VILLAGE AT BELMAR

A licensure complaint, prompted by #CO41497 and #CO42008, was completed on 4/7/26. No deficiencies were cited. A change of ownership occurred on 3/16/26.

A complaint revisit was completed on 4/7/26 for all previous deficiencies cited on 12/17/25. The residence is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO41385, was completed on 1/7/26. No deficiencies were cited.

A licensure complaint, prompted by #CO41277, was completed on 12/17/25. Deficiencies were cited.

Based on record review, observation and interview the residence failed to have documentation of routine monthly testing of all equipment and devices used to secure the environment, affecting 23 current residents in the secure environment. Findings include:1. Record ReviewOn 12/17/25 at approximately 1:30 p.m., the maintenance director provided a work order history in response to a request for documentation of routine monthly testing of all equipment and devices used to secure the memory care environment. The work order history did not show that routine monthly testing had been conducted. 2. ObservationOn 12/17/25 at 9:23 a.m., during an environmental tour, the Health Services Director (HSD) attempted to exit the memory care unit; however, the fob and access system did not function properly. The only way to exit the unit was for a person to manually open the door from the outside of the memory care unit. 3. InterviewOn 12/17/25 at approximately 1:47 p.m., the maintenance director stated that the residence did not have documentation demonstrating that monthly testing of all equipment and devices used to secure the environment had been routinely conducted. On 12/17/25 at approximately 2:00 p.m., the executive director acknowledged that the residence did not have documentation of monthly device checks in the memory care unit and confirmed that the residence had not maintained records demonstrating ongoing compliance with required testing of equipment and devices used to secure the memory care environment. The executive director further stated that it was unacceptable that residents, staff, and family members could not exit the memory care unit independently due to malfunctioning fobs and that they had to call the front desk for assistance to exit the unit.

Based on observation and interview, the residence failed to have a secure outdoor area that was independently accessible without staff assistance, affecting 23 residents in the secure environment. Findings include:1. ObservationOn 12/17/25 at approximately 9:00 a.m., a tour of the secured environment revealed that all exterior doors were locked, preventing residents from accessing the secure outdoor area independently without staff assistance. Additionally, one door leading to the outdoor environment was obstructed by a large plant terrarium. On 12/17/25 at approximately 9:00 a.m. to 2:00 p.m., all of the doors that led to the secure outdoor area remained locked; therefore, prohibiting independent access for the residents who attempted to go outside. 2. InterviewsOn 12/17/25 at approximately 9:23 a.m., Staff #1 stated that, in the memory care environment, the doors were locked at all times and residents did not have independent access to the outdoor area, requiring them to request staff assistance to go outside. She further stated that some residents enjoyed the outdoor area and frequently asked to go outside. On 12/17/25 at approximately 2:15 p.m., the executive director stated that he was unaware that the doors in the secured environment leading to the outdoor area were locked and that one of the doors was obstructed by a large plant terrarium. He further acknowledged that residents should have independent access to the secure outdoor area.

A relicensure survey with complaint #CO39721 and #CO41017 was completed on 10/8/25. No deficiencies were cited.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.12 Personnel files for current employees and volunteers shall be readily available onsite for Department review. 7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(A) A description of the employee or volunteer duties;(B) Date of hire or acceptance of volunteer service and date duties commenced;(C) Orientation and training, including, but not limited to the following, as applicable:(1) Frst aid and CPR certification,(2) Proof of portable training(s) accepted by the assisted living residence, including documentation of the acceptance conditions at Part 7.9(D) being met.(D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable;(E) Results of background checks and follow up, as applicable; and(F) Tuberculin test results or proof of a portable test compliant with Part 7.7, if applicable.(G) Documentation of initial dementia training and continuing education for direct-care staff members:(1) The residence shall maintain documentation of each employee ' s completion of initial dementia training and continuing education. Such records shall be available for inspection by representatives of the Department.(2) Completion shall be demonstrated by a certificate, attendance roster, or other documentation.(3) Documentation shall include the number of hours of training, the date on which it was received, and the name of the instructor and/or training entity.(4) Documentation of the satisfactory completion of an equivalent training as defined in sub-part 7.9(B)(2)(b) and as required in the criteria for an exception discussed in sub-part 7.9(B)(4), shall include the information required in this sub-part 7.13 (G)(2) and (3).(5) After the completion of training and upon request, such documentation shall be provided to the staff member for the purpose of employment at another covered facility. For the purpose of dementia training documentation, covered facilities shall include assisted living residences, nursing care facilities, and adult day care facilities as defined in Section 25.5-6-303(1), C.R.S.

A complaint revisit was completed on 2/13/25 for all previous deficiencies cited on 9/26/24. The residence is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO35238, #CO36931, #CO36982 and #CO37384, was completed on 9/26/24. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one of three sample residents (#7). Findings include:1. References and Residence Policya. According to the Occurrence Reporting Manual, dated May 2018, "Any occurrence involving physical...abuse of a patient or resident, as described in Section 18-3-202, 18-3-203, and 18-3-204...C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility. Section 25-1-124(2)(d), C.R.S. Two elements needed: Intent OR Knowingly OR Recklessly AND Bodily injury and/or serious bodily injury AND/OR Unreasonable confinement or restraint. If an allegation is investigated and not substantiated, is it still reportable as an occurrence? Yes, it is the allegation of the event, not the outcome of the provider's investigation, which makes it reportable."b. The residence's Abuse, Neglect and Exploitation policy, dated 2/26/24, read in part, "Report to Health Facilities Division. If there is reason to believe that an incident constitutes abuse, neglect or exploitation, the Executive Director should report such information to the Health Facilities Division within 24 hours of the observation or discovery."2. Resident #7 was admitted to the residence on 5/31/23. A community investigation document in Resident #7's record, dated 8/6/24, read Resident #7 reported to care staff that two contracted staff members were rough with him when they transferred him. Resident #7 reported he was upset, tearful and had hip pain, which required medication to be administered. The community investigation document had a checkbox that was checked that read the health department was not notified, as required. On 9/24/24 the department database did not reveal any occurrence reported on or around 8/6/24. On 9/26/24 at 1:31 p.m., a representative from the department sent an email which read the event Resident #7 reported met the requirements under physical abuse and should be reported to the department. On 9/26/24 at approximately 2:30 p.m., the administrator said he and the assisted living director should have reported the incident with Resident #7 to the department.

