ASPEN RIDGE ALZHEIMERS SPECIAL CARE CENTER

A licensure complaint, prompted by #CO40937 and #CO41356, was conducted on 1/7/26. Deficiencies were cited.

Based on record review and interview, the residence failed to report suspected physical abuse to law enforcement (LE) within 24 hours of discovery pursuant to Colorado Revised Statutes (C.R.S.), affecting two of nine sample residents (#1 & #2). (Cross-reference U0430, U1410)Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences: Part 2.8, defines an "At-risk person" means any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (F) Is mentally impaired.b. Chapter VII regulations governing assisted living residences, part 2.1, defines "Abuse" means the non-accidental infliction of bodily injury, serious bodily injurt or death and confinement or restraint that is unreasonable under general accepted caretaking standards.c. C.R.S. Section 18-6.5-108, read in part, staff of any care facility who had a reasonable cause to believe that an at-risk elder or an at-risk adult had been mistreated or was at imminent risk of mistreatment was required to report such fact to a LE agency not more than twenty-four hours after making the observation or discovery. A person who willfully violates subsection (1)(a) of this section commits a class 2 misdemeanor. 2. Record ReviewResident #1 was admitted to the residence on 10/3/25 with a diagnosis of dementia. The progress notes for Resident #1 in November 2025 and January 2026 revealed the following:On 11/9/25 Resident #5 shoved Resident #1 into a chair and walked away. Resident #1 push Resident #5 to the ground and no injuries were noted. On 1/2/26 Resident #1 was observed by two staff members walking up behind Resident #8 in the hallway. Resident #1 began hitting Resident #8 in the back for an unknown reason. Resident #8 placed his hand in front of where Resident #1 was hitting him and obtained a skin tear to his right hand. 3. InterviewsOn 1/6/26 at 3:45 p.m. the Health Services Director (HSD) was interviewed. The HSD said she was still learning the correct reporting process for alleged abuse and that she did not report or investigate the incident on 11/9/25 between Resident #5 and Resident #1. She said going forward she was going to report all incidents of alleged abuse to prevent this situation from happening again. On 1/7/26 at 9:58 a.m. the administrator confirmed the incident was not reported or investigated and that it was a matter of needing to educate the HSD on abuse again. The administrator said law enforcement was not contacted regarding the abuse allegation. 4. Similar deficient practice was found for Resident #2.

Based on record review and interview, the residence failed to report an occurrence affecting two residents (#1 & #2) out of nine sample residents. (Cross-reference U0410 and U1410) Findings include:1. Reference a. Chapter II regulations governing assisted living residences, part 4.2.2, requires that the following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department: (A) Any occurrence that results in the death of a client of the facility or agency and is required to be reported to the coroner pursuant to section 30-10-606, C.R.S., as arising from an unexplained cause or under suspicious circumstances.b. According to the Occurrence Reporting Manual, dated May 2018, the residence must report an occurrence to the Department when: "Any occurrence that results in the death of a patient or resident of the facility and is required to be reported to the coroner pursuant to Section 30-10-606, C.R.S., as arising from an unexplained cause or under suspicious circumstances." Section 25-1-124 (2)(a), C.R.S."2. Record ReviewResident #1 was admitted to the residence on 10/3/25 with a diagnosis of dementia. The progress notes for Resident #1 in November 2025 and January 2026 revealed the following:On 11/9/25 Resident #5 shoved Resident #1 into a chair and walked away. Resident #1 push Resident #5 to the ground and no injuries were noted. On 1/2/26 Resident #1 was observed by two staff members walking up behind Resident #8 in the hallway. Resident #1 began hitting Resident #8 in the back for an unknown reason. Resident #8 placed his hand in front of where Resident #1 was hitting him and obtained a skin tear to his right hand. A review of the Department ' s database on 1/5/26 revealed the incident on 11/9/25 was not reported. 3. InterviewsOn 1/6/26 at 3:45 p.m. the Health Services Director (HSD) was interviewed. The HSD said she was still learning the correct reporting process for alleged abuse and that she did not report or investigate the incident on 11/9/25 between Resident #5 and Resident #1. She said going forward she was going to report all incidents of alleged abuse to prevent this situation from happening again. On 1/7/26 at 9:58 a.m. the administrator confirmed the incident was not reported or investigated and that it was a matter of needing to educate the HSD on abuse again. 4. Similar deficient practice was found for Resident #2, who had an abuse allegation against staff.

Based on interviews and record review, the residence failed to thoroughly investigate allegations of abuse, affecting four of nine sample residents (#1, #2, #5 and #8). (Cross reference U0410,U0430, and U3062) Specifically, the residence failed to investigate allegations of abuse. On 11/9/25 an incident of resident-to-resident abuse between Resident #1 and Resident #5 occurred. Resident #1 pushed resident #5 to the ground, There was no investigation nor interventions put into place to prevent future incidents . On 1/2/26/26 Resident #1 striked Resident #8, causing a skin tear to Resident #8's hand. There was an investigation for the incident on 1/26/26 however there were multiple elements missing in the investigation including an updated care plan or how they would protect the residents during the investigation. Additionally there was an allegation of confinement for Resident #2 was not investigated. Findings include:1. Residence policy and procedureThe Resident Abuse and Neglect policy was provided by the administrator on 1/5/26 at 2:00 p.m. It read in pertinent part:"As soon as feasible, the supervisor or manager on duty will report the incident to the Health Services Director, Administrator and the corporate office, and will immediately initiate the investigation. The resident and resident ' s responsible party will be reassured that the resident is not in any further danger of alleged abuse and that the community is committed to conducting a thorough and prompt investigation. All staff who might have witnessed or have knowledge of the alleged abuse will be interviewed. "If the alleged abuser is on duty, the supervisor on duty will obtain their written statement about their knowledge or version of the alleged incident. The supervisor or manager on duty is to immediately suspend the alleged abuser, informing them they are not to be in the community until the investigation is completed.""If the alleged abuser is another resident, a thorough evaluation will be conducted to determine possible causes of their behavior, including physical, behavioral, pain and/or depression."2. Resident #1 was admitted to the residence on 10/3/25 with a diagnosis of dementia. The progress notes for Resident #1 in November 2025 and January 2026 revealed the following:On 11/9/25 Resident #5 shoved Resident #1 into a chair and walked away. Resident #1 push Resident #5 to the ground and no injuries were noted. The investigation for 11/9/25 was requested on 1/6/25, and was not provided. On 1/2/26 Resident #1 was observed by two staff members walking up behind Resident #8 in the hallway. Resident #1 began hitting Resident #8 in the back for an unknown reason. Resident #8 placed his hand in front of where Resident #1 was hitting him and obtained a skin tear to his right hand. The investigation for 1/2/26 was provided by the administrator on 1/6/25. However the investigation did not include the following;The process for investigating such allegations; How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; A requirement that the resident shall be protected from potential future abuse while the investigation is being conducted; As well as a requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action. Resident #1 ' s care plan did not reflect the resident ' s aggressive behavior towards other residents. On 1/6/26 at 3:45 p.m. the Health Services Director (HSD) was interviewed. The HSD said she was still learning the correct reporting process for alleged abuse and that she did not investigate the incident on 11/9/25 between Resident #5 and Resident #1. She said going forward she was going to report all incidents of alleged abuse to prevent this situation from happening again. The HSD said Resident #1 hit Resident #8 and was unprovoked when it occurred and caused a skin tear. She said she was able to see a pattern of escalation between the November 2025 and January 2026 incidents. On 1/7/26 at 9:58 a.m. the administrator confirmed the incident was not reported or investigated and that it was a matter of needing to educate the HSD on abuse again. 3. Similar deficient practice was found for Resident #2, who had an abuse allegation against a staff member on 12/2/25 which was not thoroughly investigated.

