COURTYARDS AT MOUNTAIN VIEW, THE

A relicensure survey with complaint #CO36287 and #CO36432 was completed on 1/15/25. A deficiency was cited.

12.2.2 (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:Based on record review and interview, the residence failed to have at least one staff member responsible for managing the site of its Infection Prevention and Control Program and training, affecting 82 current residents. During an on-site visit on 1/14/25, proof of the completion of the infection prevention and control program and training was requested. The administrator provided a certificate that was completed on the same day of the onsite visit. On 1/14/25 at approximately 9:30 a.m., the administrator said she had completed the training that day. She said a corporate staff member had the certification but no longer worked there. She said she learned the employee no longer worked for the residence when she asked the corporate office for the certification. She said did not know how long the residence did not have a staff member who had completed the infection and control program and training. She said she completed the training after we asked for the certification and she realized no one in the residence had completed the training.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.6.5 Each administrator shall have completed 40 hours of administrator training before assuming an administrator position. Individuals appointed as an interim administrator shall have completed 40 hours of administrator training within 30 days of appointment. Written proof regarding the successful completion of such training program shall be maintained in the administrator ' s personnel file. The 40 hours shall be met by one of the following: (A) Completing an administrator training program that meets the requirements of Part 6.6, below. (B) Completing a 30-hour administrator training program on or before December 31, 2018, and documenting an additional 10 hours of training in topics related to the assisted Living administrator ' s responsibilities, regulatory updates, and/or best practices before June 30, 2024. 6.6 An administrator training program shall meet all of the following requirements: (A) The program or program components are conducted by an accredited college, university, or vocational school; or an organization, association, corporation, group, or agency with specific expertise in the provision of residential care and services; and (B) The curriculum includes at least 40 actual hours, 20 of which shall focus on applicable state regulations. The remaining 20 hours shall provide an overview of the following topics: (1) Business operations including, but not limited to: (a) Budgeting, (b) Business plan/service model, (c) Insurance, (d) Labor laws, (e) Marketing, messaging and liability consequences, and (f) Resident agreement. (2) Daily business management including, but not limited to, (a) Coordination with external service providers (i.e., community and support services including case management, referral agencies, mental health resources, ombudsmen, adult protective services, hospice, and home care), (b) Ethics, and (c) Grievance and complaint process. (3) Physical plant (4) Resident care including, but not limited to: (a) Admission and discharge criteria, (b) Behavior expression management, (c) Care needs assessment, (d) Fall management, (e) Nutrition, (f) Person-centered care, (g) Personal versus skilled care, (h) Quality management education, (i) Resident rights, (j) Sexuality and aging, (k) Secure environment, and (l) Medication Management. (5) Resident psychosocial needs including, but not limited to, (a) Cultural competency (ethnicity, race, sexual orientation), (b) Family involvement and dynamics, (c) Mental health care (maintaining good mental health and recognizing symptoms of poor mental health), (d) Palliative care standards, and (e) Resident engagement. 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.

A licensure complaint revisit was completed on 1/15/25 for all previous deficiencies cited on 8/1/23. The residence is in compliance with all regulations surveyed

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

A licensure revisit was completed on 1/15/25 for all previous deficiencies cited on 8/1/23. The residence is in compliance with all regulations surveyed.

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

A licensure complaint, prompted by #CO33387, #CO34381, #CO35334, #CO35706, #CO35794, #CO35977, was completed on 5/14/24. Deficiencies were cited.

Based on record review and interview, the residence failed to report suspected caretaker neglect to law enforcement within 24 hours of observation or discovery, affecting one former resident (#14). Findings include:Former Resident #14 was admitted to the residence on 2/29/24 with diagnoses including memory loss. A grievance document, dated 4/5/24, read Former Resident #14 was taken to the emergency department on 4/3/24 for dehydration and reported bed sores. The grievance read a family member of Former Resident #14 was filing a complaint for neglect. On 5/14/24 at 3:23 p.m., the administrator said on 4/3/24 a family member of Former Resident #14 was sent to the emergency department for dehydration, alleged bed sores, and an open area on her body. She added as soon as she heard this she reported the incident to the department but had not notified law enforcement. She added she was told the emergency department reported the neglect incident to law enforcement.

