GREENRIDGE PLACE

A licensure complaint, prompted by CO41641, was completed on 6/24/26. Deficiencies were cited.

Based on observation, record review and interviews, the residence failed to ensure residents were free from restraints, affecting one of one sample residents (#6) who used a bed cane. Specifically, the residence failed to ensure devices that facilitate a resident's well-being and/or independence may be used only if the resident is able to remove the device to allow for normal movement. Findings includeI. Residence policyThe Restraints policy, undated, was provided by the administrator (AD) on 6/24/26 at approximately 3:00 p.m. It read in pertinent part:"Physical or chemical restraints are not permitted in any [Company] community."II. ObservationsOn 6/24/26 at approximately 7:55 a.m., during the onsite complaint survey, it was observed that there was a bedside cane on the left side of Resident #6's bed. During the observation, Resident #6 was able to sit up in bed without using the bed cane. At approximately 2:30 p.m., another observation of the bedside cane revealed the cane was bolted into the side of Resident #6 ' s bed and was not easily removed as required. III. Record Review Record review revealed Resident #6 was admitted to the residence on 10/2/23 with a diagnosis of dementia. On 6/24/26, review of Resident #6 ' s record revealed no orders for the use of bed canes, further record review revealed no documentation of the use of bed canes in Resident #6's care plan, dated 5/5/26. A hospice evaluation, dated 10/17/23, revealed that Resident #6 was assessed for the use of the bed cane three years prior.-However, the residence failed to ensure Resident #6 was assessed annually per state regulations. IV. InterviewsOn 6/24/26 at 4:00 p.m. The AD was interviewed on 6/24/26 at 4:00 p.m. The AD said Resident #6 used to be more mobile and used the bed cane previously, however her condition had changed She said Resident #6 was now less mobile and the AD did not think Resident #6 used the bed cane anymore. She said she was unaware that the resident needed to be assessed annually for the bed cane or that the bed cane needed to be removable by the resident. She said she was going to reach out to the hospice agency to have the resident reassessed and potentially have the bed cane removed, if it was no longer needed or used by the resident.

Based on record review and interview, the residence failed to follow the residence policy and procedure for the identification, reporting, and investigation of injuries of unknown origin, affecting one out of four (#2) residents with injuries. Findings include:I. Residence policyThe Bruises and Injuries of Unknown Origin Investigation policy, dated 2022, was provided by the administrator (AD) on 6/23/26 at 9:30 a.m. It read in pertinent part:"The Community will follow a consistent procedure to ensure all bruises are reported immediately to the executive director (ED) and clinical services director (CSD). The ED and CSD are responsible for ensuring that all bruises are assessed and investigated to determine the origin of the bruise or injury."A bruise or injury of unknown origin is reportable when two elements are present: 1) Bruise/Injury without known incident, and 2) the community is unable to rule out abuse or service/care violation. If, during the investigation, the community determines the cause, and/or abuse has been ruled out, then the incident is not reportable."II. Record review A review of Resident #2's record revealed Resident #2 was admitted to the residence on 4/26/22 with a diagnosis of Alzheimer ' s dementia. A document titled "Notes and Incidents - Resident Summary" revealed that on 5/23/26 at 1:30 p.m. Resident #2 had bruising on her upper left arm from an unknown source.-However, the residence failed to investigate the injury to ensure abuse could be ruled out. III. InterviewStaff #1 was interviewed on 6/23/26 at approximately 8:00 a.m. Staff #1 said she was new to the qualified medication administration personnel (QMAP) role and was not trained on what to do if she noticed a bruise or injury on a resident. She said she would complete a progress note but was unsure of who she would notify. Staff #3 was interviewed on 6/24/26 at 3:35 p.m. Staff #3 said if she saw a bruise on a resident, she believed she needed to complete a progress note, but she said she was not sure. The AD was interviewed on 6/24/26 at 4:00 p.m. The AD said based on the progress note an incident report should have been completed and an investigation should have been started since the injury was of unknown origin. She said she was unsure why the injury was missed but there was no investigation into the incident. The AD said the CSD was to be notified of all bruises identified on residents and to complete the investigations by asking staff and the resident what happened. She said if the resident or staff were able to come up with an explanation for the bruises such as a fall, then it would not be reported to the state agency. She said if the CSD was unable to determine a source of the bruise, then the CSD would notify the AD and a full investigation would be conducted, it would be reported to the state agency, and the residence would attempt to rule out abuse.

