Resident #1's arm. Staff #3 said Staff #4 was verbally abusive towards Resident #1 while she was in the shower and Staff #3 told her what to do in an "intimidating" tone. She added, "I've seen her (Staff #4) talk to other residents like they were her children." Staff #3 stated she thought the shower incident was considered abuse. On 1/25/23 at approximately 8:30 a.m., the administrator stated he would have expected local law enforcement to be notified within 24 hours of the incident involving Resident #1.

Based on record review and interview, the residence failed to have written documentation regarding a description of the employee duties, date of hire, orientation training and results of background checks in each personnel file, affecting two of two contracted sample staff (#5, #8). (Cross-reference Q1312, Q2976)Findings include:Chapter 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 resident care services. "Staff" does not include individuals providing external services, as defined herein. On 1/24/23 at approximately 9:15 a.m., personnel files for Contracted Staff #5 and #8 were requested. On 1/14/23 at 9:39 a.m., an invoice was provided for Contracted Staff #5 for January 2023 to February 2023. No personnel files were provided for either Contract Staff #5 or #8. On 1/24/23 at 10:10 a.m., the sales and marketing staff stated there was no other documentation for Contracted Staff #5 and #8 at the residence. On 1/24/23 at approximately 8:30 a.m., the administrator stated he was not aware contracted staff were required to have the same information included in the personnel files as residence staff.

Based on record review and interview, the residence failed to develop policies regarding unanticipated illness, injury, significant change of status from baseline, or death of a resident and practitioner assessment, affecting 19 current residents. Findings include: On 1/24/23 at approximately 7:50 a.m., the residence's policies and procedures were requested from the administrator. On 1/24/23 at approximately 11:30 a.m., the administrator provided a policy and procedure binder for the residence. However, the policy and procedure binder did not include the following policies: Unanticipated illness, injury, significant change of status from baseline, or death of resident;Practitioner Assessment. On 1/11/22 at 1:50 p.m., an additional request for the requested policies was made to the administrator. However, the requested policies were not provided. On 1/25/22 at 10:00 a.m., the administrator stated all of the policies were in the policy binder, however, could not locate the policies that pertained to the practitioner assessment or unanticipated illness, injury, significant change of status from baseline, or death of a resident policy.

Based on interview and record review the residence failed to contact the resident's practitioner when the resident sustained an injury, affecting one of seven sample residents (#1). (Cross-reference Q810, Q1312, Q1360, Q1362)Findings include:Resident #1 was admitted to the residence on 9/1/22. An unsigned handwritten timeline, written by the previous administrator, in Resident #1's record, dated 12/14/22, read, in part that Resident #1 had a shower on 12/9/22 at approximately 10:00 a.m. and Staff #8 reported Resident #1 had bruises at 12:00 p.m. Skin tear noticed on Resident #1's right forearm. There was no documentation in Resident #1's record that the practitioner had been notified of the bruises or skin tear during the shower on 12/9/22 involving Resident #1. On 1/24/23 at 3:21 p.m., the medication supervisor stated the residence did not notify Resident #1's practitioner of the bruising on Resident #1 from 12/9/22. On 1/24/23 at 3:50 p.m., the practitioner for Resident #1 stated he had no record of being notified of the bruises or skin tear from the 12/9/22 incident. He added Resident #1 came to his office on 12/12/22 and the family member notified him of the bruises and skin tear. On 1/25/23 at approximately 8:30 a.m., the administrator stated the residence should have notified Resident #1's practitioner after the incident on 12/9/22. He added he was not aware the practitioner had not been notified, as required.