Based on record review and interview, the residence failed to identify the highest potential risk, hold, and document routine drills to facilitate staff and resident response to that risk, affecting 67 current residents. (Cross-reference S3090)Findings include:The residence ' s November 2018 Evacuation policy read in part: "In some instances, the community may have to be partially or fully evacuated due to fire, flood, earthquake, tornado, power outage and/or other community emergency."The residence's January 2024 Staffing policy read in part that the residence had staff sufficient to evacuate the residence in the event of an emergency. The residence ' s Safety Systems-Fire Drill Training, dated 8/17/22, read in part: "Fire drills must be conducted quarterly on each shift and with at least one drill conducted each month, and according to state licensing regulation requirements. The drills must involve the participation of the [staff] in accordance with the emergency plan. The drill may include the activation of the fire alarm signal. Emphasize orderly evacuation under proper discipline rather than speed. Monitor the response to the drill, including the time taken to locate the source of the fire, silence the alarm, and evacuate all Residents to a safe place."The residence could not provide documented drills for any potential risk requiring evacuation, including fire, flood, earthquake, tornado, or power outage. On 5/14/24 at 2:41 p.m., the administrator stated that the residence had not identified a specific potential risk to the residence, and the residence had not conducted any drills for any possible risks within the last year. She added that her expectation of a routine drill was a drill that occurred more frequently than a year. She stated the residence should have followed the existing policy. She added that per the residence's current policy, the residence evacuated residents although they were in the process of changing the plan. She stated that the residence was staffed on the overnight shifts with four staff and affirmed there had been instances where there were three and that the residence had not performed drills to determine if three or four staff were able to evacuate the residents.

Based on interviews and record review, the residence failed to implement a fall management program that included detailing in the resident's care plan the individualized approaches necessary to address fall risks, affecting three of three current sample residents (#1-#3) and one former resident (#12). (Cross-reference S2230, S3090)Specifically, Resident #2 fell on 2/14/24, and the resident sustained a head injury and scalp hematoma. However, the residence failed to update the care plan to detail the individualized approaches necessary to address fall risks. The resident fell on 3/22/24 and sustained head pain, and the residence failed to update her care plan as required. Subsequently, the resident fell on 4/5/24 and sustained a hip contusion and hip, pelvis, and leg pain, and the residence failed to update the resident's care plan until 4/10/24. Specifically, Former Resident #12 fell on 2/1/24 and sustained a laceration to her left eyebrow. However, the residence failed to update the care plan to detail the individualized approaches necessary to address fall risks. The resident fell on 2/23/24, 2/4/24, and 2/11/24 without injury, and the residence failed to update her care plan as required. Subsequently, the resident fell on 4/13/24 and sustained a laceration to her forehead, requiring sutures, and the residence failed to update her care plan as required. Findings include:1. Residence Policy The residence's January 2020 Health Related Services Manual read in part that the residence included a summary of interventions appropriate to address the risk of falls in the care plan after the residence completed a fall risk evaluation. The residence's January 2024 Fall Management Program policy read in part: "The [residence] will implement interventions to reduce the risk of future falls and the severity of injuries for residents. The Fall Investigation/Assessment and Interventions tool can be used to guide the investigation, implement any interventions that are determined, update the Service Plan and Task Sheets, and then document all fall-related information in the resident record."2. Resident #2 was admitted to the residence on 3/18/22 with diagnoses including rheumatoid arthritis and dementiaa. Observation On 5/13/24 at approximately 7:45 a.m., the resident was in her bed. The bed was not a hospital bed, and the staff were not able to lower it. b. Record ReviewProgress notes, dated 2/15/24-4/12/24, read in part: On 2/15, the resident sustained an unwitnessed fall in the common area of the residence on 2/14, and emergency medical transport (EMT) transported the resident to the executive director (ED). The resident returned to the residence on 2/15. On 3/22, the resident sustained an unwitnessed fall near her bed. The resident reported head pain, and the EMT transported the resident to the ED. The resident returned to the residence with a diagnosed urinary tract infection (UTI) and returned to the residence with antibiotics. On 4/5, the resident sustained an unwitnessed fall in the common area of the residence. The resident reported head, back, arm, and left hip pain, and the EMT transported the resident to the ED.On 4/6, the resident returned to the residence with reported left hip pain. In the afternoon, the resident used a wheelchair. On 4/7, the residence assisted the resident with ambulation or with the use of a wheelchair. On 4/12, the resident reported pain in her right hip, she fell on 4/5. The bruising was healing. Hospital Discharge Summaries, dated 2/14/24-4/5/24, read in part the following:On 2/14, the resident sustained a fall and experienced a head injury and hematoma. On 3/22, the resident sustained a fall, experienced pain, and was diagnosed with a UTI.On 4/5, the resident sustained a fall and experienced pain in her left hip, pelvis, and leg and a contusion to her left hip. Care plans dated 12/31/23 and 3/6/24 read in part: "Resident will have no additional falls [staff]to notify community nurse of any change in gait/balance, assist with keeping room free of clutter [staff] to assist [Resident #2] with falls per community [policy] and notify nurse of all falls or near falls. The Fall Risk-Resident has either experienced one fall, or has had no falls in the past year but one or more of the following fall risk factors are present; fear of falling, poor balance, poor vision, cognitive impairment, or incontinence. Consider fall interventions based on the identified risk factors."A Post-Fall Investigation/Assessment, dated 3/23/24, read that the resident experienced a fall on 3/22. The resident was transported to the ED and diagnosed with a UTI. The residence identified the root cause of the fall as inadequate footwear and a UTI; however, the interventions read that the residence staff approach was solely to ensure adequate footwear and increase safety checks. The residence did not update the care plan with the identified interventions. A care plan, dated 4/10/24, read in part: "Resident has experienced multiple falls and requires higher level interventions such as alarms, periodic checks, mat next to the bed, low bed, etc. Established fall interventions will be followed and adjusted as needed." However, the residence did not include the risk of UTI as a cause for falls and approaches staff took to mitigate UTIs in the care plan. The care plan also did not include the frequency of the periodic checks, nor was the approach staff was to take to lower a bed that did not have a mechanism to lower it. b. InterviewsOn 5/13/24 at approximately 7:45 a.m., Staff #3 stated that Resident #2 had sustained several falls and had reported increased pain. She added that the resident began exclusively using a wheelchair approximately three weeks prior to the onsite visit. She stated that the residence had not updated the care plan with individualized approaches. She added that residence staff used the care plan to direct the services they provided residents, and without an updated care plan, staff did not know what approaches they were to take to mitigate future falls. On 5/13/24 at approximately 8:00 a.m., Confidential Staff #1 stated the residence did not regularly update care plans and that the care plans populated the task sheets that guided staff approaches to resident care. On 5/14/24 at approximately 2:00 p.m., the health and wellness director stated that the residence verbally communicated some staff approaches regarding falls to staff. She added that staff approaches to address the residents' risks for falls should have been on the care plans; however, they may not have been updated or individualized as required. On 5/14/24 at approximately 2:45 p.m., the administrator stated that the residence should have updated the residents' care plans with individualized staff approaches to address fall risks. She added she was unaware that the residence had not added individualized approaches. She stated that the Post-Fall Investigation/Assessment did not populate the care plan and, therefore, did not update the task sheet that guided staff approaches. 3. Additionally, the residence failed to implement a fall management program that included detailing in the resident's care plan the individualized approaches necessary to address fall risks for Residents #1, #3, and Former Resident #12.