Based on record review and interview, the residence failed to ensure qualified medication administration personnel (QMAP) did not perform tasks outside of their scope to include; assessing residents or using their judgment regarding medication effects when administering PRN (as needed) medications and failed to ensure that QMAPs did not use masking or deceiving techniques while concealing medication, affecting two of six sample residents (#1, #5). Findings include:A. PRN medicationsI. Professional referenceAccording to the National Library of Medicine, Practical Considerations of PRN Medicines Management, 4/12/22, retrieved on 6/30/26 from https://pmc.ncbi.nlm.nih.gov/articles/PMC9039188/#s4,?"Highly widespread use of pro re nata (PRN) medicines in various healthcare settings is a potential area for improper medication prescription and administration leading to patient harm. This is the nurse's responsibility to administer PRN medications based on the patient's health condition after receiving the physician ' s prescription order. Improper prescription and administration of PRN medications can cause medication interactions, adverse drug reactions (ADRs), overuse and abuse. The safety of PRN medicines management is influenced by healthcare professionals ' (nurses') knowledge and skills. Healthcare professionals ' competencies for PRN medicines management influences the safety of the medication process. Their pharmacological competence is having sufficient knowledge and skills to manage real-life medication circumstances and making appropriate decisions". II. Record reviewRecord review revealed that Resident #1 was admitted on 2/23/25 with diagnoses including Alzheimer ' s disease with late onset and dementia with anxiety. A practitioner's order, dated 9/25/25, directed the residence to administer lorazepam (an antianxiety medication) 2 mg/mL - 0.25 mL by mouth every eight hours as needed for agitation or anxiety to be given by the hospice nurse or the facility nurse. The February 2026 medication administration record (MAR) read that the medication was administered by a QMAP as follows:2/18/26 at 9:40 a.m. 2/21/26 at 11:30 a.m. 2/28/16 at 6:35 a.m.-However, the QMAP did not have the necessary training to assess the medication's effectiveness and document it in the MAR. III. InterviewsStaff #3 was interviewed on 6/24/26 at 3:35 p.m. Staff #3 said the QMAPs administered PRN medications as long as they got permission from the residences ' nurse. Staff #3 said the QMAPs had the nurse assess the residents when she was there. The AD was interviewed on 6/24/26 at 4:00 p.m. The AD said if the order documented that a nurse was to administer the medication then the QMAP was not to administer that medication. She said the QMAPs should not have administered the lorazepam to Resident #1 because the order documented it was to be completed by the nurse. The AD also said the QMAPs were not allowed to assess the residents because it was outside of their scope. B. Masking medicationsI. Residence policyThe Medication Management policy, updated 5/20/22, was provided by the administrator (AD) on 6/23/26. The policy read in pertinent part; "When crushing medications, a pill-crushing device is used. A completely crushed medication is mixed with an appropriate soft food such as applesauce or pudding, not a liquid. The resident is clearly informed that he/she is receiving medications."II. ObservationOn 6/24/26 at approximately 8:10 a.m., Staff #2 mixed crushed medication into juice and handed it to Resident #5. When the resident asked what it was, Staff #2 replied, "It's juice." Resident #5 took a sip, stated it tasted bad, and refused the rest. Staff #2 then dumped the remaining medication down the drain. III. InterviewsStaff #2 was interviewed on 6/24/26 at approximately 8:15 a.m. and stated that they usually put Resident #5 ' s crushed medications in coffee with creamer to help with the taste. Staff #3 was interviewed on 6/24/26 at3:35 p.m. and stated the staff used pudding or applesauce as a vessel for crushed medications and had to tell the residents their medications were in it. She said the QMAPs never masked the medications. The administrator (AD) was interviewed on 6/24/26 at approximately 4:05 p.m. and stated it was the residence's policy to put crushed medications in pudding or applesauce, and that staff should not put medications down the sink. Further, the AD stated staff were supposed to tell residents they were provided medications when given crushed medications mixed in soft foods because the facility did not use coercion. The AD acknowledged that the observed actions by Staff #2 when providing medications to Resident #5 had not been acceptable.

An administrative relicensure survey was completed on 3/25/26. No deficiencies were cited.