Based on interview and record review, the residence failed to ensure staff observed a resident's right to be free of physical and emotional abuse and intimidation, affecting one of six sample residents (#7) and one former resident (#9). (Cross-reference S1410, S3030)Specifically, Former Resident #9 was assaulted, emotionally abused, and intimidated by Former Resident #10 and Resident #1 in December 2023, March, June and July 2024. As a result of the assaults, emotional abuse and intimidation, Former Resident #9 expressed fear and pain. Findings include:1. Resident #1 was admitted to the residence on 11/30/21. Progress notes in Resident #1's record for June and July 2024 revealed the following:On 6/5/24, Resident #1 continued to touch, kiss and pull on Former Resident #9's arm. On 6/9/24, Resident #1 yelled across the dining room to get Former Resident #9 to sit with him. On 6/24/24, Resident #1 demanded Former Resident #9 sit next to him. Former Resident #9 did not want to sit next to him so Resident #1 called her names. On 6/25/24, Resident #1 went behind Former Resident #9 kissed her face and hands and scared her. Former Resident #9 was startled. On 6/29/24, Staff were about to assist Former Resident #9 to the restroom when Resident #1 yelled at Former Resident #9 and told her to stay there and not move. On 6/30/24, Resident #1 followed Former Resident #9 around the residence and was frightening her. Former Resident #9's family was concerned for her safety. On 7/11/24, Resident #1 was assisting Former Resident #9 to the bathroom after she had an incontinence accident. Resident #1 got aggressive with staff who tried to intervene and as a result, Former Resident #9 was scared and was shaking and asking to telephone her family member. 2. Former Resident #10 was admitted to the residence on 8/6/23. Progress notes in Former #10's record for December 2023 and March 2023 revealed the following:On 12/22/23, Former Resident #10 had his arm around Former Resident #9's neck and yanked her backwards. On 12/25/23, Former Resident #10 was making sexual comments to Former Resident #9. On 3/1/24, Former Resident #10 pulled the back of Former Resident #9's chair and as a result Resident #9 was scared. On 3/8/24, Former Resident #10 pulled Former Resident #9 by the hand to keep her from going to her room. Former Resident #9 expressed pain in her arm and shoulder. On 3/22/24, Former Resident #10 scared Former Resident #9 and became aggressive with her and made her move to another table. 3. Former Resident #9 was admitted to the residence on 5/1/23 and subsequently moved out on 7/12/24. Former Resident #9 had diagnoses including Alzheimer's and dementia. A practitioner's progress note in Former Resident #9's record revealed that on 3/20/24 Former Resident #9 had "Pain to bilateral arms and shoulders because there is another resident (Former Resident #10) in the memory care unit who keeps pulling (Former Resident #9's) arms."Progress notes in Former Resident #9's record for December 2023, March and July 2024 revealed the following:On 3/1/24, Former Resident #10 pulled the back of Former Resident #9's chair to get her to come with him. On 3/6/24, Former Resident #9 requested to be redirected when she was with Former Resident #10. On 3/7/24, Former Resident #9 complained of arm pain and requested to be kept away from Former Resident #10. On 3/27/24, Former Resident #10 refused to let go of Former Resident #9's arm. On 7/11/24, Resident #1 went up to Former Resident #9, took off her shoe and placed her foot in his mouth, grabbed her chair and pulled her towards him. Former Resident #9 looked worried. On 7/11/24, Resident #1 had Former Resident #9 locked in his room and Former Resident #9 appeared fearful. 4. During the onsite visits on 9/25/2024 and 9/26/2024, similar deficient practice was found for Resident #7.5. InterviewsOn 9/25/24 at 9:20 a.m., Staff #1 said Former Resident #9 was scared of Resident #1 after a while. She added, Resident #1 would makeFormer Resident #9 bend over so he could touch her bottom. She added, Former Resident #10 was aggressive with Former Resident #9 to where he pulled her arm. She added, Former Resident #10 made Former Resident #9 sit with him and Former Resident #9 was scared of him. On 9/26/24 at 8:26 a.m., Former Staff #4 said Resident #1 was possessive over Former Resident #9 and that she wore skirts and made her bend down and would touch her bottom. On 9/26/24 at 9:03 a.m., Former Staff #5 said Resident #1 was possessive when Former Resident #10 was with Former Resident #9. On 9/26/24 at 9:10 a.m., Former Staff #6 said Former Resident #10 was possessive and controlling over Former Resident #9. She added Former Resident #10 grabbed Former Resident #9's arm and neck in an aggressive manner. She added Former Resident #9 was fearful of Former Resident #10. On 9/26/24 at approximately 2:30 p.m., the administrator said residents had the right to be free from abuse and intimidation.

Based on interview and record review, the residence failed to investigate allegation of abuse of residents, document the investigation process and protect the resident from future abuse, affecting one former resident (#9). (Cross-reference S1322)Findings include:1. Residence PolicyThe residence's Abuse, Neglect and Exploitation policy, dated 2/26/24 read, in part, "Mistreat is defined in Colorado as an act or omission which threatens the health, safety, or welfare of an at-risk adult or which exposes the adult to a situation or condition that poses ... bodily injury to the adult ... Abuse which occurs ... where unreasonable confinement or restraint is imposed ... Abuse is also defined as including emotional ... Emotional abuse means harassment, threats of punishment, harm or deprivation directed towards the resident ... Upon learning of alleged abuse, neglect or exploitation, the executive director or supervisor on duty shall attempt to take necessary steps to ensure that residents are protected from subsequent episodes of abuse, neglect, or exploitation while a determination on the matter is pending ... Resident on resident contact. If an incident involves resident-on-resident contact, both residents should be evaluated for a change of condition. Residents exhibiting aggressive behavior should be considered for continued appropriateness and interventions should be developed to address their behaviors ... Upon receipt of an allegation of abuse, neglect or exploitation, the executive director or the designee should conduct a confidential internal investigation." 2. Resident #1 was admitted to the residence on 11/30/21. Progress notes in Resident #1's record for June and July 2024 revealed the following:On 6/5/24, Resident #1 continued to touch, kiss and pull on Former Resident #9's arm. On 6/9/24, Resident #1 yelled across the dining room to get Former Resident #9 to sit with him. On 6/24/24, Resident #1 demanded Former Resident #9 sit next to him. Former Resident #9 did not want to sit next to him so Resident #1 called her names. On 6/25/24, Resident #1 went behind Former Resident #9 kissed her face and hands and scared her. Former Resident #9 was startled. On 6/29/24, Staff were about to assist Former Resident #9 to the restroom when Resident #1 yelled at Former Resident #9 and told her to stay there and not move. On 6/30/24, Resident #1 followed Former Resident #9 around the residence and was frightening her. Former Resident #9's family was concerned for her safety. On 7/11/24, Resident #1 was assisting Former Resident #9 to the bathroom after she had an incontinence accident. Resident #1 got aggressive with staff who tried to intervene and as a result, Former Resident #9 was scared and was shaking and asking to telephone her family member. 3. Former Resident #10 was admitted to the residence on 8/6/23. Progress notes in Former #10's record for December 2023 and March 2023 revealed the following:On 12/22/23, Former Resident #10 had his arm around Former Resident #9's neck and yanked her backwards. On 12/25/23, Former Resident #10 was making sexual comments to Former Resident #9. On 3/1/24, Former Resident #10 pulled the back of Former Resident #9's chair and as a result Resident #9 was scared. On 3/8/24, Former Resident #10 pulled Former Resident #9 by the hand to keep her from going to her room. Former Resident #9 expressed pain in her arm and shoulder. On 3/22/24, Former Resident #10 scared Former Resident #9 and became aggressive with her and made her move to another table. 4. Former Resident #9 was admitted to the residence on 5/1/23 and subsequently moved out on 7/12/24. Former Resident #9 had diagnoses including Alzheimer's and dementia. A practitioner's progress note in Former Resident #9's record revealed that on 3/20/24 Former Resident #9 had "Pain to bilateral arms and shoulders because there is another resident (Former Resident #10) in the memory care unit who keeps pulling(Former Resident #9's) arms."Progress notes in Former Resident #9's record for December 2023, March and July 2024 revealed the following:On 3/1/24, Former Resident #10 pulled the back of Former Resident #9's chair to get her to come with him. On 3/6/24, Former Resident #9 requested to be redirected when she was with Former Resident #10. On 3/7/24, Former Resident #9 complained of arm pain and requested to be kept away from Former Resident #10. On 3/27/24, Former Resident #10 refused to let go of Former Resident #9's arm. On 7/11/24, Resident #1 went up to Former Resident #9, took off her shoe and placed her foot in his mouth, grabbed her chair and pulled her towards him. Former Resident #9 looked worried. On 7/11/24, Resident #1 had Former Resident #9 locked in his room and Former Resident #9 appeared fearful. 5. InterviewsOn 9/26/24 at approximately 10:00 a.m., the area director of memory care said she did not conduct a formal investigation into the progress notes that involved Resident #1, Former Resident #9 and Former Resident #10. She added the way the progress notes were written by staff were not accurate and she had investigated them but did not keep record of the investigation notes. On 9/26/24 at approximately 10:00 a.m., the administrator said he expected the residence to document their investigation and keep a record of the investigation for progress notes that involved Resident #1, Former Resident #9 and Former Resident #10. On 9/26/24 at approximately 2:30 p.m., the administrator said the progress notes between Resident #1, Former Resident #9 Former Resident #10 should have been investigated, as required.