Based on record review and interviews, 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 one of six sample residents with a history of falls (#3). Specifically, Resident #3 sustained a series of falls without injury on 8/31/22, 9/3/22, 9/4/22, 9/5/22, 12/30/33, 1/5/23, 1/7/23,1/14/23, 1/21/23, 1/23/23. The residence's care plan for Resident #3 had not been updated to detail the individualized approach necessary to address Resident #3's fall risks related to documented deficits in strength and balance. Subsequently, Resident #1 sustained additional falls on 12/21/22, 1/8/23, 1/14/23 which resulted in a bruise on left arm, pain in the back of her head and left shoulder and hip pain respectively. No additional individualized approached had been documented by the residence to address Resident #3's fall risk to prevent additional falls. Findings include:1. Reference and residence Policy a. Chapter VII regulations governing assisted living residences defines, in part 2.9, Care plan as "a written description, in lay terminology, of the functional capabilities of an individual, the individual's need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual's needs. In order to deliver person-centered care, the care plan shall take into account the resident's preferences and desired outcomes ..."b. The residence's undated Fall Management policy, read in part: "the falls prevention and management program is designed to develop, implement and monitor a falls prevention approach and management strategies that foster resident independence and quality of life while ensuring safety of the resident and care staff. The program focuses on reducing the incidents of resident falls and mitigating risks of falls through a resident focused approach which ensures that a resident's environment and social, physical, cognitive and emotional strengths are supported. The program ensures caregiver training, communication and effective care planning."2. Record review Resident #3 was admitted to the residence on 7/29/22 with diagnoses including Parkinson's disease, dementia, stroke and hypertension.b. Progress notes for Resident #3, dated 8/31/22-1/23/22 were reviewed and revealed the following:On 8/31/22, Resident #3 was found on the floor in her bedroom next to her bed. On 9/3/22, Resident #3 was found on the floor in her bedroom with no pants. On 9/4/22, Resident #3 was found on the floor. Resident #3 was placed back into bed and given lunch. On 9/5/22, Resident #3 was found on the floor. Staff noticed Resident #3 was pushing herself to the bathroom. On 9/22/22, Resident #3 was constantly throwing herself out of bed. On 12/21/22, Resident #3 was found on the bathroom's floor. On 12/25/22, Staff found a bruise on Resident #3 left arm. On 12/30/22, Resident #3 was found on the floor in her bedroom. On 1/5/23, Resident #3 fell from the wheelchair. Fall was unwitnessed with no note of pain or injury. On 1/7/23, Resident #3 was found on the floor in her bedroom next to her wheelchair. Resident #3 was heard yelling from her room in pain. On 1/8/23, Resident #3 was found on the floor between her bed and the fall mat. Staff lifted Resident #3 on the wheelchair. Resident #3 complained of hurting her head, pain in the head and left shoulder. Called emergency medical services (EMS) and Resident #3 was sent to the hospital. On 1/14/23, Resident #3 was found on the floor next to her bed.c. The residences' assessments for Resident #3, dated 7/20/22 was reviewed and revealed Resident #3 had documentation of three or more falls. The assessment read Resident #3 was a fall potential due to wanting to get up all the time. Resident #3 was documented as "does not require hands on assistance, and may require prompts/cues to use assistive devices." No interventions were noted to be implemented to prevent falls related to deficits related to balance and strength. d. The care plan for Resident #3, dated 11/29/22 was reviewed and revealed the following: On 11/29/22, Resident #3 was listed to be at risk for falls with the following interventions implemented:Level of assistance- transferring minimalRequires assistance with transfer and or positioning with verbal prompts/cues No hands on assistanceLanguage barrier, Needs constant cueing,Self propels quicklyHowever, no additional or updated interventions were implemented after her falls on 12/21/22, 12/30/33, 1/5/23, 1/8/23, 1/7/23,1/14/23, 1/21/23, 1/23/23. No interventions were noted to be implemented to prevent additional falls related to deficits related to balance and strength, nor did the care plan include a individualized approach necessary to address Resident #3's fall risk. 3. InterviewsOn 1/24/23 at 7:08 a.m., Staff #6 stated Resident #3 was a fall risk and added Resident #3 had numerous falls in the last three months. On 1/24/23 at 8:00 a.m., Staff #6 stated Resident #3 was a two person transfer. He stated Resident #3 fell from the bed on the floor but he was unable to recall on what that fall happened. He stated the residence's fall interventions to prevent Resident #3 falls were to "keep her bed low."On 1/24/23 at 1:30 p.m., Staff #7 stated Resident #3 was a high fall risk. She stated Resident #3 was falling because she was declining. She stated the interventions to prevent Resident #3 from falling were keeping her close to watch. Staff #7 stated she requested other staff members to always keep Resident #3's bedroom door open for her to easily keep an eye on her. She added if Resident #3 had a fall without injuries, the staff would examine her and assist her from the ground. She stated if Resident #3 had a fall with injuries, the staff would call EMS, administrator and wellness director (WD) and send her to the hospital. She added she has not received any fall prevention training in the residence. She stated RSD and the former administrator were responsible for updating the assessments and care plans. On 1/24/23 at 1:55 p.m., Staff #1 stated she