Based on observation, interview and record review, the residence failed to ensure the residents received the cooperation of the residence to achieve the maximum degree of benefit, affecting four of five sample residents (#7,#16-#18). Findings include:1. Residence PolicyThe residence's posted Resident Rights read, in part, "The statement of rights shall include, at a minimum, the following items ... The right to choice and personal involvement regarding care and services, including ... the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services which are made available by the assisted living residence." 2. Resident #7 was admitted to the residence on 12/20/23. The April and May 2024 Response Time Report for Resident #7 read that she pressed her pendant 31 times with wait times longer than 15 minutes, as follows:5/13/24, the day of the onsite visit, at 6:47 a.m. for one hour and six minutes. 5/13/24 at 10:49 a.m. for three hours and one minute5/12/24 at 8:45 p.m. for 23 minutes5/11/24 at 6:21 a.m. for 24 minutes5/10/24 at 8:41 p.m. for 17 minutes5/7/24 at 6:27 a.m. for 24 minutes5/7/24 at 11:00 a.m. for 19 minutes5/6/24 at 12:36 p.m. for 21 minutes5/6/24 at 10:57 a.m. for 20 minutes5/3/24 at 6:25 a.m. for 41 minutes4/29/24 at 7:35 a.m. for 22 minutes 4/29/24 at 11:26 a.m. for 43 minutes4/28/24 at 7:13 a.m. for 26 minutes4/28/24 at 4:08 p.m. for 29 minutes 4/27/24 at 2:08 a.m. for 22 minutes 4/26/24 at 7:04 a.m. for 22 minutes4/22/24 at 11:45 a.m. for 24 minutes4/21/24 at 5:17 p.m. for 19 minutes 4/18/24 at 8:42 p.m. for 18 minutes4/18/24 at 6:54 a.m. for 33 minutes4/15/24 at 8:33 p.m for 39 minutes4/12/24 at 7:00 a.m. for 20 minutes4/11/24 at 8:46 p.m. for 21 minutes4/8/24 at 7:23 a.m. for 26 minutes4/8/24 at 4:21 p.m. for 23 minutes4/7/24 at 6:36 a.m. for 20 minutes4/6/24 at 7:13 a.m. for 17 minutes4/5/24 at 6:23 a.m. for 22 minutes4/1/24 at 6:28 a.m. for one hour and 10 minutes4/1/24 at 4:04 p.m. at 31 minutesAn assessment for Resident #7, dated 1/24/24, read that Resident #7 required staff assistance for dressing, grooming, bathroom and escorts to and from meals.a. ObservationOn 5/13/24 at 7:08 a.m., an audible beeping sound was coming from the medication office. The sound was identified as coming from a monitor that altered staff to residents who used their call buttons or pendants for assistance. The monitor read that Resident #7 had requested assistance. On 5/13/24 at 7:41 a.m., the audible beeping sound continued and showed Resident #7 was still waiting for assistance. On 5/13/24 at 7:56 a.m., Staff #5 entered the room to turn off Resident #7's pendant. On 5/13/24 at 8:08 a.m., Staff #6 entered the room to assist Resident #7, approximately an hour after Resident #7 first requested assistance. b. InterviewsOn 5/13/24 at 7:08 a.m., Staff #7 said the monitor was a visible and audible monitor for staff to know who requested assistance. The alerts also went to portable phones the staff carried. On 5/13/24 at 7:41 a.m., Staff #7 said staff expected response time to residents' request for assistance was between five and 10 minutes. On 5/13/24 at 7:50 a.m., Resident #11 said Resident #7 requested female care staff only and on Mondays the nosecure portion of the residence was only staffed with males and no females worked. He added, on Monday's staff either came late or did not show up at all. Resident #11 said a family member had to come from her house down the street on 5/6/24 to provide assistance to Resident #7 because no staff member ever showed up when they requested assistance in the morning. He added there were other times when Resident #7 requested assistance and had to wait over an hour for assistance. On 5/13/24 at 8:08 a.m., Staff 6 said Resident #7 had to wait for assistance in the morning for a long period of time for the last three Mondays prior to the onsite visit. On 5/14/24 at 10:56 a.m., Staff #5 said Resident #7 had to wait over 15 minutes for a female staff member to assist her on Mondays. He added on Sunday afternoons she had long wait times for assistance as well. On 5/14/24 at 2:15 p.m., the health and wellness director said Monday mornings were a challenge to get staff to answer Resident #7's requests for assistance and acknowledged Resident #7 had to wait a long time for assistance. On 5/14/24 at 3:36 p.m., the administrator acknowledged the responses to Resident #7's requests for help were lengthy and added Mondays were the time Resident #7 had to wait for a female for assistance. 3. Additional evidence obtained during the onsite investigation revealed the residence failed to achieve the maximum degree of benefit for three Former Residents (#16-#18).