Based on record review and interview, the residence failed to complete a pre-admission assessment to determine the appropriateness and need for secure environment, affecting two of four residents sampled in the secure environment (#1, #4) and one of two former residents sampled in the secure environment (#10). Findings include:1. Resident #1 was admitted to the residence on 11/30/21. An Evaluation for a Secure Environment form in Resident #1's record, dated 12/7/21, approximately one week after Resident #1 moved into the residence revealed the following:The document consisted of five areas with pre-populated information that read in pertinent part: The assessment read the resident would benefit from a secure environment due to his/her need for a structured daily schedule. However, the assessment did not include detailed information from the resident's family and or representative concerning the residents recent relevant history and patterns of reduced safety awareness and wandering or an evaluation by a licensed practitioner that described the residents' medical condition and any cognitive deficits that contributed to wandering. 2. During the onsite visits on 9/25 and 9/26/24 similar deficient practice was found in the records of Resident #4 and Former Resident #10.3. InterviewOn 9/26/24 at approximately 2:30 p.m., the administrator said he was aware the residence's pre-admission assessment to determine the appropriateness of and need for a secure environment lacked detail.

Based on record review and interview, the residence failed to re-assess residents every six months for the need of a secure environment affecting one of four current residents sampled in the secure environment (#1) and two of two former residents sampled in the secure environment (#9, #10). (Cross-reference S1322, S1410)Findings include:1. Resident #1 was admitted to the residence on 11/30/21. An assessment for Resident #1, dated 7/24/24 did not include documentation to support that a re-assessment was completed on Resident #1 for his continued need for a secure environment. Additionally, the assessment read Resident #1 did not have a history with mental health issues or behaviors and had no psychosocial issues, did not require safety checks, was a low wander risk and did not need any monitoring or intervention. 2. During the onsite visits on 9/25 and 9/26/24, similar deficient practice was found for Former Residents #9 and #10. 3. InterviewOn 9/26/24 at approximately 10:00 a.m., the administrator said he did not know residents in the secure environment needed or required a specific assessment to determine their continued need for the secure environment.

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 7.13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items:(D) The right to choice and personal involvement regarding care and services, including:(4) 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;(a) For residents with limited English proficiency or impairments that inhibit communication, the assisted living residence shall find a way to facilitate communication of care needs. 14.13 The assisted living residence shall designate a QMAP supervisor who is a nurse, practitioner, or meets the requirements of a qualified medication administration person.(A) The QMAP supervisor shall, before initial assignment of each qualified medication administration person, conduct a competency assessment with direct observation of all medication administration tasks that the QMAP will be assigned to perform.(1) Whenever a QMAP is assigned additional medication administration tasks, the QMAP supervisor shall conduct a competency assessment with direct observation of each new task that the QMAP will be assigned. 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 revisit survey was completed on 12/15/2023 for all previous deficiencies cited on 1/27/2023. The facility is in compliance with all deficiencies that were cited.

A relicensure survey with complaints #CO30592 was completed on 1/27/23. Deficiencies were cited.

Based upon interview and record review, the residence failed to ensure the quality management plan (QMP) contained improvement strategies and documentation for each improvement strategy that included how the strategy would be evaluated for effectiveness affecting 83 current residents. (Cross-reference Q1180 and Q1468) Findings include:On 1/25/23 at 6:08 p.m., the assisted living director (ALD) stated she was responsible for the implementation and documentation of the residence's QMP since November 2021. She stated the QMP focused on incidents and concerns that were reported. The ALD stated once service delivery areas were identified the department heads implemented new strategies for improvement. She stated she evaluated the effectiveness monthly based on a Bench Mark Trending Report the residence pulled. The ALD subsequently stated she documented the improvements in the QMP binder and acknowledged she had not documented all improvements recently. On 1/25/23 at 6:32 p.m., the administrator stated that he and department management worked on the QMP collectively. He stated they had recently reviewed medications and falls and agreed that those areas required improvement. The administrator identified new intervention and stated they had not been implemented prior to the onsite survey and investigation. The residence's QMP revealed the following:The residence's, undated, Benchmark Trending Report revealed a total number of falls that occurred monthly:September 2022, 19 falls and none with major injury,October 2022, 37 falls and none with major injury,November 2022, 35 falls and none with major injury,December 2022, 39 falls and two with major injury. The residence's, undated, Benchmark Trending Report revealed a total number of medications documented as not available that occurred monthly:October 2022, 20 errors,November 2022, 47 errors andDecember 2022, 14 pages. A review for effectiveness, revealed the residence's service delivery areas included but were not limited to falls and medication errors. However, there was no evidence documented in the QMP for improvement strategies from October 2022 through January 2023 regarding falls and no evidence of documentation for medications from November 2022 through January 2023.