Based on record review and interview, the residence failed to ensure an enhanced care plan was developed with input from the resident's representative and detailed specific personal service needs and preferences, along with the staff tasks necessary to meet those needs, affecting two of nine sample Resident (#2 and #1). (Cross reference U0410) Specifically, Resident #2 fell 13 times in three months. Two of the falls resulted in injury and one with the resident hitting her head. On 12/4/25 Resident #2 was found on the floor with a skin tear to her right forearm which required basic first aid. On 12/11/25 Resident #2 was walking down the hallway when she fell and obtained a new skin tear to her right hand. On 12/29/25 Resident #2 fell while walking and hit her head on the cabinet. The care plan was not updated and had one intervention listed. Furthermore staff did not know what fall interventions were in place for Resident #2. Findings include:1. References & Residence policya. Chapter VII regulations governing assisted living residences, part 12.10 requires each resident care plan to include: (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs.b. The Fall Management and Post Fall Investigations policy, dated 5/15/23, was provided by the executive director (ED) on 1/6/26 at 11:00 a.m. It read in pertinent part:"Fall means unintentionally coming to rest on the ground, floor or other lower level, but not because of an overwhelming external force. An episode where a resident lost his or her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without an injury is still a fall. Unless there is evidence to suggest otherwise, a resident observed on the floor, a fall has occurred. "Fall interventions are documented in the resident individualized service/care plan. When a fall occurs the health services director (HSD) or designee will update the resident service/care plan."c. The Falls Evaluation policy, dated 11/1/14, was provided by the ED on 1/6/26 at 11:00 a.m. It read in pertinent part:"When a resident falls implement fall prevention interventions and note changes to service plan if indicated."Record review 2. Resident #2 was admitted to the residence on 1/6/25 with a diagnosis of dementia. On 10/12/25 Resident #2 tripped and fell going to the restroom. On 11/7/25 Resident #2 lost her balance and staff lowered her to the floor. On 11/8/25 Resident #2 was found on the floor rubbing her head. On 11/9/25 Resident #2 was found on the floor on her back. On 11/10/25 Resident #2 was found on the floor in the dining room. On 11/13/25 Resident #2 screamed and was witnessed grabbing another resident ' s wheelchair as she fell to the floor. Again on 11/13/25 staff heard a thud and a scream and found Resident #2 on the floor. On 11/16/25 staff heard Resident #2 yell and found her on the floor. On 11/26/25 the staff heard a thud and scream and found Resident #2 on the floor on her right side. On 12/4/25 Resident #2 was found on the floor with a skin tear to her right forearm which required basic first aid. On 12/5/25 staff heard a thud and found Resident #2 on the floor. On 12/11/25 Resident #2 was walking down the hallway when she fell and obtained a new skin tear to her right hand. On 12/29/25 Resident #2 fell while walking and hit her head on the cabinet.-However, the residence failed to implement new fall interventions into Resident #2 ' s care plan. Resident #2 ' s care plan, revised 12/5/25, contained no detailed specific personal service needed and preferences regarding falls. One intervention, undated, was entered as fall management twice a day without specific details. 3. InterviewsOn 1/6/26 licensed practical nurse (LPN) was interviewed at 10:30 a.m. The LPN said she did not read or look at the care plans very often and was unsure what Resident #2 ' s fall interventions were but that staff did what they felt was right in the moment to helpprevent a fall. Resident #2 ' s medical durable power of attorney (MDPOA) was interviewed on 1/6/26 at 12:13 p.m. He said Resident #2 fell a lot and hit her head recently. He stated he was concerned about her safety regarding falls. The health services director (HSD) was interviewed on 1/6/26 at 3:45 p.m. The HSD said Resident #2 had a lot of falls and often threw herself to the floor or into staff ' s arms. The staff were instructed to lower her to the ground and monitor her while she walked around. She said the residence tried to implement as many fall interventions as possible into the care plan, however their electronic medical record was unfamiliar to the HSD and she did not know how to add fall interventions to Resident #2 ' s care plan. The administrator was interviewed on 1/7/26 at 9:58 a.m. He said Resident #2 fell a lot and that he and the HSD needed to learn how to use their electronic health record better so the care plans reflected the correct interventions. 4. Similar deficient practice was found for Resident #1 due to no interventions for resident-to-resident abuse.

A revisit survey was completed on 9/24/25 for all previous deficiencies cited on 7/15/25. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 9/24/25 for all previous deficiencies cited on 7/15/25. The facility is in compliance with all deficiencies that were cited.

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

A relicensure survey with complaint revisit was completed on 7/15/25 for all deficiencies cited on 5/23/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The Chapter VII regulations were implemented on 5/23/23 and the new Chapter VII regulations were implemented on 3/17/25.

Based on record review and interview, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting one of four sample residents (#4). This deficiency was cited previously during a state licensure survey 5/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #4 was admitted to the residence on 2/17/22, diagnoses included dementia. A written practitioner's order, dated 11/23/23, directed the residence to administer two 325 mg acetaminophen tablets three times a day. However, the July 2025 medication administration record (MAR) revealed that the residence failed to administer two doses on 7/7 and three doses from 7/9 to 7/11/25. The MAR read the medication had not been given because it was not available. On 7/15/25 at 2:41 p.m., the health services director (HSD) said they had an order but the pharmacy needed a script from a practitioner to fill the order. The HSD said there was nothing preventing the residence from purchasing the medication until the pharmacy was able to deliver. On 7/15/25 at 4:30 p.m., the administrator said the deficiency was being cited again because the residence was continuing to work on a process with the pharmacy to avoid medication not being available.

A relicensure survey with complaint #CO038130 and CO40248 were completed on 7/15/25. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting one of four sample residents (#4). This deficiency was cited previously during a state licensure survey 5/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #4 was admitted to the residence on 2/17/22, diagnoses included dementia. A written practitioner's order, dated 11/23/23, directed the residence to administer two 325 mg acetaminophen tablets three times a day. However, the July 2025 medication administration record (MAR) revealed that the residence failed to administer two doses on 7/7 and three doses from 7/9 to 7/11/25. The MAR read the medication had not been given because it was not available. On 7/15/25 at 2:41 p.m., the health services director (HSD) said they had an order but the pharmacy needed a script from a practitioner to fill the order. The HSD said there was nothing preventing the residence from purchasing the medication until the pharmacy was able to deliver. On 7/15/25 at 4:30 p.m., the administrator said the deficiency was being cited again because the residence was continuing to work on a process with the pharmacy to avoid medication not being available.