A Relicensure Survey and complaint revisit was completed on 9/9/25 for all previous deficiencies cited on 6/10/25. 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 #CO40877, was completed on 9/10/25. No deficiencies were cited.

A relicensure survey with complaint #CO40194, #CO40181, and #CO39269 was completed on 6/10/25. Deficiencies were cited. A change of ownership occurred on 5/1/25.

Based on record review and interviews, the residence failed to have a readily available roster of current residents that included emergency contact information, affecting 66 current residents. Findings include:A roster provided by Staff #3 on 6/9/25 at 7:20 a.m. did not include residents ' emergency contact information. A second roster, provided by the administrator as part of an evacuation binder on 6/9/25 at 8:50 a.m., also lacked residents ' emergency contact information. A third roster provided by the concierge on 6/9/25 at 9:00 a.m. similarly lacked emergency contact information. On 6/9/25 at 7:20 a.m., Staff #3 stated she could retrieve the roster from the back. On 6/9/25 at 9:00 a.m., the concierge stated the census was the most up-to-date document but did not include emergency contacts. She added that she had access to a digital spreadsheet that did include emergency contact information, but it was not as current as the census. On 6/10/25 at 9:30 a.m., the administrator stated the resident roster did not include emergency contact information and confirmed that while the concierge had access to this information, it was not readily available as required.

Based on record review and interview, the residence failed to ensure residents had the right to be treated with dignity, affecting one of six sample residents (#1). Findings include:1. Resident #1 was admitted to the residence on 4/4/23 with diagnoses including vascular dementia with behavioral disturbance and cerebral infarction. An Investigation Report Summary for Resident #1, performed and conducted, in part by the administrator read, in part that on 5/26/25 Staff #1 was training Former Staff #10 as they were assisting Resident #1 with her shower. Staff #1 slapped Resident #1 on her bottom as she was exiting the shower and Resident #1 was heard saying "ouch". Staff #1 was interviewed and acknowledged she patted Resident #1's bottom as she was exiting the shower. She added it was typical behavior that she and Resident #1 had. Lastly, the investigation report summary read that Staff #1 was re-trained on the appropriate way to approach and care for residents, in addition to "Being mindful of demonstrating and upholding company standards of conduct."On 6/9/25 at 8:54 a.m., Former Staff #10 said when she was training with Staff #1 in giving Resident #1 a shower, as Resident #1 was stepping out of the shower Staff #1 spanked her bottom. She added, she heard Staff #1 telling Resident #1 not to tell anyone because she could get fired. On 6/10/25 at approximately 9:30 a.m., the administrator said a detective came to the residence to interview Resident #1, Staff #1 and Former Staff #10. The administrator confirmed that Staff #1 tapped Resident #1 on her bottom in a playful manner. When asked if the slap or tap on Resident #1's bottom by Staff #1 was dignified, the administrator said "I do ..." they flipped each other off and then hug. Different dynamic. Friendship dynamic. They have known each other for years." She added, if another staff member did the same thing to Resident #1, Resident #1 would complain. The administrator affirmed that Staff #1's action was dignified.