Based on observation, record review, and interview, the residence failed to ensure a comprehensive assessment was updated for a resident whenever the residents' conditions changed from baseline status, affecting four of five sample residents (#1, #6, #8, #10) who experienced a change in condition. (Cross-reference Q1180). 1. References and Residence Policiesa. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(B) Information regarding the resident's overall health and physical functioning ability;(E) Current diagnoses and any known or anticipated need or impact related to the diagnoses;(J) History and circumstances of recent falls and any known approaches to prevent future falls;(L) Types of physical, mental, and social support required.b. The residence's change in condition policy, dated 2/1/22, read in part: "All resident associates will continuously monitor residents' health status by noting and reporting changes in a resident's behavior, condition, and general health to the Health Services Director (HSD). If a change warrants a medical evaluation, this will be arranged."2. Resident #1 was admitted to the residence on 1/15/21 with a diagnosis of dementia. The progress notes for Resident #1 read that the resident had fallen on the following dates 11/28, 12/3, 12/24, 12/25/22, 1/2, 1/7 and 1/9/23. Incident reports identified by the residence, as assessments read the following:On 11/28/22 Resident #1 had a fall, the predisposing situational factor was the resident was using a wheeled walker and predisposing environmental factor was rugs/carpeting. On 12/3/22 Resident #1 had a fall, the predisposing factor from the fall was ambulating without assistance. On 12/24/22 Resident #1 had a fall, the predisposing situational factor was the resident was using a walker, and predisposing psychological factors were the resident had a recent illness and weakness/fainted. On 12/25/22 Resident #1 had a fall, there was no predisposing environmental, situational or psychological factors listed on the incident report. On 1/2/23 Resident #1 had a fall, the predisposing factors were confusion and gait imbalance. On 1/7/23 Resident #1 had a fall, the predisposing factors were confusion, gait imbalance and memory impairment On 1/9/23 Resident #1 had a fall, the predisposing factors were confusion, gait imbalance, memory impairment and ambulating without assistance. However, the above seven incident reports failed to include any known approaches to prevent future falls. The residence's six month Care Assessment, dated 10/6/22 read in part: Resident #1 had a history of falls some resulting in injury, was independent with transfers and ambulation, did not require escorts to meals, required reminders to use assistive devices and to keep them within reach. The assessment further read the resident had an unstable gait, staff were required to anticipate the resident's needs before the resident attempted them, required monitoring three days after a fall, staff were required to evaluate the resident's enviroment at the time of the fall and document any contributing factors to the fall. On 1/25/23 at 5:52 p.m., the assisted living director (ALD) stated residents were assessed at the time of falls. She stated she did not consider one fall to be a change in baseline. However, she stated if the resident fell a second time, then an assessment would have been completed as it was a change in baseline. The ALD further stated assessment should have had documentation of what changes were required to prevent a reoccurrence. She stated the residence documented assessments on incident reports. 3. Resident #10 was admitted to the residence on 11/11/20 with a diagnosis of mild cognitive impairment. The progress notes for Resident #10 read that the resident had fallen on the following dates 12/4, 12/5, 12/12, 12/14/22, 1/7, 1/13 and 1/16/23. Incident reports identified by the residence, as assessments read two additional falls and revealed the following:On 11/21/22 Resident #10 had a fall, the predisposing factors were confusion, gait imbalance, memory impairment, wandering and ambulating without assistance. On 11/23/22 Resident #10 had a fall, the predisposing factors were poor lighting, confusion, gait imbalance, memory impairment and ambulating without assistance. On 12/4/22 Resident #10 had a fall, the predisposing factors were confusion and memory impairment. The predisposing situation factor was transferring. On 12/5/22 Resident #10 had a fall, the predisposing situational factor was transferring. On 12/12/22 and 12/14/22 Resident #10 had a fall, the predisposing factors were confusion, gait imbalance and memory impairment. However, the above six incident reports failed to include any known approaches to prevent future falls. Additionally, there were no incident reports provided for the falls that occurred on 1/7, 1/13 and 1/16/23. The residence's Care Assessment, dated 10/20/22 read in part: Resident #10 had a history of falls, required two person transfer assistance, escorts to meals and activities, used assistive devices, had an unstable gait, was confused and incontinent. The assessment further read staff were required to monitor the resident three days after a fall, staff were required to evaluate the resident's enviroment at the time of the fall and document any contributing factors to the fall. Staff were required to anticipate the resident's needs and provide assistance prior to the resident needing the assistance, provide safety checks and directed the resident to stay in the common areas for close supervision. On 1/25/23 at 6:32 p.m., the administrator stated that when a resident fell the residence would conduct an assessment and document the assessment on an incident report. 4. Resident #8 was admitted to the residence on 7/11/21, with diagnoses including dementia, primary hypertension, hyperlipidemia, atrial fibrillation, and repeated falls. Incident reports identified by the residence, as assessments read the following:On 12/20/22 Resident #8 has a fall, the predisposing factors were confusion, gait imbalance and impaired memory. On 12/26/22 Resident # 8 had a fall, the predisposing factors to the fall were memory impairment, ambulating without assistance and improper footwear. However, the above two incident reports failed to include any known approaches to prevent future falls. 3. Resident #6 was admitted to the residence on 4/10/17, with diagnoses including Alzheimer's disease and a history of falling. Progress notes read Resident #6 fell on 12/4, 12/6, 12/7 and 12/13/22. Incident reports identified by the residence, as assessments read the following:On 11/23/22 Resident #6 had a fall, the predisposing factor to the fall was memory impairment. On 12/4/22 Resident #6 had a fall, the predisposing factors to the fall were confusion, gait imbalance, memory impairment and the situational factors were transferring and using a walkerOn 12/6/22 Resident #6 had a fall, the predisposing factors were confusion, gait imbalance, impaired memory, recent change in medication and the situational predisposing factors were transferring and ambulating without assistance. On 12/13/22 Resident #6 had a fall, the predisposing factors were clutter, confusion, gait imbalance, impaired memory, weakness/fainted and ambulating without assistance. However, the above two incident reports failed to include any known approaches to prevent future falls.

Based on interview and record review the residence failed to coordinate care with known external service providers affecting one sample resident (#8). (Cross-reference Q1180)Findings include:Resident #8 was admitted to the residence on 7/11/21, with diagnoses including dementia and repeated falls. A progress note for Resident #8, dated 12/26/22, read in part: "Staff reported that (Resident #8) had an unwitnessed fall at 3:45 a.m., and hit her head on the dresser. (Resident #8 complained of) pain to head, and so 911 was called and she was sent. No vitals were taken. (Resident #8's family member) was contacted and (informed staff that Resident #8) was on hospice. Staff member called the nursing line in the building and not the nurse on call, and was unaware of procedures for hospice patients. Resident was taken to hospital and has returned as of 9:00 a.m., this morning. (Seen by hospice). No noted bumps or skin tear to residents head."A hospital discharge summary, dated 12/26/22, read that Resident #8 was admitted to the hospital for a fall, and numerous imaging tests were conducted and revealed there was no injury. On 1/25/23 at 1:10 p.m., the assisted living director (ALD), stated that on 12/26/22, Contracted Staff #1 notified emergency medical responders and had Resident #8 sent to the emergency department. The ALD stated that Staff #1 was unaware that Resident #8 should not have been sent out as she was on external hospice. On 1/25/23 at 4:03 p.m., Resident #8's family member stated that Resident #8 fell out of bed on 12/26/22 and hit her head and was not supposed to be sent out since she was on hospice. Resident #8's family member stated that there was a contracted staff member on shift that night who was not aware that hospice residents should not be sent out. In a second interview on 1/25/23 at 5:52 p.m., the ALD stated since the incident on 12/26/22 Contracted Staff #1 no longer worked at the residence. She confirmed that since the incident they had not set up any training's with contracted staff regarding residents who received external hospice and coordination of care. On 1/25/23 at 6:32 p.m., the administrator stated he was aware that Contracted Staff #1 sent Resident #8 to the emergency department after a fall instead of coordinating care with external hospice. He stated he was also aware that the residence had not provided contracted staff with a training on coordinating care since the incident.