Based on record review and interview, the residence failed to re-assess residents every six months for the need of a secure environment, affecting four of four sample residents (#4 - #7) who resided in a secure environment (SE). Findings include:Resident #4 was admitted to the residence on 2/17/22, diagnosis included dementia. The record for Resident #4 contained an initial practitioner's evaluation, date unknown, for the placement in a secure environment. However, the record contained no further evidence that the residence included the attending practitioner to reassess the resident every 6 months for the continued need of a secure environment. On 7/15/25 at 4:30 p.m., the administrator said she did not know it was required to include the attending practitioner to assess the residents in the secure environment every six months to determine their continued need for a secure environment. Similar deficient practice was found for Residents #5 - #7

Based on observation, interview and record review the residence failed to ensure resident care plans contained a description of of how residents would have continuous independent access to his or her individual room, along with the a plan to protect the resident from unwanted visitation by other residents, affecting four of four sample residents (#4 - #7) who resided in a secure environment (SE). Findings include:Resident #5 was admitted to the residence on 2/3/23, diagnosis included dementia. A care plan, dated 4/11/25, did not include a description of how the resident would have continuous independent access to her individual room. On 7/15/25 at 7:20 a.m, Staff #17 approached an unknown resident's room, knocked on the door and used a key from her pocket to unlock the door. Staff #17 said all the residents' rooms were locked at all times and staff assisted residents when asked by a resident or if staff saw that a resident was trying to go in their room. On 7/15/25 at 3:45 p.m., Staff #19 said some residents had their own room keys but she did not know where the information was located. On 7/15/25 at 4:00 p.m, the administrator said care plans did not document how residents would have continuous access to their rooms while keeping unwanted guests out. Similar deficient practice was found for Resident #4, #6 and #7.

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 7.25.26 A secure environment shall meet the following criteria: Is independently accessible to residents without staff assistance for entrance or exit.

A revisit survey was completed on 7/10/24 for all previous deficiencies cited on 3/19/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO34050 and #CO34904, was completed on 3/19/24. Deficiencies were cited.

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 three sample residents (#7). Findings include:1. Residence PolicyThe residence's Abuse, Neglect, Misappropriation and Injuries of Unknown Sources policy, dated 8/1/21 read in part, "An injury should be classified as an injury of an unknown source when both of the following conditions are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident. The injury is suspicious because of the extent of the injury, the location of the injury ...the number of injuries observed at any particular point in time, or the incidence of injuries over time ... Interview and obtain a statement from any persons allegedly involved, including the affected resident, the complainant, the accused perpetrator, any witnesses and any other persons who may have firsthand knowledge of the incident. Document all the findings ... Document all findings about the incident, including the allegation; the statements of persons involved, the date, time and location of the incident, including the location of persons and things, the effect of the incident on the resident and other information that may be helpful."2. Resident #7 was admitted to the residence on 12/11/23 with diagnoses including dementia. Progress notes for March 2024 in Resident #7's record revealed she fell on 3/5, 3/6, 3/14 and 3/15/24 with no apparent injuries noted by staff who assessed Resident #7. An incident report, written by Staff #17 on 3/16/24 for Resident #7 read there was a black and blue bruise on Resident #7's right wrist. Staff were unsure of what happened and did not observe the bruise on Resident #7 the day prior. There was no specific investigation documentation or interview statements in Resident #7's record for the bruise that was observed on 3/16/24.3. InterviewsOn 3/19/24 at 10:22 a.m., Staff #17 said when she was notified a resident had a bruise not from a specific fall or incident she would ask staff where it came from and what had happened and progress note her findings. She added she had not kept the staff statements. On 3/19/24 at 12:31 p.m., the administrator said if staff noticed an injury of unknown origin on a resident, staff were required to fill out a form similar to an incident report. She added the nurse was required to talk with staff and complete an assessment on the resident. On 3/19/24 at 1:07 p.m., the health services director said for injuries of unknown origin, the residence completed a risk management form, interviewed staff and observed the injury. She added the nurse who was told about the bruise on Resident #7 should have filled out a risk management form and documented the interviews conducted with staff. She added she did not tell the nurse she was required to fill out a risk management form or document interviews.

Based on record review and interview, the residence failed to ensure that no medication was administered by a qualified medication administration person (QMAP) on a pro re nata (PRN) or "as needed" basis, affecting one of three sample residents (#5) and one former resident (#8). Findings include:1. Resident #5 was admitted to the residence on 5/23/23 with diagnoses including dementia. A written practitioner's order, dated 2/12/24, directed the residence to administer quetiapine 25 mg as needed for behavioral disturbance. The March 2024 medication administration record for Resident #5 read on 3/15/24 Resident #5 was administered quetiapine 25 mg at 8:53 p.m., "Per (health services director, HSD)."2. Evidence obtained during the onsite visit revealed the residence additionally failed to ensure that no medication was administered by a QMAP on a PRN basis for Former Resident #8. 3. InterviewsOn 3/19 at 10:22 a.m.. Staff #17 said Resident #5 was unable to request or understand the need for one of her as needed medications. She added QMAPs were allowed to administer as needed over the counter medications and were required to telephone the HSD for permission to administer controlled substances. She added she was unaware QMAPs were not allowed to administer as needed medications to residents who were unable to understand their purpose. On 3/19/24 at approximately 1:15 p.m., the HSD said QMAPs were required to telephone herself or one of the other nurses to approve whether or not a resident could be administered an as needed medication. She added, Resident #5 was not alert and oriented enough to request an as needed medication. The HSD said she was not aware QMAPs could not telephone nurses after hours to obtain an over the phone assessment and approval to administer as needed medication.