considered Resident #3 a fall risk and added she witnessed Resident #3 fall four times since the day of her employment with the residence on 12/30/22. She stated she was not aware of any interventions that are in place for Resident #3. She stated Resident #3 was falling because Resident #3 was independent and added Resident #3 wanted to do everything herself and falls because her hips do not have any strength. She added she had not received any fall prevention training in the residence to help prevent Resident #3's falls. On 1/24/23 at 2:10 p.m., the WD stated care plans should be updated monthly unless there was a fall or a change of condition. She stated a post fall assessment should have been completed for each of Resident #3's falls and added she failed to update the care plan because the former administrator was not sure if she was falling or putting herself on the ground. The WD stated she was responsible for updating assessments and care plans. She stated if a resident fell the staff would notify her and she would assess the resident for injury. The WD stated if a resident was a fall risk the care plan should have included elements of frequent safety checks, strength and balance training. The WD stated the care plan read that the same approaches had been implemented on 11/29/22 and added no additional individualized approaches had been implemented for Resident #3 after she had sustained the six falls between December 2022 and January 2023. She stated the interventions listed on the 11/29/22 care plan were not individualized for Resident #3. The WD stated she would expect the care plan for Resident #3 to contain detailed individualized approaches to address Resident #3's fall risks related to deficit in strength and balance addedResident #3's care plan was not personalized in any way. On 1/25/23 at 9:30 a.m., the administrator stated the care plan should be completed for each resident prior to admission and after every fall. He stated the WD completed the assessments and care plan for residents. The administrator stated Resident #3's care plan should have been updated to reflect individualized approaches to minimize her risk of falls. He stated the interventions listed on 11/29/22 care plan were not individualized for Resident #3. He stated that when Resident #3 had additional falls he would have expected the care plan to be updated with detailed approaches to prevent additional falls for Resident #3 and added he would have expected to see updated and new approaches after repetitive falls due to previous approaches not having worked.

Based on record review and interview, the residence failed to have defined procedures to prevent the spread of influenza from unvaccinated staff, affecting 19 current residents. Findings include:On 1/24/23 at 7:50 a.m. and again at 11:30 a.m., the administrator was asked to provide the residence's influenza policy that defined procedures to prevent the spread of influenza from unvaccinated staff. On 1/24/23 at 1:00 p.m., the administrator was unable to provide the residence's procedures to prevent the spread of influenza from unvaccinated staff. On 1/25/23 at approximately 10:00 a.m. the administrator stated the residence did not have the influenza policy. He stated he was unaware the residence was required to have a policy that defined procedures to prevent the spread of influenza from unvaccinated staff.

Based on record review and interview, the residence failed to observe a resident's right to be treated with dignity and respect and to be free from physical abuse, verbal abuse, and restraint, affecting two of seven sample residents (#1, #7). (Cross-reference Q410, Q1360) Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.1, defines abuse as the non-accidental infliction of bodily injury, serious bodily injury or death and confinement or restraint that is unreasonable under generally accepted caretaking standards.b. Chapter VII regulations governing assisted living residences, part 2.28, defines mistreatment as abuse, caretaker neglect, or exploitation.c. Chapter VII regulations governing assisted living residences, part 2.42, defines restraint as any method or device used to involuntarily limit freedom of movement including, but not limited to, bodily physical force, mechanical devices, chemicals, or confinement.d. The residence's undated posted resident rights, read, in part, "The right not to be sexually, verbally, physically or emotionally abused, humiliated, intimidated, or punished ... The right to live free from involuntary confinement, or financial exploitation and to be free from chemical restraints as defined within these regulations."2. Resident #1 was admitted to the residence on 9/1/22 with diagnoses including dementia with behavioral disturbance. Internal investigation notes for 12/9/22, in Resident #1's record revealed the following:An incident report, written by Staff #4, dated 12/9/22 at 10:00 a.m., read that Resident #1 had bruising to her forehead, both arms and legs. Additionally, Resident #1 had reopened a skin tear to her arm. The description of the incident read, in part, "Walked into shower to see if help was needed. Found (Resident #1) in shower hitting, kicking, biting, pinching staff and stating she was being bruised. I tried to calm (Resident #1) down, we all finished (Resident #1's) shower." An incident report, written by an unknown staff member, dated 12/9/22 at 12:00 p.m., read Resident #1 had bruising on both her left and right forearms from her wrist to her elbow as well as small bruising up higher on her arm. A faded bruise with a bump was noticed on the right side of her forehead. An unsigned handwritten timeline, written by the previous administrator, dated 12/14/22, read, in part that Resident #1 had a shower on 12/9/22 at approximately 10:00 a.m. and Staff #8 reported Resident #1 had bruises at 12:00 p.m. Staff #3 was spoken to on 12/9/22 at 6:37 p.m. and stated Resident #1 did