Based on record review and interview, the residence failed to implement a fall management program, affecting five of five sample residents with falls (#1,#6-#8, #10). (Cross-reference Q1146). Findings include: 1. Residence Policy The residence's fall management policy, dated 2/1/22, read in part: "the (residence) will provide detailed information (in) the residence's service plan for individualized approaches that address fall risk related to strength, balance, vision, and potential side effects of medications, based on the comprehensive assessment ... After a resident fall an evaluation will be completed to identify contributing factors and develop interventions to decrease the chance of a recurrence."2. Resident #1 was admitted to the residence on 1/15/21 with a diagnosis of dementia. A progress note, dated 11/28/22, read Resident #1 was found on the floor, he had an unwitnessed fall which resulted with an injury to the head. A nursing assessment was conducted and revealed Resident #1 had a one inch laceration the the right side of the face and two other skin tears noted above the laceration by the right ear. There was blood noted on the corner of resident's wooden chair in his room. Resident #1 was lifted off the floor by the nurse and two other staff, the nurse subsequently cleansed and bandaged the lacerations. A incident report for the fall on 11/28/22 read the predisposing situation factor was the resident was using a wheeled walker and predisposing environmental factor was rugs/carpeting. A progress note dated, 12/3/22, read upon entering Resident #1's room, the external hospice nurse found the resident on his right knee. The resident stated that a black hole swallowed up his leg. Resident was complaining of his right knee being sore from kneeling on it. External hospice nurse and one other staff were able to get him up off the floor as the resident was not able to assist. External hospice notified the family for Resident #1 of the fall. A incident report for the fall on 12/3/22 noted the predisposing factor from the fall was ambulating without assistance. A progress note dated 12/24/22 read Resident #1 was found on the floor of his room at 1:00 p.m. The resident was sitting on the floor, back resting on the bed, denies pain or discomfort, denies hitting head, range of motion was within normal limits. A incident report for the fall on 12/24/22 read the predisposing situation factor was the resident was using a walker, and predisposing situational factors were the resident had a recent illness and weakness/fainted. A progress note dated 12/25/22 read Resident #1 was heard yelling for help around 2:30 a.m. When staff responded they noticed the resident had fallen; however, there were no reports of a head injury or pain. A progress note, dated 12/27/22, read resident was on alert charting for two falls within 72 hours and was considered at high risk for falls. A incident report, dated, 1/2/23, read staff went to administer medications to the resident and he was found on the floor by his bed. Staff notified a second staff to assist the resident off the floor and into his wheelchair. A incident report, dated 1/7/23, read Resident #1 was found on the floor near the footrest of his recliner and the resident stated he fell sometime in the early morning. The incident report read the predisposing environmental factor was clutter. A incident report, dated 1/9/23, read Resident #1 fell while going to lunch with another resident. Resident was walking with rollator, lost his balance and fell when going into the elevator. The fall was witness by the external hospice nurse and was noted that the predisposing situational factor was the resident ambulated without assistance. The note further read Resident #1's "Gait is too unstable for a walker at this time." The external hospice nurse transported the resident back to his room via wheelchair. The care plan for Resident #1, dated 11/11/22 read in part after falls notify theresident's practitioner and family and directed staff to keep assistive devices and other objects within reach. However, the care plan was not updated to include individualized approaches and the resident fell eight times one with injury from 11/28 to 1/9/23. The care plan updated on 1/9/23 read the resident used a wheelchair, required escorts with ambulation, wore shoes or non skid socks, had a hospital bed and a lift chair. The care plan did not address how often staff should check on the resident. On 1/25/23 at 1:15 p.m., the health services director (HSD) stated both her and the assisted living director were responsible for updating care plans. She stated approximately one month prior to the on-site visit and investigation Resident #1 received a hospital bed and a reclining chair to prevent falls. The HSD stated the resident suddenly would become confused, agitated and would fall when getting up from his bed. She stated staff should have been checking on the resident every two hours. On 1/25/23 at 3:45 p.m., the assisted living director stated when after each fall that she or the HSD would review the incident report and update the care plan with interventions that the residence would implement to prevent falls. In a second interview on 1/25/23 at 4:05 p.m., the HSD stated the residence standard practice was to conduct alert charting for 72 hours after a fall to see if the resident had any injury or pain. She stated it depended on the fall if the care plan would be updated. The HSD stated sometimes it would take her a week to review the incident report and update the care plan for interventions. 3. Resident #10 was admitted to the residence on 11/11/20 with a diagnosis of mild cognitive impairment. A incident report dated 11/21/22, read staff found Resident #10 on the floor, on his knees three staff lifted him into his wheelchair. A progress note, dated 12/4/22, read staff was walking down the hallway when she heard someone say "help me." Upon entering resident's room Resident #10 was found sitting on the floor facing the window. Resident #6 stated "I just slid out of bed". A progress note, dated 12/5/22, read Resident #10 slid out of bed. A progress note, dated 12/12/22, read Resident #10 was found on the floor behind his bed. A progress note, dated 12/14/22, read a post fall assessment was conducted for Resident #10's fall on 12/12/22. Resident #10 was found on the floor with his pants off repeating help, he was noted to have bruising on his bilateral extremities from possible previous falls. A progress note, dated 1/7/23, read staff heard Resident #10 yelling for help through his closed apartment door. Resident was found on the floor near the foot of his bed. A progress note, dated 1/13/23, read Resident #10 was found on the floor beside his bed. A progress note, dated 1/16/23, read Resident #10 had an unwitnessed fall out of his bed. The resident reported that he slipped out of bed. The care plan, dated 10/10/22, read Resident #10 required two person transfers, escorts to and from the dining room, to evaluate after a fall, anticipate the residents needs and provide assistance assistance before the resident needed it, encourage the resident to be in the common areas, to evaluate the environment at the time of the fall and report any contributing factors to the fall and provide hourly safety checks; additionally, the care plan directed staff to report any change in level of mobility to the nurse. The care plan had one updated on 12/8/22 which directed the residence to keep assistive device and other objects within reach. However, the care plan was not updated to include any other individualized approaches after the resident fell seven times. On 1/25/22 at 4:05 p.m., the HSD stated staff interventions to prevent the falls was a fall mat placed beside his bed. 4. Resident #6 was admitted to the residence on 4/10/17, with diagnoses including Alzheimer's disease and a history of falling. A progress note, dated 11/23/22, read in part: "Caregiver reported finding (Resident #6) sitting in front of the kitchen counter where the cookie display was. No injuries (were) noted, (Resident #6 denied) hitting (his) head, (neurology check and range of motion) within limit. (Resident #6) was assessed for pain and injury ... (family and practitioner) notified."A progress note, dated 12/4/22, read that Resident #6 had an unwitnessed fall with right hip pain, and was admitted to the hospital for evaluation. A progress note, dated 12/6/22 at 3:29 p.m., read that Resident #6 was sent back from the hospital with multiple hip fractures. A progress note, dated 12/6/22 at 8:00 p.m., read that Resident #6 was found on the floor by a caregiver. A progress note, dated 12/7/22 at 6:00 a.m., read that staff were alerted that Resident #6 was found on the floor next to a chair. A care plan for Resident #6, dated 12/12/22, read that he was a high fall risk, and required cueing, reorientation and guidance. However, the care plan did not include the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight. A progress note, dated 12/13/22, read that resident was found on the floor in front of his recliner chair at 3:00 p.m. and no injuries were obtained from the fall. (Resident #6) denied pain or discomfort, and required assistance with transfers to and from his wheelchair since his fractured hip was inoperable. However, no updates were made to Resident #6's care plan after he fell on 12/13/22. On 1/25/23 at 3:12 p.m., Staff #5 stated that Resident #6 had a wheelchair and fall mat and transferred with a walker prior to his fall on 12/4/22, where he broke his hip. On 1/25/23 at 3:23 p.m., Staff #4 stated that Resident #6 had a wheelchair, fall mat, and hourly checks. He also had an escort to help him walk longer distances. On 1/25/23 at 4:32 p.m., the HSD stated that Resident #6 had falls when ambulating and it was also difficult to put interventions in place for him. 3. Resident #8 was admitted to the residence on 7/11/21, with diagnoses including dementia, primary hypertension, hyperlipidemia, atrial fibrillation, and repeated falls. A progress note for Resident #8, dated 12/20/22, read in part: "(Resident #8's family member) called the nurse at 11:00 p.m., on 12/19/22 to report that she had received a call that (Resident #8) had fallen out of bed. There was no report to other staff members on the night shift. At the beginning of the shift a nurse went to assess (Resident #8)... no apparent injuries and resident at baseline with condition."A progress note for Resident #8, dated 12/26/22, read in part: "Staff reported that (Resident #8) had an unwitnessed fall at 3:45 a.m., and hit her head on the dresser. (Resident #8 complained of) pain to head, and so 911 was called and she was sent. No vitals were taken. (Resident #8's family member) was contacted and (informed staff that Resident #8) was on hospice. No noted bumps or skin tear to residents head."The care plan for Resident #8 dated 10/18/22, read that she was a high fall risk and needed reminders to use assistive devices for mobility. The interventions in the care plan were initiated on 10/18/22, and read to provide safety checks. However, the care plan did not include any updates after Resident #8 fell on 12/20/22, or 12/26/22, to include fall interventions that reduce the risk and severity of falls sustained by Resident #8 in the future, or include how often safety checks would be provided. On 1/26/23 at 4:32 p.m., the HSD stated that they did not have any interventions in place for Resident #8, because she had falls when ambulating. 4. Resident #7 was admitted to the residence on 1/10/20, with diagnoses including dementia and repeated falls. A progress note, dated 11/10/22, read in part: "Staff reported to a nurse that (Resident #7 had sustained a) fall (at approximately 6:00 a.m.,) during shift change. (The) fall was unwitnessed in the (dining room). (Resident #7) was found lying upright on (her left) side. No evidence of head injury ...(Resident #7 denied) any pain when asked. No nonverbal cues of pain witnessed."A progress note, dated 11/15/22, read in part: "unwitnessed fall with injury on 11/15/22 (at approximately 12:00 a.m. (according to the) staff on duty, (Resident #7) had two falls in 30 minutes. She was heard yelling and she was found on the floor again of her apartment. (Resident #7) had 2 skin tears on her right arm. (Two) staff (members) assisted her off of the floor and into a chair to change her shirt. (The) qualified medication administration personnel (QMAP) tried to cover (the) wounds but (Resident #7) wouldn't allow him to do it. She had no other injuries and she wasn't in any other pain when ambulating. All responsible parties (were) notified."A progress note, dated 11/19/22, read in part: "Report received that (a caregiver) was doing hourly rounds and found (Resident #7) on the floor by the heater in (Resident #7's) room on 11/18/22 at (11:30 p.m.). Right elbow skin tear reopened with intact dressing. (Resident #7) denie(d) hitting (her) head during (the) fall. (Practitioner) and hospice notified ..."A progress note, dated 12/6/22, read in part: "Staff alerted (the) nurse that (Resident #7) had a(n) witnessed fall (in the dining room) area of (the secured environment). There was another resident sitting in a (wheelchair) with his legs slightly extended and (Resident #7) tripped over their feet. Fall was witnessed by qualified medication administration person (QMAP). Resident did not hit (her) head. Pupils reacted to light appropriately. Resident did obtain (tear) in skin to (right) elbow. (The wound) was cleansed and bandaged. (Resident #7 was) ambulating at her baseline. (Resident #7) did say the area was hurting where the skin tear was, and scheduled Tylenol (to be) administered. Resident alert but not oriented per her baseline due to (diagnoses) of dementia. (Resident #7 was) in (some) acute distress. Hospice, (practitioner) and (medical power of attorney) all notified."A progress note, dated 1/16/23, read that Resident #7 had an unwitnessed fall with a hematoma. A progress note, dated 1/22/23, read that Resident #7 was found on the floor next to her bed. A care plan for Resident #7, dated 12/12/22, read that she was a high fall risk, and required assistive devices to ambulate. However, the care plan did not include an individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, and did not specify what devices Resident #7 required to ambulate. Additionally, the care plan was not updated after the falls on 1/16 and 1/22/23. On 1/25/23 at 4:35 p.m., the HSD stated that Resident #7 had a habit of pacing, and they would try to keep her in common areas. The HSD stated that Resident #7 had a walker, but would leave it behind. The HSD stated she was not aware why Resident #7's ambulation device was not specified in Resident #7's care plan.