Based on interview and record review, the residence failed to thoroughly investigate allegations of abuse in accordance with the residence's written policy, affecting two of six sample residents (#1, #3). (Cross-reference T3062)Specifically, on 4/20/25 Resident #3 struck Resident #7. The residence failed to investigate and protect Resident #7, and subsequently, on 5/21/25, Resident #3 stepped on Resident #7's toe, which caused a red mark and pain. Further, allegations of abuse by Resident #3 on 5/17, 5/24, and 6/2/25 were not investigated in accordance with the residence policy. Findings include:1. Residence PolicyThe residence's Abuse, Fraud and Wrongdoing policy, dated May 2023 read, in part, "Resident/responsile person, their responsible parties, personnel, health professionals ... are mandated to report in good faith any activity ... abuse and any other wrongdoing that he/she believes violates professional standards of practice or is against the law, or poses a substantial risk to the health, safety and welfare or rights of a resident ... All staff will receive training on elder abuse incidence, signs and symptoms, and reporting requirements ... Allegations may include ... physical abuse ... any other incident which may cause harm or immediate danger to residents ... If a report of abuse, fraud or other wrongdoing is received the executive director (administrator) is notified immediately ... the executive director or other designated representative initiates an investigation ... a written report shall be made to the licensing agency ... the resident's responsible party and physician are notified ... if the alleged offender is another resident, the other resident will be assessed for appropriateness of remaining in the community. All appropriate parties are notified of the outcome of the investigation." 2. Resident #3 was admitted to the residence on 12/29/23 with diagnoses including dementia with agitation, restlessness and frontotemporal neurocognitive disorder. The progress notes for Resident #3 in April, May and June 2025 revealed the following:On 4/20/25 Resident #7 was following Resident #3. Resident #3 became agitated and mumbled under his breath. Resident #7 became agitated and hit Resident #3. Resident #3 stepped on Resident #7's foot and shoved her to the ground. On 5/17/25 Resident #3 was aggressive to other residents and staff and started shoving and moving residents and forcing them to stand up. On 5/21/25 Resident #3 stepped on another resident's toe. On 5/24/25 Resident #3 was aggressive, grabbed and shoved a resident. On 6/2/25 Resident #3 was agitated when another female resident walked past him in the living room. Resident #3 attempted to kick a female resident. A female resident was able to stop him from kicking her with her hands. On 6/4/25 a care coordination meeting was held with Resident #3's practitioner and residence staff where both agreed Resident #3 was doing well and had no concerns. A review of the Department's database on 6/10/25 revealed the incidents on 4/20 and 5/21/25 were investigated. However, adult protective services were not notified, as required. Specifically, on 5/21/25 Resident #3 stepped on Resident #7's toe. "Victim's (Resident #7's) toe appeared red, but there were no complaints of lasting pain." On 6/9/25 at 9:30 a.m., the administrator said for resident to resident altercations, "We didn't do formal investigations. The information is in the initial incident report and then in (department database. Most of our residents don't remember what happened after the event occurred."On 6/9/25 at 4:22 p.m., the clinical services director confirmed she only had investigations for the two altercations on 4/20 and 5/21/25. On 6/9/25 at 4:26 p.m., the administrator said the residence did not have a resident to resident abuse investigation template but talked with staff afterwards and completed internal incident reports. She added, "Most likely they (residents) don't recall." The administrator confirmed there were no investigations conducted for the three progress notes that involved Resident #3 on 5/17, 5/24 and 6/2/25. On 6/10/25 at 9:13 a.m., the clinical services director acknowledged that there was no investigation for the altercations involving Resident #3 on 5/17 and 5/24/25. On 6/10/25 at approximately 9:30 a.m., the administrator said she did not report to adult protective services unless there were some "legs" (not just an allegation). The administrator confirmed that adult protective services were not notified for the 4/20 and 5/21/25 altercations. She added knowing what she knows now she should have reported the 5/17 and 5/24/25 altercations to adult protective services. 3. Similar deficient practice was found for Resident #1, who had an abuse allegation on 5/26/25 where adult protective services was not notified by the residence.

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 if the resident did not understand the purpose of the medication or was not capable of voluntarily requesting the medication, affecting one sample resident (#5). Findings include:Resident #5 was admitted to the residence on 5/31/24 with diagnoses including dementia and chronic pain. Resident #1 lived in a secure environment (SE). A written practitioner's order, dated 4/1/25, directed the residence to administer topically diclofenac gel 1% to the right knee as needed for pain. The May and June 2025 electronic medication administration records (eMARs) read that Staff #6 administered the medication on 5/15 and 5/19. Progress notes for Resident #5 read in part:On 5/15/25, the resident was unable to verbalize what was causing her pain. Staff #6 notified CSD, and CSD instructed staff to administer diclofenac gel to the resident. On 5/19/25, Staff #6 administered topically diclofenac gel to Resident #5 at the direction of the clinical services director (CSD). On 6/9/25 at 3:40 p.m., the CSD stated Staff #6 was a QMAP and not a nurse. She added that the staff member applied diclofenac to Resident #5 despite the resident's inability to request the medication. She stated that the staff member contacted her or the resident's external service provider (ESP) and described the symptoms. She affirmed that the symptom description was an assessment and, therefore, out of the scope of the QMAP. Furthermore, she stated that the eMARs of Residents #2-#7 contained PRN medications that the residence had not yet administered; however, Residents #2-#7 were unable to request the medication due to cognitive impairment.