Based on record review and interview the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting two of three sample residents (#5, #6) and one former resident (#8). Findings include:1. Residence PolicyThe residence's Medication Errors policy, dated 3/10/23, read in part, "Medication assistance and/or administration will be provided to residents in a manner that is safe and consistently free of errors ... The community will document and will be responsible to ensure that medications are administered without errors ... Examples of medication errors include ... a missed dose of medication ... "2. Resident #6 was admitted to the residence on 3/14/24 with diagnoses including fractured ribs and humeral fracture.a. Acetaminophen A written practitioner's order, dated 3/15/24, directed the residence to administer acetaminophen 325 mg two tablets every six hours. However, the March 2024 medication administration record (MAR) for Resident #6 read the medication was "not available" on 3/16, 3/17 for all doses and 3/18 for three doses, for a total of 11 missed doses of acetaminophen. On 3/19/24 at 10:31 a.m., a family member of Resident #6 said the residence did not have acetaminophen to administer to Resident #6 because of a miscommunication with the hospital and an external hospice provider. b. MelatoninA written practitioner's order, dated 3/15/24, directed the residence to administer melatonin 6 mg once daily. However, the March 2024 MAR for Resident #6 read the medication was "not available" and not administered on 3/15-3/17, for a total of three missed doses. c. FluoxetineA written practitioner's order, dated 3/15/24, directed the residence to administer fluoxetine 20 mg once daily. However, the March 2024 MAR for Resident #6 read the medication was "not available" on 3/18/24. 3. Evidence obtained during the onsite visit revealed the residence additionally failed to comply with authorized practitioner's orders associated with medication administration for Resident #5 and Former Resident #8.4. InterviewsOn 3/19/24 at approximately 12:30 p.m., the administrator said the medication for Resident #6 was not in stock or administered because of a miscommunication between the hospital and an external hospice provider's orders. The administrator said she expected medications to be in stock and administered to residents as ordered. On 3/19/24 at approximately 1:00 p.m., the health services director said if a qualified medication administration person documented the medication was not available on the MARs then the medication was not in stock or administered, as ordered.

A relicensure survey with complaint #CO32003 was completed on 5/23/23. Deficiencies were cited.

Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents, for three of three sample staff (#1-#3), affecting 39 current residents. Findings include:1. References a. Chapter VII regulations governing assisted living residences, part 2.7, defines an "At-risk person" as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (D) Is a person with an intellectual and developmental disability as defined in Section 25.5-10-202, C.R.S.; (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.b. Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include written documentation regarding the following items:(E) Results of background checks and follow up, as applicable.c. According to Colorado Revised Statutes (2017) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult."d. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado adult protective services data system pursuant to section 26-3.1-111.2. Record Reviews Review of the personnel files for Staff #1-#3 revealed no evidence a CAPS check had been requested prior to their hire. Staff #1-#3 were hired on 3/10/23, 3/28/23 and 2/21/23, respectively. Review of the residence's May 2023 staff schedule revealed Staff #1-#3 worked at the residence as follows: Staff #1: on 5/5-5/7/23, 5/12-5/14/23 and 5/20/23; Staff #2: on 5/1-5/4/23, 5/9-5/11/23 and 5/15-5/19/23; Staff #3: on 5/1-5/5/23, 5/8-5/12/23 and 5/15-5/19/23. 3. InterviewOn 5/23/23 at 3:00 p.m., the administrator stated she and the business office manager were responsible for maintaining personnel files. She stated she was aware a CAPS check was required for all staff; however, she stated the residence was backlogged on completing them. The administrator added she was aware Staff #1-#3 did not have CAPS checks. Further, the administrator confirmed all residents were considered at risk and had cognitive deficits.

Based on record review and interview, the administrator failed to be responsible for establishing and maintaining an infectious disease mitigation, vaccine and treatment plan; and, assigning at least one staff member responsible for the site management of the residence's Infection Prevention and Control Program and training, affecting 39 current residents. Findings include:1. ReferencesChapter II regulations governing assisted living residences, part 12.2.1 for Infectious Disease Mitigation, Vaccine, and Treatment Plans requires: (A) All facilities licensed under this chapter shall establish and maintain an infectious disease mitigation, vaccine and treatment plan. This plan shall address, at a minimum, the following: (1) Identification of designated staff who shall coordinate vaccine information, administration, and tracking and reporting of the vaccination status of staff and, if applicable, residents on an ongoing basis; (2) The name and location of the infectious disease vaccine and treatment provider(s) that will be used by the facility to facilitate administration of vaccines and treatment; (3) How the facility will assess and address the vaccination of new staff and, if applicable, residents. Chapter II regulations governing assisted living residences, part 12.2.2 for an Infection Control Officer requires: (B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following: (1) Completing an infection prevention and control training from a nationally recognized provider within two (2) weeks of appointment/designation that meets the following requirements based on facility type; (a) Infection Control Officers at nursing care facilities and intermediate care facilities for persons with intellectual and developmental disabilities shall complete at least nineteen (19) hours of initial training. (b) Infection Control Officers at assisted living residences and all group homes for persons with intellectual and developmental disabilities shall complete at least 1.5 hours of initial training. (2) Completing a minimum of 1.5 hours of continuing education in infection prevention and control on an annual basis from a nationally-recognized provider sufficient to stay current on changing guidance and requirements in the field; (3) Providing on-site management of infectious disease prevention and response activities and general infection prevention duties; (4) Ensuring the facility complies with Department reporting requirements related to infectious diseases; (5) Providing facility access to, and ensuring proper supply, use, handling, and implementation of Personal Protective Equipment (PPE) and disinfectants, used per manufacturer's guidelines; (6) Maintaining a facility respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard (29 CFR 1910.134); (7) Advising and educating residents, staff, and visitors on current precautions being taken in the facility for infectious diseases and the prevention of their spread; and (8) Notifying residents, designated representatives, and staff of updated Centers for Disease Control (CDC) vaccination recommendations, and ensuring vaccines for infectious diseases are available to staff and residents inside their facility within sixty (60) days of any update to the CDC's vaccine recommendations. 2. Infectious Disease Mitigation, Vaccine, and Treatment PlanOn 5/23/23 at 8:18 a.m., the residence's infectious disease mitigation, vaccine and treatment plan was requested from the administrator. However, no vaccine and treatment plan was provided. On 5/23/23 at 2:43 p.m., the administrator stated the residence did not have a current infectious disease mitigation, vaccine and treatment plan because the residence had planned to work on it in their June 2023 meeting. 3. Infection Prevention and Control Program and TrainingOn 5/23/23 at 8:18 a.m., the residence's infection prevention and control staff (IPC) training was requested from the administrator. On 5/23/23 at 11:42 a.m., the health services director (HSD) stated the administrator was the residence's IPC staff member. On 5/23/23 at 2:43 p.m., discrepancies arose when the administrator stated the HSD would be the staff member responsible for the residence's infection prevention and control program but confirmed the residence did not have an IPC staff member during the onsite visit. The administrator added she was not aware the residence was required to have at least one staff member responsible for the site management of the residence's Infection Prevention and Control Program and training.