Based on record review and interviews, the residence failed to follow its policy regarding investigation of abuse affecting twenty-four current residents in the secure environment. Findings include:1. References and residence policya. Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following: (A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; (C) The process for investigating such allegations; (D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; (E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted; (F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and (G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. b. Chapter II regulations governing assisted living residences, part 4.2.2, 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: (D) Any occurrence involving physical, sexual, or verbal abuse of a resident.c. The residence's policy of abuse and neglect dated 2/1/22 read in part: Abuse which occurs where there is subjection to non-consensual sexual conduct. Any associate who witnesses or becomes aware of alleged abuse should report such abuse to the administrator or direct supervisor on duty immediately. The supervisor should report the incident to the administrator or designee. Upon learning of the alleged abuse the administrator or supervisor should attempt to take necessary steps to ensure that residents are protected from subsequent episodes of abuse while a determination on the matter was pending. If an incident involves resident-on resident contact, both residents should be evaluated for a change in condition. The resident care plan should be updated as appropriate. Upon receipt of an allegation of abuse the administrator or their designee, should conduct a confidential internal investigation of the incident. The investigation should include interviews with potential witnesses, which may include the alleged perpetrator, the alleged victim, associates, other residents and visitors to the community. The administrator should maintain a written record of the investigation. A summary of interviews should be prepared by the administration or designee, including the date, time, name of person being questioned and impartial report of the facts. A report with the investigation of findings should be made available for review by the Colorado Department of Health and Environment no later than five working days of the allegation. The legal representative should be notified within 24 hours of the alleged abuse and the practitioner for the resident should be notified as soon as practicable. If there is reason to believe that an incident constitutes abuse, the administrator should report the allegation within 24 hours of discovery. In incidents of sexual abuse a plan should be developed as soon as practicable and implement to protect the suspected victim. 2. Resident #6 was admitted to the residence on 4/10/17, with diagnoses including Alzheimer's disease and history of falling. A progress note, dated 10/28/22, read in part: (Resident #6) was found by female (Resident #11's) son ...in ...apartment in her bed with her. The son of (Resident #11) called for staff to come. (Resident #11) was noted crying (when staff entered the) apartment. (Resident #6) was wearing a shirt and had his pants (were) down. (Resident #11's) shirt was off and her pants slightly down. (Resident #6) had his hand in her groin area. (Resident #6) was immediately removed from the apartment. Upon being escorted (Resident #6) had stated to staff, "don't let anyone see me ..." (Resident #11) was in distress and stated he (touched her) places on her body and she screamed." A progress note, dated 11/4/22, read in part: " an (unidentified) female resident just reported that (Resident #6) came into her apartment even when they told him no ... working on getting (Resident #6) a sitter." A progress note, dated 11/27/22, read in part: "staff were alerted that (Resident #6) tr(ied) to put his hands down a female resident's pants at the (dinner) table today, and it was that same female resident that was found in his room, but they were unsure if any activity took place. Staff also reported that (Resident #6) went into a different female resident's room and pulled down his pants. The female resident began to scream and staff were able to intervene and get (Resident #6) out of her room." A care plan for Resident #6, dated 12/12/22, read that Resident #6 had socially inappropriate behaviors, and the residence would administer medications as ordered, and remove triggers including other female residents. On 1/25/23 at 3:23 p.m., Staff #4 stated that Resident #6 had a history of sexual behaviors toward other female residents. Staff #4 stated that she did not know which residents were involved on 11/4 and 11/27/22 incidents. However the staff stated the incident that occurred on 10/28/22 was with Resident #11. On 1/25/23 at 3:45 p.m., the assisted living director (ALD) stated she became aware in the last two weeks that Resident #6 was starting to have more behavioral expressions such as reaching and slapping staff. She stated that after the incident on 10/28/22, Resident #6 had a one to one staff member to ensure the safety of other residents; however she could not recall when the one to one staff ceased. The ALD stated Resident #6 on 12/4/22 had a fall which resulted in a hip fracture and was bed bound; however, she stated that Resident #6 was now ambulatory and could not remember the exact date of when the resident went back to baseline. The ALD stated she had become aware approximately two weeks ago the resident stated exhibiting behavioral expressions such as reaching and slapping a staff. The ALD further stated that both her and the health services director were responsible for conducting all investigations regarding allegations of abuse. She stated the HSD reviewed all progress notes and if there was anything concerning the HSD would report it to her and she would take it to the administrator. The ALD stated she was not made aware of the incident that occurred on 11/27/22 and therefore she did not conduct an investigation; however, the ALD stated she would check to see if an investigation was completed. On 1/25/22 at 4:05 p.m., the HSD stated on 10/28/22 there was an allegation of sexual abuse, she stated the residence completed an investigation and reported an occurrence to the department. The HSD stated on 11/4/22 Resident #6 did go into another resident's room. However, the HSD said she was not sure who the resident was. She stated shortly after that incident the resident had a medication adjustment. The HSD further stated that on 11/27/22 Resident #6 "was getting handsy with a female resident in the dining room and staff redirected" the resident. She stated she was not sure who Resident #6 touched. However, she stated the practitioner for Resident #6 "was notified of sexual behaviors continuing." The HSD stated she was verbally told by the staff about the incident on 11/28/22 and subsequently informed the ALD contrary to what the ALD stated. The HSD confirmed no investigation was conducted as "he just started to touch (the resident) and did not get anywhere." She stated she was not sure if anyone ever "spoke to the resident he was touching" as she was not at the residence when the incident happened. Additionally, the HSD stated she was not aware of any current behavioral expressions by Resident #6. On 1/25/23 at 5:02 p.m., the family member for Resident #6 stated that he was aware of the all the above instances where Resident #6 had sexual encounters with other residents. Resident #6's family stated that the first incident was on 10/28/22. However, the family member stated when Resident #6 fell on 12/4/22 and fractured his hip, it slowed him down. On 1/25/23 at 6:32 p.m., the administrator stated he had just been made aware of the incident that occurred on 11/27/22. He stated regarding the incident which occurred on 11/27/22, there was communication that was missed and there was no investigation completed. However, he stated he did not think the incident was in fact a reportable occurrence. On 1/25/23 at approximately 6:45 p.m., the HSD and the ALD both stated they did not agree with the findings as no abuse occurred. Further the HSD stated Resident #6 never physically touched the other resident therefore no investigation was needed. An email dated 1/27/23 from the occurrences department read the allegation of abuse which occurred on 11/27/22 was a reportable occurrence. According the the residence's policy, the residence failed to ensure:The supervisor reported the incident to the administrator or designee. Upon learning of the supervisor should have attempted to take necessary steps to ensure that residents are protected from subsequent episodes of abuse while a determination on the matter was pending. Failed to ensure the alleged victim should have been evaluated for a change in condition. Conduct a confidential internal investigation of the incident. The investigation should include interviews with potential witnesses, which may include the alleged perpetrator, the alleged victim, associates, other residents and visitors to the community. Maintain a written record of the investigation. A summary of interviews should be prepared by the administrator or designee, including the date, time, name of person being questioned and impartial report of the facts. Retain a report with the investigation of findings should be made available for review by the Colorado Department of Health and Environment no later than five working days of the allegation. Notify within 24 hours of the alleged abuse and the practitioner for the victim should be notified as soon as practicable. The administrator should report the allegation within 24 hours of discovery. In incidents of sexual abuse a plan should be developed as soon as practicable and implement to protect the suspected victim.