not want to shower but staff finally were able to get her into the shower and Resident #1 started screaming so Staff #4 assisted and held Resident #1's arms so Resident #1 was not able to hit the staff during the shower. Skin tear noticed on Resident #1's right forearm. Resident #1 stated to Staff #3, "look at what they did to me." An undated hand written statement by Staff #3 read, in part, that Staff #3 and Staff #8 entered Resident #1's room, undressed her and walked her to the shower. Staff #8 guided Resident #1 to the shower and Resident #1 started kicking, fighting and screaming real loud and Staff #4 heard this from the hallway and entered Resident #1's room to assist. When Staff #4 entered Resident #1's room Resident #1 started to get physical and Staff #4 was holding Resident #1's hands and arms and tried to calm her down while Staff #8 washed her body and hair. After the shower, staff tried to dress Resident #1 but she refused and said she would pick out her own outfit. When Resident #1 picked out her own outfit she refused to put it on so Staff #4 and Staff #8 grabbed a dress and dressed Resident #1 while she was refusing. Staff #3 noticed blood on Resident #1's right forearm. Afterwards Resident #1 was not in a good mood. A handwritten statement by Staff #4, dated 12/12/22, read, in part that she heard screaming coming out of Resident #1's room and asked if the staff needed help. Resident #1 screamed expletives and that she was going to get us in trouble for hurting her. Resident #1 had bruises on her arms, forehead and inner leg. Resident #1 began to bit Staff #8 and swing her arms at Staff #3. Resident #1 screamed she was being hurt. Resident #1 had soap in her eye so Staff #4 grabbed the shower head and Staff #8 rinsed her off and Resident #1 began hitting Staff #4. Resident #1 hit the shower head out of #8's hand, which caused a skin tear to Resident #1's arm. Resident #1 fought with Staff #4 and Staff #8 when they were dressing her. An interview was conducted with Resident #1, her family member and an outside agency representative. The interview was conducted on 12/15/22. Resident #1 was asked a series of questions relate to the shower on 12/9/22. The outside agency representative asked, "Do you know where your bruises came from?" and Resident #1 replied, in part, "three tough women ... actually only two ... pushing me around, laughing ... grabbing my arms ... turn around ... turn around ..."On 1/24/23 at 10:34 a.m., a family member of Resident #1 stated she was notified by the medication supervisor (MS) on 12/9/22 about a bruises on Resident #1's shoulder and head. She added she was told that Resident #1 probably hit her head on a door and the bruises were healing. The family member said she would come the following day on Saturday 12/10/22 to check on Resident #1. She added that the wellness director (WD) telephoned her in the morning on 12/10/22 at 8:10 a.m. to let her know that Resident #1 had been abused in the shower and that staff were fired and that the WD notified local law enforcement, an outside agency representative, and the Department. She added, the WD made comments about how the residence was, "getting rid of all bad staff." The family member stated that Resident #1 may have been combative in the past but, "doesn't give them the right to assault her (Resident #1)."On 1/24/23 at 2:23 p.m., the WD stated on 12/9/22 Resident #1's shower was not handled correctly and that two staff members helped Resident #1 in the shower. She added, Resident #1 "Started tussling with QMAPs (qualified medication administration persons)." She added a staff member was holding her hands and the other staff tried to get the shampoo out of Resident #1's hair. She added she was not in the building when the incident happened and, "Was told the shower was not handled correctly." On 1/25/23 at 7:30 a.m., Staff #3 stated during Resident #1's shower Staff #4 and #8 were forceful. She added Staff #3 was restraining Resident #1's wrist or arm area because Resident #1 was hitting and kicking staff. Staff #3 noticed a skin tear on Resident #1's arm. Staff #3 said Staff #4 was verbally abusive towards Resident #1 while she was in the shower and Staff #3 told her what to do in an "intimidating" tone. She added, "I've seen her (Staff #4) talk to other residents like they were her children." Staff #3 stated she thought the shower incident was considered abuse. 3. Resident #7 was admitted to the residence on 6/20/22 with diagnoses including Lewy Body dementia. An Employee Disciplinary Action Form in Staff #4's personnel file, dated 12/1/22 read, in part that on 11/29/22 Staff #4 received a violation of "Neglect/abusive behavior towards a resident." The statement read, "On 11/29 we received (sic) witness account of you getting verbally and physically aggressive with a resident."On 1/24/23 at 3:21 p.m., the medication supervisor (MS) stated on 11/29/22 there was an incident with Resident #7 and Staff #4. She added it was an allegation of abuse on Resident #7 and the way Staff #4 interacted with Resident #7. She added Staff #4 spoke to residents in a "very military (like) structure." She said, "The way he (Resident #7) was approached was inappropriate." She added there were no supplemental investigation notes documented for this incident other than Staff #4's disciplinary action on 12/1/22. On 1/24/23 at 4:05 p.m., Staff #7 stated on 11/29/22 Staff #4 was aggressive towards Resident #7, "(Staff #4) was abusive ... going after him. Pushing his chest. She was getting aggressive. She smacked his hand and said "don't do that." On 1/24/23 at 5:08 p.m., Staff #8 stated on 11/29/22 there was an incident with Resident #7. She added Resident #7 grabbed a cookie from another residents hand and Staff #4 tried to redirect Resident #7 and her voice got louder. On 1/25/23 at approximately 8:20 a.m., the administrator stated he did not expect staff to restrain or abuse residents.