Based on record review and interview, the residence failed to ensure each personnel file included written documentation of training for three of three sample staff (#1-#3), affecting 39 current residents. (Cross-reference Q2978) Findings include: 1. ReferenceChapter VII regulations governing assisted living residences, part 7.8, requires that the assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (B) The assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self-study courses, or on-the-job training, and shall include, but is not limited to, the following topics:(1) Overview of state regulatory oversight applicable to the assisted living residence;(2) Person-centered care;(3) The role of and communication with external service providers;(4) Recognizing behavioral expression and management techniques, as appropriate for the population being served;(5) How to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, as appropriate for the population being served;(6) Training related to fall prevention and ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobility;(7) How to safely provide lift assistance, accompaniment, and transport of residents;(8) Maintenance of a clean, safe and healthy environment including appropriate cleaning techniques;(9) Food safety; and(10) Understanding the staff or volunteer's role in end of life care including hospice and palliative care. 2. Record ReviewReview of the residence's personnel files read Staff #1-#3 were hired on 3/10/23, 3/28/23 and 2/21/23, respectively. The personnel files for Staff #1-#3 did not contain documentation they had completed training relevant to their specific duties and responsibilities. Review of the residence's May 2023 staff schedule revealed Staff #1-#3 worked at the residence as follows: Staff #1: on 5/5-5/7/23, 5/12-5/14/23 and 5/20/23; Staff #2: on 5/1-5/4/23, 5/9-5/11/23 and 5/15-5/19/23; Staff #3: on 5/1-5/5/23, 5/8-5/12/23 and 5/15-5/19/23. 3. InterviewOn 5/23/23 at 3:02 p.m., the administrator stated the residence had set up their staff members on an electronic training system. She added some staff had been completing their training and some had not. The administrator added she was aware Staff #1-#3 did not have the required documentation of training. Additionally, she confirmed she was aware staff were required to receive all required training prior to working independently.

Based on interview and record review, the residence failed to ensure at least one staff member was onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 39 current residents. Specifically, the residence failed to have at least one staff member onsite at all times who had current certification in CPR and obstructed airway techniques for 20 overnight shifts from 5/1-5/20/23. The residence was unable to provide proof of certification for staff members who worked the residence's overnight shifts. This failure created an immediate jeopardy risk to 39 current residents who required obstructed airway techniques in the event of an emergency. On 5/23/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References a. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that's useful in many emergencies, such as a heart attack or near drowning, in which someone's breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to both untrained bystanders and first responders." Mayo Clinic (5/1/21) Cardiopulmonary Resuscitation, retrieved from: https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600b. According to Nolo Legal Encyclopedia, "A MOST (Medical Orders for Scope of Treatment) form is a doctor's order that helps you keep control over medical care at the end of life. Like a Colorado CPR Directive, the form tells emergency medical personnel and other health care providers whether or not to administer cardiopulmonary resuscitation (CPR) in the event of a medical emergency. A MOST form may be used in addition to -- or instead of -- a CPR Directive. The MOST form may also provide other information about your wishes for end-of-life health care." Irving, S., J.D., Colorado's Medical Orders for Scope of Treatment (MOST) Form, retrieved from: https://www.nolo.com/legal-encyclopedia/colorados-medical-orders-scope-treatment-most-form.html 2. Personnel files and staff scheduleOn 5/23/23 at 9:11 a.m., the residence's personnel files were requested for Staff #1-#3. The personnel files did not contain proof of certification in CPR and obstructed airway techniques. On 5/23/23 at 9:49 a.m., all staff CPR and obstructed airway techniques certifications were requested. The residence's staff schedule for May 2023 in conjunction with the staff CPR and obstructed airway techniques certifications revealed the residence did not have at least one staff who was certified in CPR and obstructed airway techniques overnight from 6:30 p.m. to 6:00 a.m. on 5/1-5/20/23. The residence's staff schedule read as follows: Staff #6 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/1-5/3/23, 5/8-5/10/23, 5/15-5/17/23, and 5/20/23. The residence did not have evidence Staff #6 had a certification in CPR and obstructed airway techniques. Staff #7 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/1-5/4/23, 5/11/23, and 5/15-5/19/23. The residence did not have evidence Staff #7 had a certification in CPR and obstructed airway techniques. Staff #8 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/4-5/6/23, 5/11-5/13/23 and 5/18-5/20/23. The residence did not have evidence Staff #8 had a certification in CPR and obstructed airway techniques. Staff #9 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/1-5/5/23, 5/8-5/12/23 and 5/15-5/19/23. The residence did not have evidence Staff #9 had a certification in CPR and obstructed airway techniques. Staff #10 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/4-5/5/23, 5/7/23, 5/11-5/12/23, 5/14/23, and 5/19/23. The residence did not have evidence Staff #10 had a certification in CPR and obstructed airway techniques. Staff #11 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/6-5/7/23, 5/13-5/14/23 and 5/20/23. The residence did not have evidence Staff #11 had a certification in CPR and obstructed airway techniques. Staff #12 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/1-5/3/23 and 5/8-5/10/23. The residence did not have evidence Staff #12 had a certification in CPR and obstructed airway techniquesStaff #13 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/1-5/3/23, 5/8-5/10/23 and 5/15-5/17/23. The residence did not have evidence Staff #13 had a certification in CPR and obstructed airway techniquesStaff #14 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/4-5/6/23, 5/11-5/13/23 and 5/18-5/20/23. The residence did not have evidence Staff #14 had a certification in CPR and obstructed airway techniquesStaff #15 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/1-5/3/23, 5/8-5/10/23 and 5/15-5/16/23. The residence did not have evidence Staff #15 had a certification in CPR and obstructed airway techniquesStaff #16 worked at the residence from 6:00 p.m. to 6:30 a.m. on 5/1-5/3/23, 5/8-5/10/23 and 5/15-5/17/23. The residence did not have evidence Staff #16 had a certification in CPR and obstructed airway techniques 3. InterviewOn 5/23/23 at 10:33 a.m., the administrator stated she could not find all of the CPR and obstructed airway techniques certifications for staff. She added she would provide what she was able to locate. The administrator confirmed the residence did not have evidence of certification in CPR and obstructed airway techniques for Staff #6-#16 for the residence's overnight shifts from 6:30 p.m. to 6:00 a.m. on 5/1-5/20/23. On 5/23/23 at 3:04 p.m., the administrator stated she was aware the residence was required to have one staff member onsite at all times who was certified in CPR and obstructed airway techniques. 4. Immediate Jeopardy Risk- Written Evidence, Immediate CorrectionThe survey established that the findings above placed the 39 residents who required obstructed airway techniques in the event of an emergency, at immediate jeopardy risk for the failure to ensure at least one staff member who was CPR and obstructed airway techniques certified was onsite at all times. 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 5/23/23 at 2:36 p.m., the administrator submitted written evidence that read in pertinent part: "Health services director (HSD) to be in building during night shift to ensure CPR/first aid certified member in the building-this will take place immediately (Effective immediately-today). Once we have documentation/evidence of CPR/first aid certification for night caregivers/QMAPs the scheduler will ensure that every night has at least 1 (one) certified staff member when developing the schedule moving forward. Administrator and business office manager will work together to ensure all certified staff members have evidence of their CPR/first-aid certification in their employee file."

Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents with emergency contact information along with a residence diagram, affecting 39 current residents. Findings include: On 5/23/23 at 8:17 a.m., the residence's roster was requested from the administrator. The residence's provided roster did not include emergency contact information or a residence diagram. On 5/23/23 at 3:04 p.m., the administrator stated she had printed the roster from the residence's electronic record system. The administrator was unaware the residence's roster was required to include resident names, room numbers and emergency contact information along with a residence diagram.