Based on record review and interview, the residence failed to ensure that no medication was administeredby a qualified medication administration person (QMAP) on a pro re nata (PRN) or "as needed" basis if the resident did not understand the purpose of the medication or was not capable of voluntarily requesting the medication, affecting one of two sample residents (#1, #6). (Cross-reference S1600)Findings include:1. Resident #1 was admitted to the residence on 10/24/23 with diagnoses including dementia and anxiety. Resident #1 lived in a secured environment. A written practitioner's order, dated 3/15/24, directed the residence to administer oxycodone 5 mg tablet as needed for pain. The March 2024 medication administration record (MAR) for Resident #1 documented on 3/17/24 Resident #1 was administered oxycodone at 11:17 p.m. A written practitioner ' s order, dated 3/20/24, directed the residence to administer acetaminophen 500 mg of two tablets three times a day as needed for pain. The March 2024 medication administration record (MAR) for Resident #1 read on 3/1/24 Resident #1 was administered acetaminophen 500 mg on 3/1/24 at 7:32 p.m., 3/3/24 at 9:02 p.m., 3/5/24 at 1:20 p.m., 3/7/24 at 4:18 p.m., 3/10/24 at 5:34 a.m. and 2:46 p.m., 3/13/24 at 6:07 p.m. and 3/16/24 at 9:48 p.m. 3. Interviews On 5/14/24 at 9:42 a.m., Staff #1 said Resident #1 had medications prescribed that were as needed. Staff # 1 said Resident #1 had PRN medications. Staff #1 further stated she asked Resident #1 if she wanted to take her acetaminophen. Additionally, Staff #1 said nurses administered PRN medications most of the time. On 5/15/24 at 10:59 p.m., the wellness director (WD) said residents who lived in the secured environment were not allowed to have PRN medications, and residents who were admitted to the secured environment were not always able to communicate their needs. The WD acknowledged that Resident #1 and Resident #6 lived in the secured environment and had active PRN medication orders. The WD said the PRN medications needed to be either discontinued or changed for both residents. The WD said Residents #1 and #6 did not understand the purpose of the medication and would not know to request the medications. On 5/15/24 at approximately 2:00 p.m., the administrator said residents who lived in the secure environment could not have PRN medications because they could not appropriately tell staff when they needed their medications or understood the purpose of the medication. The administrator acknowledged that residents who resided in the secure environment and were unable to understand the purpose of a medication or request the PRN medication, should not be administered a PRN medication. 4. Evidence obtained during the on-site visit revealed the residence additionally failed to ensure that medication was not administered by a QMAP on a PRN basis for Resident #6, who lived in the secured environment.