Based on record review and interview, the residence failed to investigate all allegations of abuse of residents in accordance with Part 5.3 and its written policy, affecting one of seven sample residents (#7). (Cross-reference Q410, Q1312)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences requires, in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator(B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation;(E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted(G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review.b. Chapter VII regulations governing assisted living residences, part 2.1, defines abuse as the non-accidental infliction of bodily injury, serious bodily injury or death and confinement or restraint that is unreasonable under generally accepted caretaking standards.c. The residence's undated Investigation of Abuse and Neglect Allegations and All Unexplained and Unobserved injuries policy read, in part, "(The Residence) will investigate all allegations of verbal, physical, and sexual abuse ... Will report all allegations and injuries to the appropriate agency such as the adult protection services in (Residence's) County, department of human services ... Colorado Health Department, Colorado ombudsman. Will protect the resident from future abuse ... while the investigation is being conducted ... Will report allegation ... to residents emergency contact and department of health within 24 hours. Will complete the procedural process for such allegations ... and document the investigation process by conducting a thorough investigation ... will take appropriate corrective action if the alleged ... abuse ... are verified. Will report the investigation final findings to the Department no later than five working days after the initial occurrence." 2. Incident on 11/29/22 involving Resident #7. Resident #7 was admitted to the residence on 6/20/22 with diagnoses including Lewy Body dementia. An Employee Disciplinary Action Form in Staff #4's personnel file, dated 12/1/22 read, in part that on 11/29/22 Staff #4 received a violation of "Neglect/abusive behavior towards a resident." The statement read, "On 11/29 we received (sic) witness account of you getting verbally and physically aggressive with a resident."On 1/24/23 at 3:21 p.m., the medication supervisor (MS) stated on 11/29/22 there was an incident with Resident #7 and Staff #4. She added it was an allegation of abuse on Resident #7 and the way Staff #4 interacted with Resident #7. She added Staff #4 spoke to residents in a "very military (like) structure." She said, "The way he (Resident #7) was approached was inappropriate." She added there were no supplemental investigation notes documented for this incident other than Staff #4's disciplinary action on 12/1/22. On 1/24/23 at approximately 4:00 p.m., the administrator in training stated the previous administrator was out of town and he was acting as the administrator when he was notified of the incident with between Staff #4 and Resident #7. He added he had not conducted an investigation. On 1/24/23 at 4:05 p.m., Staff #7 stated on 11/29/22 Staff #4 was aggressive towards Resident #7, "(Staff #4) was abusive ... going after him. Pushing his chest. She was getting aggressive. She smacked his hand and said "don't do that." Staff #7 stated she notified the administrator in training of the incident. On 1/24/23 at 5:08 p.m., Staff #8 stated on 11/29/22 there was an incident with Resident #7. She added Resident #7 grabbed a cookie from another residents hand and Staff #4 tried to redirect Resident #7 and her voice got louder. On 1/24/23 at approximately 8:30 a.m., the administrator stated for the incident involving Resident #7 and Staff #4 there should have been investigation notes and all parties should have been notified, per the policy.

Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting one of seven sample residents (#1). (Cross-reference Q410, Q1312)Findings include:1. Residence PolicyThe residence's undated Investigation of Abuse and Neglect Allegations and All unexplained and Unobserved Injuries policy, read, in part, "... all unexplained and unobserved injuries involving residents will be investigated (sic) accordance with our written policy. Will report all ... injuries to the appropriate agencies such as the adult protection services in Mesa County, Department of Human Services ... Colorado Health Department, Colorado ombudsman. Will protect the resident ... from unexplained and unobserved injuries while the investigation is being conducted. Will report ... injuries to residents, emergency contact and department of health within 24 hours. Will complete the procedural process for such ... injuries and document the investigation process by conducting a thorough investigation. Document the date of ... injuries. Begin and complete the investigation. Interview resident directly affected by ... injuries unexplained or unobserved. Interview other residents and staff for all reported ... injuries. Take corrective action to ensure ... injuries unexplained or unobserved cannot be repeated ... will report the investigation final findings to the Department no later than five working days after the initial occurrence." 2. Resident #1 was admitted to the residence on 9/1/22 with diagnoses including dementia with behavioral disturbance. Resident #1 was 86 years old. Internal investigation notes for Resident #1, dated 12/9/22, revealed the following:An incident report, written by Staff #4, dated 12/9/22 at 10:00 a.m., read that Resident #1 had bruising to her forehead, both arms and legs. Additionally, Resident #1 had reopened a skin tear to her arm. An incident report, written by an unknown staff member, dated 12/9/22 at 12:00 p.m., read Resident #1 had bruising on both her left and right forearms from her wrist to her elbow as well as small bruising up higher on her arm. A faded bruise with a bump was noticed on the right side of her forehead. An unsigned handwritten timeline, dated 12/14/22, read, in part that Resident #1 had a shower on 12/9/22 at approximately 10:00 a.m. and Staff #8 reported Resident #1 had bruises at 12:00 p.m. A handwritten statement by Staff #4, dated 12/12/22, read, in part that Resident #1 had bruises on her arms, forehead and inner leg. There were no other progress notes in Resident #1's record that showed Resident #1 had sustained any injuries of known or unknown origin other than a skin tear to Resident #1's right forearm on 12/9/22. b. InterviewsOn 1/24/23 at 10:34 a.m., a family member of Resident #1 stated she was notified by the medication supervisor (MS) on 12/9/22 about a bruise on Resident #1's shoulder and head. She added she was told that Resident #1 probably hit her head on a door and the bruises were healing. The family member said that she was never notified prior to 12/9/22 about any other bruises or injuries Resident #1 might have sustained. On 1/24/23 at 5:08 p.m. Staff #8 stated Resident #1 may have fallen a couple weeks prior to the incident on 12/9/22. She added, the wellness director knew of the bruising on Resident #1's forehead. On 1/25/23 at 7:30 a.m., Staff #3 stated the bruise on Resident #1's right bicep was there before the shower on 12/9/22. On 1/25/23 at 8:05 a.m., the activity director stated, "I came in on a Monday ...not sure if it was (12/12/22) or the Monday prior (12/5/22). (Resident #1) had a goose egg on her head. I asked the wellness director (WD) ... if she had a fall. She had a goose egg on her head. (WD) said she did not think so. (WD) went to find an (incident report) and there was no (incident report). Friday (12/9/22) I saw her arms and they were bruised." The activity director added there were no other bruises prior to the ones she reported that she had noticed on Resident #1. On 1/24/23 at approximately 8:30 a.m., the administrator stated he expected the residence to complete an investigation for all injuries of known/unknown origin.

Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting four of six sample residents (#1, #2 ,#5, #6). Findings include:1. Referencesa. According to WebMD, "Statins are "life-saving" drugs and, according to the findings of the study, "the discontinuation of this therapy has significant effects,"Stopping your statin can put you at risk of having heart disease and other preventable health problems like stroke and heart attack from high cholesterol ..." WebMD (2023) Simvastatin, retrieved from :https://www.webmd.com/cholesterol-management/news/20210623/stopping-statins-elderly-risky-study.b. According to WebMD, "Beclomethasone (albuterol fumarate) is used to prevent and control symptoms (wheezing and shortness of breath) caused by asthma. This medication belongs to a class of drugs known as corticosteroids. It works by reducing the swelling of the airways in the lungs to make breathing easier. This medication must be used regularly to prevent breathing problems (attacks of wheezing/shortness of breath). Do not stop using this medication without consulting your doctor. Some conditions may become worse when the drug is suddenly stopped. Your dose may need to be gradually decreased ..." WebMD (2021) Beclomethasone, retrieved from: https://www.webmd.com/drugs/2/drug-148390/budesonide-formoterol-inhalation/detailsc. According to WebMD, "Allopurinol is used to treat gout and certain types of kidney stones. It