Based on observation, record review and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting one sample resident (#2). Specifically, Resident #2 was admitted to the residence on 8/22/22 with a diagnosis of Alzheimer's disease. Resident #2 had falls on 2/2/23, 2/10/23, 4/29/23, and 5/18/23. The fall on 4/29/23 resulted in the resident's transport to the hospital via ambulance. Resident #2 was diagnosed with a cervical fracture which resulted in sutures and the use of a neck brace. The cervical fracture put Resident #2 at risk of paralysis in the event he had another fall. The residence did not update the comprehensive assessment or the care plan for Resident #2 with individualized approaches to prevent future falls after the falls on 4/29/23 and 5/18/23. This failure created an immediate jeopardy risk of injury or paralysis from falls to Resident #2. On 5/23/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include: 1. Residence Policy The residence's falls policy, dated 8/1/21, read in part: "Resident must be placed on the appropriate fall prevention interventions as listed on the fall protocols." 2. Resident #2 was admitted to the residence on 8/22/22 with a diagnosis of Alzheimer's disease. On 5/23/23 at 7:29 a.m., Resident #2 was observed walking around the common area of the residence with a neck brace on. The residence's progress notes and incident reports for Resident #2, dated 2/2/23-5/20/23, read in part: An incident report, dated 2/2/23, read Resident #2 had a fall without injury. A progress note, dated 2/10/23, read Resident #2 was seen falling backwards to the ground by a family member. An incident report, dated 2/10/23, read Resident #2 had a fall without injury. A progress note, dated 4/29/23, read care staff noticed Resident #2 had an unwitnessed fall. Resident #2 was taken to the hospital via ambulance. Resident #2 had cervical fracture and needed to wear a neck brace for four to six weeks and had sutures. An incident report, dated 4/29/23, read Resident #2 had a fall which resulted in the fracture to his neck. An incident report, dated 5/18/23, Resident #2 had a fall without injury. A progress note, dated 5/20/23, read Resident #2 was seen with dried blood on his forehead. It was suspected Resident #2 had hit his head on something. Staff encouraged resident to sit and rest. The residence's assessment for Resident #2, dated 4/11/23, read Resident #2 had not had any falls in the past year and was at a "low" risk for falls. The assessment read Resident #2 ambulated independently. The residence's care plan for Resident #2, dated 4/11/23, read Resident #2 needed to be escorted to meals and activities. The care plan did not address falls or Resident #2's mobility or that Resident #2 wore a neck brace following his fall on 4/29/23. The care plan for Resident #2 was not updated to include individualized approaches necessary to address fall risks after Resident #2's falls on 4/29/23 or 5/18/23. On 5/23/23 at 7:29 a.m., Staff #4 stated Resident #2 had a history of falls and stated one had led to his neck being fractured. On 5/23/23 at 7:55 a.m., Staff #5 stated Resident #2 had a history of falls. She added Resident #2 constantly walked around and staff attempted to get him to sit down to prevent falls from fatigue or tripping over items in the residence. On 5/23/23 at 11:10 a.m., an external service provider for Resident #2 stated he was at a risk of falls due to him being impulsive. She added Resident #2 had a fracture in the vertebrae in his neck and if he were to fall and hit that vertebrae again, he was at risk for paralysis. The external service provider stated Resident #5 wore a neck brace due to the risk of paralysis. Additionally, she stated the fracture occurred on 4/29/23; however, since the fracture he had two additional falls on 5/14/23 and 5/18/23. The external service provider added staff were expected to keep an eye on him but stated interventions with Resident #1 were difficult because he did not like to stay in one spot. On 5/23/23 at 11:43 a.m., the health services director (HSD) stated following Resident #2's fall, which resulted in a cervical fracture, the residence had not updated his care plan. On 5/23/23 at 12:03 p.m., the HSD stated Resident #2 was at risk of paralysis with further falls. He stated the resident had sustained additional falls after his fracture. He added Resident #2's practitioner and external service provider had not provided the residence with interventions to prevent future falls. On 5/23/23 at 12:03 p.m., the administrator stated it was the resident's responsibility to implement interventions to prevent future falls. The administrator stated Resident #2 was at risk to become paralyzed and added Resident #2 had additional falls after his fracture. On 5/23/23 at 2:12 p.m., the HSD stated Resident #2's falls had been increasing in the past three months. He stated that, regardless of the staff's interventions, Resident #2 continued to walk independently and frequently throughout the residence. The HSD stated staff spent a lot of time with Resident #2 trying to redirect him. On 5/23/23 at 2:54 p.m., the administrator stated prior to Resident #2's cervical fracture, he had frequent falls. She stated staff were expected to move obstacles while he walked and added staff were to make sure his room door was closed behind him. The administrator acknowledged the residence's interventions for Resident #2 were not working, since he had continued to sustain falls. On 5/23/23 at 3:06 p.m., the administrator stated she would expect the care plan for Resident #2 to be updated with interventions after each fall. She added, she was not aware of why Resident #2's care plan had not been updated. Further, she stated she would expect the residence to be in compliance with the residence's fall management policy. On 5/23/23 at 4:38 p.m., Resident #2's family member stated Resident #2's falls had gotten worse in the past couple of months and stated he was losing his balance more. She added Resident #2 would lose his coordination and trip over items such as other residents' walkers. The family member stated Resident #2 was in a neck brace due to the fall on 4/29/23 and stated he had a couple of falls since then. She stated staff were expected to encourage Resident #2 to sit down and relax. She added Resident #2 had always liked to walk frequently and as he progressed more in the Alzheimer's disease process, he stumbled more. The family member stated if Resident #2 fell again, his neck could fracture more, which would be very serious, and she added that was "kind of scary." 3. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the one current resident (#2) at immediate jeopardy risk for injury in the event of additional falls. 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 5/23/23 at 1:20 p.m., the administrator submitted written evidence which read in pertinent part: "There will be an initial in service on fall risk and monitoring to be completed in 1800 (at 6:00 p.m. on) 5-23-23 to provide staff education to both day and night shift staff. There will be daily in service completed from 1800 5-23-23 until 6/5/23 in order to properly prevent any harm to residents. Staff will be given an in service whenever there is a new plan of care implemented to ensure the patient is being properly care for. As of May 23, 2023, the following additions shall be made to the chart of (Resident #2): Up to date plan of care, up to date evaluation data collection, care plans to include prevention and mitigation's of falls, inclusion of individualized approaches of fall prevention, address falls related risk and strengths, medication overview to be completed."