Based on interview and record review, the residence failed to ensure that each qualified medication administration person documented accurate information in the medication administration record (MAR), including any medication omissions, affecting three of five sample residents (#1, #6, and #8). (Cross-reference S1526)Findings include:1. Resident #8 was admitted to the residence on 12/31/23. A written practitioner's order, dated 3/12/24, directed the residence to administer tramadol 50 mg twice daily. However, the April 2024 MAR read the medication was either refused or out of stock, as follows:4/21/24 morning dose; medication on order4/21/24 evening dose; medication refused4/22/24 morning dose; medication on order4/22/24 evening dose; medication refused4/23/24 morning and evening doses; medication on order. On 5/14/24 at 2:13 p.m., the health and wellness director said the inconsistencies in the documentation for the tramadol were not a medication error and were incorrectly documented. On 5/14/24 at 3:40 p.m. the administrator said she expected the MARs for residents to be accurately documented. 2. Additional evidence obtained during the on site visit revealed the residence had similar deficient practice related to documenting accurate information in MARs for current Residents #1 and #6.

Based on record review and interview, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event, and failed to ensure that the resident records contained documentation of ongoing services provided by external service providers (ESP). Additionally, the residence failed to ensure that staff members had documented, before the end of their shift, events or issues regarding a resident that they observed or reported to them, affecting five of seven sample residents (#2-#6) and five former residents (#12-#14, #16, #17). (Cross-reference S1180, S3060)Findings include: 1. Residence PolicyThe residence ' s October 2018 Resident Record policy read in part that the residence required residence staff to document before the end of the shift any out-of-the-ordinary event or issue the staff observed. Further, the residence included all documentation from ESP for whom the resident received services. 2. Former Resident #12 was admitted to the residence on 8/14/23 with diagnoses including dementia and chronic pain. The resident record did not contain a care plan or notes by the external hospice provider (EHP); however, the residence later provided EHP notes. The resident record did not contain a discharge summary from the emergency department (ED) from the resident ' s reported visit on 4/14/24. The EHP notes, dated 4/14/24-5/3/24, read in part:On 4/14, the social worker (SW) received a call from a family member of Former Resident #12. The family member reported that the resident sustained a fall and reported concerns with her care. The social worker notified the registered nurse case manager (RNCM) about the resident ' s fall. On 4/14, the RNCM received a telephone call that the resident had fallen and had been transported to the ED. The RNCM visited the resident and met with a family member of the resident, who reported that the resident was found on the floor with a wound to her head. The resident was in bed with sutures to her forehead that measured five centimeters by one centimeter. The resident had dried blood all over her head and face. The RNCM cleaned the resident ' s face. On 4/15, the SW left a voicemail for the residence staff to call the EHP. On 4/16, the SW tried calling the residence and left a voicemail for the administrator. The SW then spoke to the residence sales director (SD), who affirmed that the resident had sustained a fall. On 4/29, the resident had a recent decline and was no longer responding; however, breathing was normal with oxygen in place. The wound to her forehead continued to heal with sutures in place. On 5/3/24, the resident passed away at the presumed time of 10:30 a.m. and was pronounced dead at 11:41 a.m. The residence progress notes, dated 2/11/24-4/24/24On 2/11, the HWD noted that the resident had no injury after a fall; however, the HWD had not noted the details of the fall. On 4/14 at 2:40 p.m., the HWD noted that the resident was found on the floor in the early morning with a laceration to the right side of her forehead with active bleeding. Emergency medical transport (EMT) was called, and the resident was transported to the ED. EHP and a family member of the resident were notified. The resident returned this afternoon with sutures to her head. However, the HWD had not noted which staff found the resident, the time the resident fell, the circumstance of the fall, when the EHP was notified, directions from the EHP, and the time the resident went to the ED. On 4/24, the HWD noted that the resident continued to decline; however, the HWD had not noted the nature or details of the resident ' s decline. The residence failed to note any additional events for the resident, including the date and circumstances of her passing. 3. InterviewsOn 5/13/24 at 12:22 p.m., the health and wellness director (HWD) stated that the EHP notes were not in the resident ' s record, and she had to request them from the EHP. On 5/14/24 at approximately 2:00 p.m., the HWD stated that she expected the progress notes to contain information such as the incident that occurred, who was notified, and to seek direction. She stated that she expected the residence to add hospital discharge summaries, along with ESP documents, such as EHP notes, to the resident record. She stated that residence staff were not required to document at the end of the shift because the residence was not a skilled nursing facility. On 5/14/24 at approximately 2:30 p.m., the administrator stated that the staff who witnessed out-of-the-ordinary events, such as a fall or elopement, should have documented the events in the residents ' progress notes, including who was notified and a synopsis of the event. She added that she expected ESP documents such as external home health notes, EHP notes, or after-discharge summaries to be included in the resident record. She stated that she was unaware that care staff had not documented in the resident record at the end of their shifts and that the documentation was solely completed by the HWD. 4. Additionally, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affected a resident, and failed to ensure that the resident records contained documentation of ongoing services provided by an ESP. Further, the residence failed to ensure staff members documented, before the end of their shift, events or issues regarding a resident that they observed or was reported to them for Residents #2-#6 and Former Residents #13-#14, #16, and #17.