Based on record review and interviews, the residence failed to comply with authorized practitioner orders for three of eight sample residents (#2, #4, #6). Findings include:Resident #4 was admitted on 1/19/24 with diagnoses of dementia, major depressive disorder, and nonpsychotic mental disorder. A practitioner ' s order dated 8/8/24 directed lorazepam 0.5 mg to be administered once daily at 8:00 p.m., except on shower days, when it was to be given one hour prior. The May 2025 medication administration record indicated that lorazepam was not administered on 5/9 to 5/11, 5/13, 5/14, 5/16 to 5/18, 5/20, 5/21, 5/23 to 5/25, 5/27, 5/28, 5/30, and 5/31. On 6/9/25 at 1:28 p.m., the clinical services director stated, "That is a huge discrepancy." She reported contacting the hospice provider, who confirmed that lorazepam was intended to be administered daily. She added, "We missed that. When I read [the order], I thought it said only [administer] on shower days."On 6/10/25 at 9:30 a.m., the administrator confirmed that the order directed daily administration. She stated that she expected staff to comply with practitioner orders and that the clinical services director should ensure clear orders for medication administration. Similar deficient practice of failure to comply with practitioners' orders was found with regard to Residents #2 and #6.

Based on record review and interviews, the residence failed to maintain documentation of jointly counted controlled substances, affecting one of eight sample residents (#4). Findings include:Resident #4 was admitted on 1/19/24 with diagnoses of dementia, major depressive disorder, and nonpsychotic mental disorder. A practitioner ' s order dated 8/8/24 directed lorazepam 0.5 mg to be administered once daily at 8:00 p.m., except on shower days, when it was to be given one hour prior. The controlled substance count sheet for Resident #4 ' s lorazepam showed a count of zero on 3/29/25 at 7:09 p.m., and a count of eight on 5/18/25 at 1:00 p.m. No documentation of the controlled substance count was available for the period from 3/30/25 to 5/17/25. The May 2025 medication administration indicated that lorazepam was administered on 5/8, 5/12, and 5/15. On 6/9/25 at 2:40 p.m., the clinical services director confirmed that the residence did not have controlled substance count documentation for the stated period for Resident #4. On 6/10/25 at 9:30 a.m., the administrator stated she expected accurate recordkeeping of controlled substance counts and was unaware that documentation was missing for Resident #4.

Based on observations and interviews, the residence failed to maintain the grounds free of garbage and rubbish, affecting 66 current residents. Findings include:An environmental tour on 6/10/25 at 9:15 a.m. revealed that the dumpster storage area contained garbage and rubbish and had a lid left open, allowing wildlife access. Additionally, a discarded bedframe and wooden pallet were observed on the backside of the residence, left in the garden, and on a walking path in front of a resident ' s window. On 6/10/25 at 9:30 a.m., the administrator stated she was aware the dumpster area needed to be cleaned and that the dumpster lid must remain closed. She added she was unaware it had been left open during the tour, but had known of this issue in the past. She also acknowledged that the discarded bedframe and pallet were rubbish and needed to be removed.

Based on observations and interviews, the residence failed to maintain interior areas free from accumulations of extraneous materials, affecting 66 current residents. Findings include:An environmental tour on 6/9/25 at 9:15 a.m. revealed the fire suppression sprinkler control room contained a large mobile toolbox, a large ladder, and gardening equipment, including racks, hedge trimmers, and a tree trimmer. On 6/10/25 at 9:30 a.m., the administrator confirmed she was aware of the clutter and acknowledged that the sprinkler control room should be clear of extraneous materials.