Based on observation, record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting two of four sample residents (#1, #4). (Cross-reference Q1514)Specifically, the residence failed to administer metoprolol tartrate and lisinopril (medications to treat high blood pressure) to Resident #1 as prescribed. Resident #1 was not administered metoprolol tartrate on 5/1-5/12/23 for the 8:00 a.m. dose and 5/1-5/6/23 and 5/8-5/11/23 for the 8:00 p.m. dose. There were a total of 22 missed doses. Resident #1 was not administered lisinopril on 5/7-5/12/23. There were a total of six missed doses. The resident was hospitalized on 5/10/23 after he had numerous falls due to dizziness. Additionally, Resident #1 was not administered tamsulosin on 5/2-5/6/23 and 5/8-5/11/23. There were a total of nine missed doses. The resident was hospitalized on 5/16/23 with urinary retention and acute kidney damage. The residence's health services director (a licensed practical nurse) stated the residence's failure to administer the resident's medications for high blood pressure led to the resident's dizziness and subsequent fall. Findings include: 1. References According to Medical News Today (2023), Metoprolol, "Metoprolol is a drug called a beta-blocker. It's used to treat conditions such as high blood pressure, heart failure, and angina (chest pain) ... However, Metoprolol tartrate is also used to treat and prevent heart attacks, while Metoprolol succinate is also used to treat heart failure ... FDA warning: Don't stop taking metoprolol. Don't stop taking metoprolol suddenly. If you do, you may experience worse chest pain, a jump in blood pressure, or even have a heart attack. Stopping metoprolol is not recommended. If you need to stop taking the drug, first talk to your doctor. Your dosage should be gradually decreased under a doctor's supervision ... increasing your blood pressure damaging your blood vessels or main organs, such as your lungs, heart, or liver increasing your risk of a heart attack. Also, if you suddenly stop taking metoprolol for high blood pressure, chest pain, or after a heart attack, you raise your risk of heart attack. If you miss doses or don't take the drug on schedule: Not taking metoprolol every day, skipping days, or taking doses at different times of day also come with risks. Your blood pressure might fluctuate too often. That might increase your risk for a heart attack." Retrieved From https://www.medicalnewstoday.com/articles/metoprolol-oral-tabletAccording to the National Health Service (12/17/21), Common Questions about Lisinopril, "Talk to your doctor if you want to stop taking lisinopril. Stopping lisinopril may cause your blood pressure to rise. This can increase your chances of having a heart attack or stroke." Retrieved from: https://www.nhs.uk/medicines/lisinopril/common-questions-about-lisinopril/According to the National Health Service (2/2/23), Common Questions about Tamsulosin, Tamsulosin is a medication used to treat an enlarged prostate gland. "Stopping tamsulosin suddenly can make your condition worse as your symptoms may return." Retrieved from: https://www.nhs.uk/medicines/tamsulosin/common-questions-about-tamsulosin/#:~:text=What%20will%20happen%20if%20I,to%20prescribe%20a%20different%20medicine. 2. Resident #1 was admitted to the residence on 4/24/23 with diagnoses including dementia, hypertension, chronic obstructive pulmonary disease, and a history of a transient ischemic attack. a. Metoprolol tartrate A written practitioner order, dated 4/11/23, directed the residence to administer metoprolol tartrate 25 mg twice daily. The residence's May 2023 MAR for Resident #1 read metoprolol tartrate 25 mg was not available for administration on 5/1-5/12/23 for the 8:00 a.m. dose and 5/1-5/6/23 and 5/8-5/11/23 for the 8:00 p.m. dose. There were a total of 22 missed doses. b. Lisinopril A written practitioner order, dated 4/11/23, directed the residence to administer lisinopril 40 mg once daily. The residence's May 2023 MAR for Resident #1 read lisinopril 40 mg was not available for administration on 5/7-5/12/23. There were a total of six missed doses. c. Tamsulosin A written practitioner order, dated 4/11/23, directed the residence to administer tamsulosin 0.4 mg once daily. The residence's May 2023 medication administration record (MAR) for Resident #1 read tamsulosin 0.4 mg was not available for administration on 5/2-5/6/23 and 5/8-5/11/23. There were a total of nine missed doses. On 5/23/23 at 1:26 p.m., the external service provider for Resident #1 stated staff told her that Resident #1 was a little agitated. She stated she had heard from the practitioner for Resident #1 that since the residence had failed to administer the medication as directed, the lack of it could have resulted in urinary retention. She added that Resident #1 had been diagnosed at the hospital on 5/16/23 with urinary retention and acute kidney damage, per the hospital records, which the residence did not have onsite. d. Amlodipine A written practitioner order, dated 4/11/23, directed the residence to administer amlodipine 10 mg once daily. The residence's May 2023 MAR for Resident #1 read amlodipine 10 mg was not available for administration on 5/1-5/13/23. There were a total of 13 missed doses. e. Hydralazine A written practitioner order, dated 4/11/23, directed the residence to administer hydralazine 10 mg three times daily. The residence's May 2023 MAR for Resident #1 read hydralazine 10 mg was not available for administration on 5/1-5/7/23 and 5/19-5/20/23 for the 9:00 a.m. dose, 5/1-5/4/23 and 5/6/23 for the 1:00 p.m. dose and 5/1/23 and 5/3-5/7/23 for the 5:00 p.m. dose. There were a total of 19 missed doses. f. Potassium chloride A written practitioner order, dated 4/11/23, directed the residence to administer potassium chloride 20 mEq once daily. The residence's May 2023 MAR for Resident #1 read potassium chloride 20 mEq was not available for administration on 5/1-5/12/23. There were a total of 12 missed doses. g. Trazodone A written practitioner order, dated 4/11/23, directed the residence to administer trazodone 100 mg once daily. The residence's May 2023 MAR for Resident #1 read trazodone 100 mg was not administered on 5/1-5/6/23 and 5/8-5/11/23. There were a total of 10 missed doses. h. Aspirin A written practitioner order, dated 4/11/23, directed the residence to administer Aspirin 81 mg. The residence's May 2023 MAR for Resident #1 read Aspirin 81 mg was not available for administration on 5/1-5/5/23. i. Calcium carbonate A written practitioner order, dated 4/11/23, directed the residence to administer calcium carbonate 600 mg once daily. The residence's May 2023 MAR for Resident #1 read calcium carbonate 600 mg was not available for administration on 5/1-5/12/23. There were a total of 12 missed doses. j. Melatonin A written practitioner order, dated 4/11/23, directed the residence to administer melatonin 10 mg once daily. The residence's May 2023 MAR for Resident #1 read melatonin 10 mg was not administered on 5/1-5/6/23 and 5/8-5/11/23. There were a total of 10 missed doses. k. Daily-Vite A written practitioner order, dated 4/11/23, directed the residence to administer a multivitamin once daily. The residence's May 2023 MAR for Resident #1 read daily-vite was not available for administration on 5/1-5/12/23. There were a total of 12 missed doses. On 5/23/23 at 12:53 p.m., Resident #1's family member stated Resident #1's medications had been a "big mess" due to pharmacy issues. He added she was aware the residence had issues with Resident #1's being in stock. On 5/23/23 at 1:48 p.m., Staff #5 stated the residence had been out of Resident #1's medications due to a pharmacy stock issue. On 5/23/23 at 2:19 p.m., the HSD stated the residence had kept contacting Resident #1's family members about his medications and tried to get the medications ordered through the residence's pharmacy instead of waiting for Resident #1's personal pharmacy to respond. He added Resident #1 was then admitted to the hospital due to falls on 5/10/23 and his blood glucose being high, although he was not a diabetic. The HSD, who was a licensed practical nurse, stated: "100 percent - those missing medications led to him having a fall that day. Had he had his blood pressure medications he would have been less dizzy." On 5/23/23 at 2:57 p.m., the administrator stated there was some confusion when Resident #1 first moved into the residence in regards to his medications because he came from out of the area. She confirmed the residence had not administered medications to Resident #1 as ordered by his practitioner. 3. Resident #4 was admitted to the residence on 2/18/22 with a diagnosis of dementia. a. Quetiapine fumarate A written practitioner order, dated 3/23/23, directed the residence to administer quetiapine fumarate 25 mg twice daily. The residence's May 2023 MAR for Resident #4 read quetiapine fumarate 25 mg was not available for administration on 5/1-5/12/23 for the 8:00 a.m. dose and for 5/1-5/6/23 and 5/8-5/11/23 for the 8:00 p.m. dose. There were a total of 22 missed doses. On 5/23/23 at 1:48 p.m., Staff #5 stated the residence had been out of Resident #4's quetiapine because the practitioner was slow to send medication orders. On 5/23/23 at 2:08 p.m., the HSD stated for Resident #4's quetiapine fumarate, the practitioner had been faxing the orders to the wrong pharmacy. b. Vitamin B-12 A written practitioner order, dated 5/2/23, directed the residence to administer Vitamin B-12 once daily. The residence's May 2023 MAR for Resident #4 read Vitamin B-12 was not available for administration on 5/15-5/19/23 and 5/21-5/22/23. There were a total of seven missed doses. On 5/23/23 at 7:29 a.m., Staff #4 stated the residence was out of stock of Resident #4's Vitamin B-12 due to the pharmacy waiting to hear back from Resident #4's practitioner. On 5/23/23 at 10:20 a.m., Resident #4's family member stated she had concerns with medications being out of stock at the residence but stated she was not aware Resident #4 was still out of stock of medications. On 5/23/23 at 1:48 p.m., a medication audit revealed the residence was out of stock of Resident #4's Vitamin B-12. On 5/23/23 at 2:08 p.m., contrary to the practitioner's order in Resident #4's record, the HSD stated he believed there was not a current order for Resident #4 Vitamin B-12. On 5/23/23 at 2:52 p.m., the administrator stated she believed she had been made aware Resident #4 had been out of medications. She added she believed the issue had been someone faxing information to the wrong pharmacy and stated the residence had reeducated that staff member. 4. InterviewOn 5/23/23 at 3:09 p.m., the administrator stated practitioner's orders should be followed at all times. She added residents should absolutely not go without their ordered medications. The administrator confirmed she was aware of Resident #1 and Resident #4 not being administered practitioner-ordered medication and stated it was due to miscommunication.