Based on record review and interview, the residence failed to provide an enhanced care plan, affecting 21 current residents who lived in a secure environment. Findings include:1. Residence PolicyThe residence's Secure Environment policy, dated January 2020, read in part, "The community must help ensure that they provide a safe, insecure environment while allowing for privacy and confidentiality for each resident they serve .... The community will ensure they have received the face-to-face evaluation and that the resident is appropriate for the memory care environment. HWD or will complete the evaluation and service plan for the resident that will contain the following information: a description of the residents wandering patterns. Past or present behaviors and how they presented and known triggers. The staff should take approaches that would protect the resident and other residents during a behavioral outbreak. Description of the amount of oversight the resident will need to allow for independence within secure environment and secure outdoor area while still providing oversight. Independence to the residence apartment while protecting the resident from unwanted visitors by other residents."2. Resident #5 was admitted to the residenc's secure environment on 3/8/24 with diagnoses including dementia. A progress report dated 3/14/24 documented that the resident continued to wander and enter other residents' rooms at night. A progress report dated 4/15/24 documented that staff continued to report Resident #5 continued to display exit-seeking behavior. A progress report dated 4/26/23 at 6:15 p.m. , read in part, the resident had been agitated since 4:00 p.m., and was exit-seeking, cursing, and yelling. A progress report dated 4/27/24 documented the resident had increased agitation and attempted to open the doors and exit the secured unit. A progress note dated 5/7/24 documented that Resident #5 would have medications reviewed due to exit-seeking behaviors. A progress note dated 5/12/24 documented that Resident #5 was up during the night. Staff would continue to monitor wandering. The care plan dated 5/7/24 documented that Resident #5 had exit-seeking behaviors. Staff were required to observe Resident #5's location day and night. Interventions included Resident #5 would remain in the community. Staff would provide one-hour checks, calmly approach the resident, and weekly medication reviews. 3. InterviewsOn 5/14/24 at 1:25 p.m., the wellness director (WD) said she was unaware of what an enhanced care plan required. The WD said residents who exhibited wandering behaviors need a personalized care plan. The WD was unaware that residents in a secured environment required a way to secure their apartments while having independent access. The WD said residents in the secured environment could not have their keys. The WD said Resident #5 had exit-seeking behaviors. The WD said resident #5 did go into other residents' rooms. On 5/14/24 at 3:02 p.m.,the administrator said she needed to learn the requirements for an enhanced care plan. The administrator said resident care plans should be specific to the resident's needs, including redirection techniques. The administrator said staff used the residents' care plan to know how to care for the individual. The administrator also stated she was unaware of the requirement for independent access while protecting residents from other residents entering their rooms. The administrator said Resident #5 wandered and exit seeked. The administrator said Resident #5 went into other residents' rooms. 4. Additionally, the residence failed to ensure that each resident had an enhanced care plan documenting how residents in the secured unit would have independent access to their rooms while keeping other residents from entering them.