is also used to prevent increased uric acid levels in patients receiving cancer chemotherapy. These patients can have increased uric acid levels due to release of uric acid from the dying cancer cells. Allopurinol works by reducing the amount of uric acid made by the body. Increased uric acid levels can cause gout and kidney problems. Do not stop taking allopurinol suddenly unless you have a skin rash or allergic reaction. Speak to your doctor or nurse before stopping. Stopping allopurinol quickly can cause a flare up and make your gout worse ..." WebMD (2022) Allopurinol, retrieved from: https://www.webmd.com/drugs/2/drug-8610/allopurinol-oral/details/list-contraindications d. According to WebMD, "Quetiapine fumarate is used to treat certain mental/mood conditions (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder). It is also used with other medications to treat depression. Quetiapine is known as an antipsychotic drug (atypical type). It works by helping to restore the balance of certain natural substances (neurotransmitters) in the brain. This medication can decrease hallucinations and improve your concentration. It helps you to think more clearly and positively about yourself, feel less nervous, and take a more active part in everyday life. It may also improve your mood, sleep, appetite, and energy level. Quetiapine can help prevent severe mood swings or decrease how often mood swings occur ..." WebMD (2023) Quetiapine fumarate, retrieved from: https://www.webmd.com/drugs/drugreview-4689-quetiapine-orale. According to WebMD, "Citalopram is used to treat depression. It may improve your energy level and feelings of well-being. Citalopram is known as a selective serotonin reuptake inhibitor (SSRI). This medication works by helping to restore the balance of a certain natural substance (serotonin) in the brain. Some conditions may become worse when this drug is suddenly stopped. Also, you may experience symptoms such as mood swings, headache, tiredness, sleep changes, and brief feelings similar to electric shock ..." WebMD (2023) Citalopram, retrieved from: https://www.webmd.com/depression/guide/withdrawal-from-antidepressantsf. The residence ' s undated Administering Medications policy, read in part, "staff shall only administer medications upon the written order of a licensed physician or other authorized practitioner."2. Resident #6 was admitted to the residence on 11/19/21 with diagnosis including chronic obstructive pulmonary disease (COPD) with exacerbation and cough.a. Mucus reliefA written practitioner's order, dated 10/21/22, directed the residence to administer mucus relief 400 mg one capsule daily, however, the January 2023 electronic medication administration record (eMAR) revealed mucus relief had not been administered as ordered on morning, afternoon and evening dose of 1/11/23; morning and evening dose of 1/12/23; and evening dose of 1/16/23 due to the medication being unavailable, for a total of six missed doses. b. Cerovite senior reformulated A written practitioner's order, dated 3/31/22, directed the residence to administer cerovite senior reformulated 6-29-10 one tablet daily, however, the January 2023 eMAR revealed cerovite had not been administered as ordered on the morning of 1/5 -1/9/23 due to the medication being unavailable, for a total of five missed doses. c. Senexon-SA written practitioner's order, dated 7/7/22, directed the residence to administer 8.6-50 mg one tablet daily, however, the January 2023 eMAR revealed Senexon had not been administered as ordered on the evening of 1/1/23, morning of 1/2/23 and evening of 1/13/23 due to the medication being unavailable, for a total of three missed dosesd. Albuterol fumarateA written practitioner's order, dated 10/26/22, directed the residence to administer albuterol fumarate 2.5 mg/3 ml twice daily, however, the January 2023 eMAR revealed albuterol fumarate had not been administered as ordered on the evening of 1/2-1/3/23 due to the medication being unavailable, for a total of two missed doses.e. Allopurinol A written practitioner's order, dated 3/31/22, directed the residence to administer allopurinol 100 mg once daily, however, the January 2023 eMAR revealed the morning dose of allopurinol had not been administered as ordered on 1/5/23 due to the medication being unavailable, for a total of one missed dose. f. Quetiapine fumarateA written practitioner's order, dated 9/23/22, directed the residence to administer quetiapine fumarate 25 mg one tablet daily, however, the January 2023 eMAR revealed quetiapine fumarate was not administered as ordered on 1/13/23 due to the medication being unavailable, for a total of one missed dose. 3. Resident #5 was admitted to the residence on 9/26/22 with diagnosis including dementia and anxiety.a. SimvastatinA written practitioner's order, dated 9/21/22, directed the residence to administer Simvastatin 20 mg, one tablet daily, however, the January 2023 (MAR) revealed Simvastatin had not been administered as ordered on 1/1-1/24/23 due to the medication not documented on eMAR, for a total of 24 missed doses.b. Citalopram A written practitioner's order, dated 9/21/22, directed the residence to administer citalopram 20 mg, one tablet daily, however, the January 2023 eMAR revealed Citalopram had not been administered as ordered on 1/14-1/16/23, 1/18/23, 1/20/23 due to the medication being unavailable, for a total of five missed doses. c. Metoprolol A written practitioner's order, dated 9/21/22, directed the residence to administer metoprolol 25 mg one half tablet daily, however, the January 2023 eMAR revealed metoprolol had not been administered as order on afternoon and evening of 1/1/23 and evening of 1/2/23 for a total of three missed doses due to medication being unavailable. On 1/24/23 at 12:50 p.m., the wellness director (WD) stated Simvastatin was not given since the resident was admitted on 9/6/22. She stated the medication must not have been transcribed on the eMAROn 1/25/23 at 8:30 a.m., Staff #7 stated when the medication was not available and out of stock, the staff were trained to document the discrepancy in a binder and inform the medication supervisor. 