Based on record review and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor audited the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, quarterly, affecting 39 current residents. (Cross-reference Q1468)Findings include: On 5/23/23 at approximately 8:26 a.m., the residence's quarterly audits of the medication administration records, controlled substance list, medication error reports, and medication disposal records were requested. However, no such audits were provided. On 5/23/23 at 11:29 a.m., the health services director stated the residence did not have medication audits that were completed under the current administrator. He added he believed the medication audits were required to be completed every six months. On 5/23/23 at 3:07 p.m., the administrator stated other than counting narcotics, she did not believe the residence had medication audits completed. She added she was not aware she and the residence's QMAP supervisor were required to complete medication audits quarterly. The administrator confirmed the residence provided medication administration to all residents.

Based on record review and interview, the residence failed to ensure staff preparing or serving food completed recognized food safety training and maintained evidence of completion onsite, affecting 39 current residents. Findings include: The residence's staff list read Staff #1 was a qualified medication administration personnel (QMAP) and a caregiver. Review of the residence's personnel file for Staff #1 read she was hired by the residence on 3/10/23. The personnel file for Staff #1 did not contain documentation that she had completed recognized food safety training. Review of the residence's May 2023 staff schedule revealed Staff #1 worked at the residence on 5/5-5/7/23, 5/12-5/14/23 and 5/20/23. On 5/23/23 at 3:25 p.m., the administrator stated the the residence's dietary aides, QMAPs and caregivers all assisted in food service. The administrator stated Staff #1 served food to residents. The administrator confirmed Staff #1 had not completed recognized food safety training. She was unaware the residence was required to complete food safety training training through a recognized expert or agency. Further, she added the residence's food safety training was completed through their electronic training system, not through a recognized expert or agency.

Based on record review and interview, the residence failed to ensure each staff was provided with training and education within 60 days on providing care and services to residents with dementia/cognitive impairment, that included all required topics for two of three sample staff (#1, #3), affecting 39 current residents. (Cross-reference Q0664)Findings include: The residence operated as a secure environment serving those with dementia or cognitive impairments. 1. Record ReviewsThe residence's personnel files revealed Staff #1 and #3 were hired on 3/10/23 and 2/21/23, respectively. The residence's staff list read Staff #1 was a qualified medication administration persons and caregiver. It read Staff #3 was a caregiver. The personnel files for Staff #1 and Staff #3 did not contain any documentation of training regarding information on disease processes associated with dementia and cognitive impairment, including progression of the diseases, types and stages of memory loss, family dynamics, behavioral symptoms and limitations to normal activities of daily living; nor information on recognizing physical symptoms that may cause a change in dementia/cognitive impairment such as dehydration, infection, and swallowing difficulty, along with individualized approaches to assist or address associated symptoms such as pain, decreased appetite and fluid intake, and/or isolation. 3. InterviewsOn 5/23/23 at 3:27 p.m., the administrator stated the residence did have training on dementia on the residence's online training system. She added, dementia training was provided by herself, the health services director and the activities director. However, the administrator confirmed she was aware Staff #1 and Staff #3 had not completed their online dementia training. The administrator stated she was aware Staff #1 and Staff #3 were required to have training and education on providing care and services to residents with dementia/cognitive impairment within 60 days.

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 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status. 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (I) Masking or deceiving administration of medication including, but not limited to, concealing in food or liquid. 14.7 The assisted living residence shall ensure that each resident receives proper administration and/or monitoring of medications. 18.9 The face sheet shall be updated at least annually and contain the following information: (A) Resident's full name, including maiden name, if applicable; (B) Resident's sex, date of birth, and marital status; (C) Resident's most recent former address; (D) Resident's medical insurance information and Medicaid number, if applicable; (E) Date of admission and readmission, if applicable; (F) Name, address and contact information for family members, legal representatives, and/or other persons to be notified in case of emergency; (G) Name, address, and contact information for resident's practitioner and case manager, if applicable; (H) Resident's primary spoken language and any issues with oral communication; (I) Indication of resident's religious preference, if any; (J) Resident's current diagnoses; and (K) Notation of resident's allergies, if any.