Based on record review and interview, the residence failed to have a sufficient number of trained staff members on duty in the secure environment to ensure each resident's physical, social, and emotional health care and safety needs are met in accordance with their individualized care plan, affecting 21 current residents and two former residents in the secure environment (#12, #13). (Cross-reference S0918, S1180)Specifically, Former Resident #12 fell on 4/13/24, sustained a laceration to her forehead, and, due to limited staffing, remained in a secure environment, remained on the floor, bleeding for approximately 45 minutes before the residence contacted emergency medical transport (EMT) to transport her to the emergency department (ED). Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 8.4, requires the residence to have staff sufficient in number to help residents needing or potentially needing assistance, considering individual needs such as the risk of accident, hazards, or other challenging events. The residence's January 2024 Staffing policy stated, in part, that the residence had sufficient staff to maintain safety and ensure adequate supervision and care of residents. Additionally, the residence had staff sufficient to evacuate the community in the event of an emergency. 2. Record Reviewa. Staff schedules, dated 4/13/24-4/27/24 read in part as follows:On 4/13 from approximately 10:00 p.m. until 6:00 a.m., Staff #2-#4, and #8 worked at the residenceOn 4/27 from approximately 10:00 p.m. until 6:00 a.m., Staff #2, #3, #8, and #9 worked at the residence from 10:00 p.m. until 6:00 a.m.b. Contrary to the residence schedules, residence timecards dated 4/13/24 and 4/27/24 read in part: On 4/13, from approximately 10:00 p.m. until 6:00 a.m., Staff #2, #4, and #8 worked at the residence. On 4/27, from approximately 10:00 p.m. until 6:00 a.m., Staff #2, #8, and #9 worked at the residence. The residence was unable to provide additional timecards for staff working on 4/13/24 or 4/27/24 from 10:00 p.m. until 6:00 a.m. c. Former Resident #12 was admitted to the residence on 8/14/23 with diagnoses including dementia and chronic pain. External hospice provider (EHP) notes, dated 4/14/24-5/3/24, read in part:On 4/14, the social worker (SW) received a call from a family member of Former Resident #12. The family member reported that the resident sustained a fall and reported concerns with her care. The SW notified the registered nurse case manager (RNCM) about the resident's fall. On 4/14, the EHP RNCM received a telephone call that the resident had fallen and had emergency medical trasport (EMT) transported the resident to the executive director (ED). The RNCM visited the resident and met with a family member of the resident, who reported that the resident was found on the floor with a wound to her head. The resident was in bed with sutures to her forehead that measured five centimeters by one centimeter. The resident had dried blood all over her head and face. The RNCM cleaned the resident's face. A residence progress note, dated 4/14/24 at 2:40 p.m., read in part that the health and wellness director (HWD) noted that the resident was found on the floor during the early morning with a laceration to the right side of her forehead with active bleeding. Emergency services was notified, and the EMT transported the resident to the ED. EHP and a family member of the resident were notified. The resident returned this afternoon with sutures to her head. However, the HWD had not noted which staff found the resident, the time the resident fell, the circumstance of the fall, when the EHP was notified, directions from the EHP, and the time the resident went to the ED. 4. InterviewsOn 5/13/24 at approximately 8:00 a.m., Confidential Staff #1 and #2 stated that there were at least two overnight shifts where only one staff member worked alone in the secure environment (SE) with between 21 and 23 residents. Anonymous Staff #1 stated that as of 4/13/24, Resident #1, Former Resident #13, and one unidentified resident required two staff for transfer assistance or incontinence care, and Residents #4 and #5 were elopement risks. On 5/14/24 at 11:21 a.m., Staff #2 stated she worked at the residence alone in the SE at least twice on Saturday nights from 10:00 p.m. until at least 6:00 a.m. She added that she worked alone with more than 21 residents on 4/13/24, and at 5:15 a.m., she found Former Resident #12 on the floor with a bleeding head laceration. She added she contacted the resident's EHP multiple times and attempted to call assisted living (AL) staff. She said while she was attempting to make these calls, other residents were wandering throughout the residence. She stated that at some point, Resident #4 exited the front door of the SE while she was attempting to make telephone calls to the EHP. She stated that Staff #6 arrived for a 6:00 a.m. shift and redirected Resident #4 back into the building. Staff #2 stated she notified the HWD, and the HWD directed her to call the EMT to transport the former resident to the ED. She affirmed the former resident was on the floor and bleeding for approximately 40-45 minutes. She added there had been other instances when she worked alone in the SE and had to ask for help. She stated that these requests for help from the management required multiple telephone calls. She added that when the residence directed AL staff to help on other Saturday nights in the SE, they often helped after 1:00 a.m. and did not stay for the entirety of the shift. She stated that two staff members were required to meet the needs of residents in the SE. On 5/14/24 at approximately 2:00 p.m., the HWD stated on 4/13/24 at 6:35 a.m. Staff #2 contacted her to report that Former Resident #12 fell, hit her head, and was bleeding. She added that she believed that the resident fell between 6:20 a.m. and 6:35 a.m.; however, she affirmed she had nothing to refer to that established that timeline. She added that she believed that it occurred after the 6:00 a.m. shift began and other staff arrived. Contrary to this, she stated that she instructed Staff #2 to telephone for assistance from the AL staff. She added that Staff #2 reported that she attempted to notify the resident's EHP and was unable to speak with them. The HWD stated she directed Staff #2 to call the EMT to transport the resident to the ED. The HWD stated she was unaware that the resident reportedly had been on the floor for 45 minutes and added that she was able to get in touch with hospice within five minutes. She affirmed that there was no documentation of the residence's attempts to get in touch with the EHP. She stated that Staff #2 did not report that she was working in the SE alone; however, she affirmed it was possible. The HWD affirmed she had no evidence that their additional staff other than Staff #2 worked in the SE on the night of 4/13/24. On 5/14/24 at 2:41 p.m., the administrator stated that her expectation for adequate staffing to meet residents' needs at the residence was two staff in the AL and two staff in the SE during the overnight shift, which began at 10:00 p.m. and ended at approximately 6:00 a.m. She affirmed that on 4/13/24, the residence had three staff working from 10:00 p.m. until 6:00 a.m. She added she was unable to confirm which staff worked in AL and SE during that shift. She stated Staff #2 might have worked alone in the SE with approximately 23 residents at that time. She affirmed that there was an additional Saturday overnight in April or May 2024 and that there may have only been three staff working instead of four. She stated she was unaware of the fall that Former Resident #12 sustained or the reported elopement of Resident #4 on 4/13. She added she was unaware that the residence waited approximately 45 minutes to contact the EMT to transport the former resident to the ED and that while the resident waited, she remained on the floor bleeding. She stated that the residence failed to have sufficient staff to meet the residents' needs on 4/13/24. She added that even with four staff working from 10:00 p.m. until 6:00 a.m., she was unable to confirm that there was adequate staffing to evacuate the building in the event of an emergency.