Based on record review and interview, the residence failed to update the care plan to reflect changes in the staff approach required to meet resident needs and when any medical assessment, appraisal, or observations indicated the resident's care needs had changed, affecting two of four residents (#3, #4) who experienced challenging behaviors (Cross-reference T1410)Findings include:1. Resident #3 was admitted to the residence on 12/29/23 with diagnoses including dementia with agitation, restlessness and frontotemporal neurocognitive disorder. The progress notes for Resident #3 in March, April, May and June 2025 revealed the following:On 3/12/25 at 1:23 p.m., Resident #3 refused to be changed after he had a bowel movement on the floor. On 4/2/25 at 10:34 a.m., Resident #3 was being very aggressive with staff. On 4/20/25 at 3:30 p.m., Resident #7 was following Resident #3. Resident #3 became agitated and mumbled under his breath. Resident #7 became agitated and hit Resident #3. Resident #3 stepped on Resident #7's foot and shoved her to the ground. On 5/17/25 at 9:54 p.m., Resident #3 was aggressive to other residents and staff and started shoving and moving residents and forcing them to stand up. On 5/21/25 at 12:56 p.m., Resident #3 stepped on another resident's toe. On 5/24/25 at 9:38 p.m., Resident #3 was aggressive, grabbed and shoved a resident. On 6/2/25 at 8:05 p.m., Resident #3 was agitated when another female resident walked past him in the living room. Resident #3 attempted to kick a female resident. A female resident was able to stop him from kicking her with her hands. An assessment in Resident #3's record, dated 10/14/24. No other assessments were conducted, nor found in his record. The assessment read Resident #3 was restless during the night, was oriented to person, was resistant to care, had socially inappropriate behavior and wandered but did not require redirection. A care plan in Resident #3's record, updated 3/26/25 read that he had a behavior management plan where staff are to document behaviors, and for staff to assist him to bed when tired and redirect him when he was trying to leave the building. The care plan did not reflect changes in the staff approach required to meet his needs when observations indicated his care needs had changed in regards to his aggressive behaviors towards residents. On 6/9/25 at 1:51 p.m., Staff #3 said she was not told about Resident #3's behaviors or that he was agitated and aggressive with residents. She added she was required to check on him so he did not use the bathroom in inappropriate places. On 6/9/25 at 1:55 p.m., Staff #8 said she was not notified about Resident #3's aggressive behaviors. On 6/9/25 at 1:57 p.m., Staff #9 said was not made aware of any of Resident #3's aggressive behaviors. On 6/10/25 at approximately 10:00 a.m., the administrator said she expected the residence to update resident care plans with the most up to date information. She added she was aware that morning shift was not aware of Resident #3's aggressive behaviors because his behaviors did not happen on the morning shift. 2. Similar deficient practice was found onsite for Resident #4.

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 7.5.1 Assisted living residence personnel engaged in the admission, care or treatment of at-risk persons shall report suspected physical or sexual abuse, exploitation and/or caretaker neglect to law enforcement within 24 hours of observation or discovery pursuant to Section 18-6.5-108, C.R.S.12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: (B) Detailing in each resident ' s care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment;14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. 21.2 The assisted living residence grounds shall be maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction. 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident ' s condition changes from baseline status.(A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident ' s attending practitioner, family, and/or resident ' s representative and review service documentation dating back to the most recent comprehensive assessment.

A revisit survey was completed on 4/9/25 for all previous deficiencies cited on 12/31/24. The facility is in compliance with all deficiencies that were cited.

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

A revisit survey was completed on 4/9/25 for all previous deficiencies cited on 12/31/24. The facility is in compliance with all deficiencies that were cited.

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

A relicensure survey and a complaint revisit was completed on 12/31/24 for all previously deficiencies cited deficiencies on 9/19/24. Deficiencies were cited.

Based on observation, interview, and record review, the residence failed to update comprehensive assessments whenever a resident's condition changed from baseline status, affecting two of four sample residents (#20, #24). This deficiency was cited previously during a relicensure survey and complaint revisit on 9/19/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #20 was admitted to the residence on 2/20/24 with a diagnosis of shortness of breath.a. ObservationOn 12/30/24 at 11:35 a.m., the oxygen (O2) concentrator for Resident #20 read that it had been last set at two liters per minute.b. Record ReviewA hospital discharge note, dated 11/7/24, read that the practitioner ordered O2 at four liters per minute for continuous use by the resident. The most recent assessment, dated 11/8/24, read in part that the resident had no O2 concentrator; further, the assessment failed to contain information about the resident no longer wearing O2 during the day, continuing to wear it at night, or what assistance the residence was to provide the resident at night with the O2. A practitioner's order, dated 11/21/24, directed the residence to discontinue the O2 for Resident #20. A progress note, dated 11/29/24, read in part that the external service provider (ESP) directed the resident to ensure the resident wore O2 at night only. A practitioner's order, dated 12/30/24, directed the residence to ensure that Resident #20 used two liters per minute of O2 at night.c. InterviewsOn 12/30/24 at 11:27 a.m., Staff #11 stated that Resident #20 began using O2 at night at two liters per minute approximately five weeks prior to the onsite visit. On 12/30/24 at 11:45 a.m., the administrator stated that the residence should have reassessed Resident #20 when his O2 order changed in November as it was a change in condition. In a later interview, the administrator stated that the previous deficient practice was not corrected due to the home office's change to the assessment process that required all assessments to be redone. She added that this likely led to the residence not completing all assessments in a timely manner. On 12/31/24 at 11:23 a.m., the ESP stated that the practitioner directed the residence's registered nurse verbally to begin O2 at two liters per minute at night on 11/29/24 for Resident #20. She added the written order was sent to the residence on 12/30/24. 2. Additionally, the residence demonstrated deficient practice for Resident #24.