4. Resident #2 was admitted to the residence on 11/16/22 with diagnoses including hypertension. AmlodipineA written practitioner's order, dated 1/9/23, directed the residence to administer amlodipine 5 mg once daily. However the January eMAR for Resident #2 read the medication was not available and not administered on 1/19/23.5. Resident #1 was admitted to the residence on 9/1/22 with diagnoses including dementia with behavioral disturbance. RisperidoneA written practitioner's order, dated 12/13/22, directed the residence to administer risperidone 0.5 mg twice daily. However, the January eMAR for Resident #1 read the medication was not available and not administered on 1/1 a.m and p.m. dose and 1/2/23 a.m. dose. For a total of three missed doses. On 1/25/23 at 10:00 a.m., the administrator stated it was not acceptable for a resident to run out of medications and not receive them as ordered. He stated that all the qualified medication administrators (QMAPs) were responsible for ordering resident medications and he expected them to order the medication when the resident had seven days worth of medication remaining. The administrator said he was unaware of many medications being out of stock.

Based on record review and interview, the residence failed to provide, within 60 days, a minimum of six (6) hours of general training and education on providing care and services for residents with dementia/cognitive impairment with training content provided or recognized by an academic institution, a recognized state or national organization or association, or an independent contractor or group that emphasizes dementia/cognitive impairment care, affecting all current residents. (Cross-reference Q1312)Findings include: 1. ObservationOn 1/24/22 from 7:00 a.m., to 4:00 p.m., Staff #1 provided care and services to all the residents. On 1/24/22 from 2:00 p.m., to 5:00 p.m., Staff #2 provided care and services to all the residents. 2. Record review The residence's individual personnel files were reviewed and revealed: Staff files for Staff #1-#5 were provided and revealed the following;Staff #2 was hired on 1/11/23Staff #3 was hired on 11/28/22Staff #4 was hired on 8/15/22Staff #5 was hired on 1/7/23The residence's dementia training was not provided by or recognized by an academic institution, a recognized state or national organization or association, or an independent contractor or group that emphasizes dementia/cognitive impairment care. Staff files for Staff #2-#5 contained no documentation of completed dementia training. 3. Interviews On 1/24/23 at 10:10 a.m., the business office manager (BOM) stated Staff #5 and Staff #8 were the agency staff and added there were no files in residence for those staff. She added if the dementia training checklist is not in the file, it was not given. On 1/24/23 at approximately 1:30 p.m., Staff #7 stated she was unsure if the residence had a dementia specific training program for staff providing care to residents in the secure environment. On 1/24/23 at approximately 1:55 p.m., Staff #1 stated she had not received any training specific to dementia upon hire approximately a month ago, nor had she received training specific to dementia after she began working at the residence. On 1/24/23 at 3:45 p.m., Staff #2 stated she did not receive any dementia training upon hire which was approximately 15 days ago. On 1/24/23 at 2:23 p.m., the WD stated no residence specific dementia training was provided to contracted staff. On 1/24/23 at 5:08 p.m., Staff #8 stated she had been working at the residence for at least 90 days. She added she had not received any training at the residence, especially training on how to provide care and services to residents with dementia at the residence.

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 7.7.10 The assisted living residence shall maintain a personnel file for each of its employees and volunteers. 12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status. 22.28 The assisted living residence shall prohibit the use of electric blankets and/or heating pads in resident rooms unless there is staff supervision or written documentation that the administrator has assessed the resident and determined he or she is capable of using such device in a safe and appropriate manner. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following:(A) A description of the resident's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact;(B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR's plan to protect the resident from unwanted visitation by other residents;(C) Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and(D) Documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents. 25.26 A secure environment shall meet the following criteria:(F) There shall be a secure outdoor area that is available for resident use year-round that:(2) Is independently accessible to residents without staff assistance for entrance or exit.