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 7.17.4 Assisted living residence staff shall observe resident food consumption on a regular basis in order to detect unplanned changes such as weight gain, weight loss, or dehydration. Changes in consumption that may indicate the need for assistance with eating shall be reported to the resident ' s practitioner and case manager, if applicable.

A licensure revisit was completed on 8/1/23 for all previous deficiencies cited on 12/29/22. No deficiencies were cited given that on 8/1/23, the residence was operating under the terms of an intermediate condition imposed by the department.

The department was unable to determine if the residence demonstrated an understanding of regulatory requiremens for ensuring that oxygen tanks are secured upright at all times in a manner that prevents tanks from falling over, being dropped, or striking each other, as the residence was operating under the terms of an intermediate condition imposed by the department at the time of the 8/1/23 onsite revisit.

A licensure revisit was completed on 8/1/23 for all previous deficiencies cited on 11/17/22. No deficiencies were cited given that on 8/1/23, the residence was operating under the terms of an intermediate condition imposed by the department.

The department was unable to determine if the residence demonstrated an understanding of regulatory requirements to ensure that each staff member and volunteer receives orientation and training, as the residence was operating under the terms of an intermediate condition imposed by the department at the time of the 8/1/23 onsite revisit.

The department was unable to determine if the residence demonstrated an understanding of regulatory requirements to ensuring that each resident care plan include the required elements, as the residence was operating under the terms of an intermediate condition imposed by the department at the time of the 8/1/23 onsite revisit.

A licensure revisit was completed on 8/1/23 for all previous deficiencies cited on 12/29/22. The residence is in compliance with all regulations surveyed.