Based on observation, interview, and record review, the residence failed to comply with practitioner orders, affecting three of four sample residents (#20, #24, #25). This deficiency was cited previously during a licensure survey and complaint revisit on 9/19/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #25 was admitted to the residence on 12/7/24 with a diagnosis of pneumonia.a. ObservationOn 12/30/24 at 2:51 p.m., a medication cart review was conducted with Staff #30 for Resident #25. During the review the levofloxacin bottle was observed in the cart and contained three tablets.b. Record ReviewA signed practitioner order, dated 12/13/24, directed the residence to administer Resident #25, levofloxacin 750 mg tablet once per day for seven days. However, the December 2024 medication administration record (MAR) revealed the medication was not administered until 12/15/24. The December 2024 MAR revealed Resident #25 was prescribed seven tablets of levofloxacin 750 mg once a day for seven days. The MAR revealed Resident #25 began the medication on 12/15 and did not receive doses on 12/20 and 12/21/25.c. Interview On 12/31/24 at 1:30 p.m., the administrator could not explain why levofloxacin was not administered to Resident #25 on 12/20 and 12/21/24.2. Additionally, the residence demonstrated similar deficient practice for Residents #20 and #24.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (F) Decision making regarding PRN or "as needed" medication administration;14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner

A complaint revisit was completed on 12/31/24 for all previous deficiencies cited on 9/19/24. Deficiencies were cited.

Based on observation, and record review, the residence failed to provide protective oversight, affecting one of four sample residents (#25). Findings include:1. Resident #25a. Record ReviewResident #25 was admitted to the residence on 12/7/24 with a diagnosis of pneumonia. A signed practitioner order, dated 11/21/24, read that the practitioner ordered oxygen (O2) at two liters per minute for continuous use at night/sleep by the resident. An electronic medication administration record (eMAR) dated 12/1/24 to 12/31/24 revealed Resident #25 was prescribed O2 at two liters per minute for continuous use at night/sleep. The eMAR revealed the residence failed to administer O2 for Resident #25 from 12/7-12/16/24.b. InterviewOn 12/31/24 at 1:30 p.m., the administrator could not explain why O2 was not administered to Resident #25 from 12/7-12/16/24. She stated "there was confusion as to what she needed".

Based on observation, interview, and record review, the residence failed to comply with practitioner orders, affecting three of four sample residents (#20, #24, #25). This deficiency was cited previously during a complaint revisit on 9/19/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #25 was admitted to the residence on 12/7/24 with a diagnosis of pneumonia.a. ObservationOn 12/30/24 at 2:51 p.m., a medication cart review was conducted with Staff #30 for Resident #25. During the review the levofloxacin bottle was observed in the cart and contained three tablets.b. Record ReviewA signed practitioner order, dated 12/13/24, directed the residence to administer Resident #25, levofloxacin 750 mg tablet once per day for seven days. However, the December 2024 medication administration record (MAR) revealed the medication was not administered until 12/15/24. The December 2024 MAR revealed Resident #25 was prescribed seven tablets of levofloxacin 750 mg once a day for seven days. The MAR revealed Resident #25 began the medication on 12/15 and did not receive doses on 12/20 and 12/21/25.c. Interview On 12/31/24 at 1:30 p.m., the administrator could not explain why levofloxacin was not administered to Resident #25 on 12/20 and 12/21/24.2. Additionally, the residence demonstrated similar deficient practice for Residents #20 and #24.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (F) Decision making regarding PRN or "as needed" medication administration;14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner.

A complaint revisit was completed on 12/31/24 for the previous deficiency cited on 9/19/24. The residence is in compliance with all regulations surveyed.