Based on observation, record review and interview, the residence failed to ensure qualified medication administration persons (QMAPs) were not permitted to mask medication affecting one sample resident (#5) for 28 of 42 administered doses of a medication. Findings include:1. Reference a. Chapter VII regulations governing assisted living residences, part 2.26, defines ''Medication administration'' as assisting a person in the ingestion, application, inhalation, or, using universal precautions, rectal or vaginal insertion of medication, including prescription drugs, according to the legibly written or printed directions of the attending physician or other authorized practitioner ... (B) Medication administration by a QMAP does not include judgment, evaluation, assessments, or injecting medication (unless otherwise authorized by law in response to an emergent situation.) b .The residence's Medication Administration policy, dated 2/1/22, read in part that all QMAPs were required to operate within their scope such as masking or deceiving administration of medication including, but not limited to, concealing in food or liquid. 2. ObservationOn 1/25/23 at 8:28 a.m., Staff #5 crushed medication for Resident #5 and added the resident's medication to the coffee. Staff #5 gave the coffee masking the medications to Resident #5 and did not state that the resident's medications were in the coffee. 3. Record ReviewResident #5 was admitted to the residence on 6/24/22 with a diagnosis of dementia with behavioral disturbance. A written practitioner's order dated, 12/9/22, directed the residence to administer Seroquel 25 mg twice daily. The practitioner's order further read, "For Seroquel, okay to crush tab and put in food for ease of administration." The January 2023 electronic medication administration record (eMAR) for Resident #5 read in part that Staff #5 administered Seroquel to Resident #5 for the morning dose on 1/1-1/3, 1/7, 1/9-1/11, 1/15, 1/17-1/18, 1/21, 1/23, 1/25 and the evening dose on 1/7/22 for a total of 14 doses. Staff #6 administered Seroquel for the morning dose on 1/8, 1/22, and the evening dose on 1/3-1/5, 1/9-1/12, 1/17-1/19, 1/23-1/24 for a total of 14 doses. Progress notes for Resident #5 read in part:On 12/16/22, Staff #7 administered medications to Resident #5 by adding it to the resident's tea. On 1/2/23, Staff #6 offered coffee or lemonade for staff to mix in medications to Resident #5; however, the resident refused. On 1/3/23, Staff #6 administered medications that were crushed and mixed into mashed potatoes to Resident #5. On 1/6/23, Resident #5 refused to take medication three times. The resident stated there was nothing wrong with her and did not need any medication. 4. InterviewsOn 1/25/23 at 7:39 a.m., Staff #5 stated that the residence crushed Seroquel and administered the medication in coffee or another drink without identifying the medication to Resident #5. She stated that she crushed the medication for Resident #5 and added it to the resident's coffee without the resident's knowledge during each medication administration. She added that when staff identified medication, Resident #5 refused it. On 1/25/23 at 8:26 a.m., Resident #5 stated that she did not take any medications regularly. On 1/25/23 at 5:46 p.m., the health services director stated that Resident #5 had a crush order for Seroquel; however, staff were required to identify the medication when they added it to the resident's drink. She added that she was made aware that staff were not identifying the medication on the date of the onsite visit. On 1/25/23 at approximately 6:00 p.m., Staff #6 stated that he crushed Seroquel and added the medication to coffee or another drink for Resident #5 without her knowledge. He added that he expressed concerns to an unidentified nurse that the practice of not identifying medication was masking; however, he was told it was not. He stated that Resident #5 refused Seroquel unless it was masked in a drink. On1/25/23 at approximately 6:30 p.m., the administrator stated that the residence's policy was to identify all medications to the resident upon administration when the medications were crushed and in food or a drink. He added that if he had been aware of residence staff masking medications when administering them to Resident #5, he would have stopped the practice.

Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting six of ten sample residents (#1,#5-#9). (Cross-reference 0514)Findings include: 1. References and Residence Policya. According to the Mayo Clinic Macrobid should be taken as prescribed by the practitioner. If a dose is missed it should be taken as soon as possible. If it is almost time for the next scheduled dose, skip the dose and go back to your regular dosing schedule. Mayo Clinic 2023, retrieved from https://www.mayoclinic.org/drugs-supplements/nitrofurantoin-oral-route/proper-use/drg-20065102b. The residences' medication policy, dated 2/1/22, read in part: "(the residence) will ensure that each resident receives proper administration and monitoring of medications by complying with all federal and state laws and regulations related to the ...administration of medication."2. Resident #9 was admitted to the residence on 1/3/19, with diagnoses including Alzheimer's disease, anemia, hyperlipidemia, hypertension, and heart disease.a. GabapentinA written practitioner's order, dated 2/22/21, directed the residence to administer gabapentin 100 mg three times daily. However, the December 2022 and January 2023 electronic medication administration records (eMARs) for Resident #9 read that gabapentin was not administered on 12/12 for the evening dose, and on 12/13/22 in the morning and afternoon doses, for a total of three missed doses. A progress note, dated 12/12/22, read in part: "medication (would) arrive later tonight."A progress note, dated 12/13/22, read in part: "pharmacy issues."3. Resident #8 was admitted to the residence on 7/11/21, with diagnoses including dementia, primary hypertension, hyperlipidemia, and atrial fibrillation.a. SeroquelA written practitioner's order, dated 9/28/22, directed the residence to administer Seroquel 25 mg three times daily. However, the December 2022 and January 2023 eMARs for Resident #8 read that Seroquel was not administered on 1/6/23 in the morning and afternoon, for a total of two missed doses. A progress note, dated 1/6/23, read in part: "medication not available."b. EliquisA written practitioner's order, dated 11/1/22, directed the residence to administer Eliquis 2.5 mg two times daily. However, the December 2022 and January 2023 eMARs for Resident #8 read Eliquis was not administered on 1/1/23 in the morning, for a total of one missed dose. A progress note, dated 1/1/23, read in part: "waiting on the pharmacy."4. Resident #6 was admitted to the residence on 4/10/17, with diagnoses including Alzheimer's disease, macular degeneration, and a history of falling.a. Citalopram hydrobromideA written practitioner's order, dated 9/7/22, directed the residence to administer citalopram hydrobromide 20 mg once every evening. However, the January 2023 eMAR for Resident #6 read citalopram hydrobromide was not administered on 1/22/23 for a total of one missed dose. A progress note, dated 1/22/23, read in part: "staff called (pharmacy), they said medication (would) arrive on Monday."5. Resident #7 was admitted to the residence on 1/10/20, with diagnoses including hyperlipidemia and dementia.a. AcetaminophenA written practitioner's order, dated 10/6/22, directed the residence to administer acetaminophen 500 mg two times daily. However, the December 2022 and January 2023 eMARs for Resident #7 read acetaminophen was not administered on 12/27/22 in the afternoon, for a total of one missed dose. On 1/25/23 at 4:32 p.m., the health services director (HSD), stated that qualified medication administration persons (QMAPs) were in charge of ordering missed medication for all residents. The HSD stated that the medications with just one missed medication were likely due to QMAPs not looking hard enough in the cart to find the medications. The HSD acknowledged that medications should have been administered in accordance with practitioner orders. 6. Resident #1 was admitted to the residence on 1/15/21 with diagnoses including unspecified atrial fibrillation, hypertension, bradycardia, ventricular tachycardia and dementia.a. Potassium ChlorideA written practitioner's order, dated 11/29/22, directed the residence to administer potassium chloride extended release 20 mEq once daily. However, the January 2023 eMAR read the medication was not administered on 1/2/23 for a total of one missed dose. b. RisperdalA written practitioner's order, dated 12/21/22, directed the residence to administer Risperdal 1 mg once daily in the morning. However, the January 2023 eMAR read the medication was not administered on 1/5/23 as the medication was not available, for a total of one missed dose. A progress note, dated 1/5/23, read in part that the medication was out of stock and external hospice was notified about the refill. 7. Resident # 5 was admitted to the residence on 6/24/22, with a diagnosis of dementia.a. SeroquelA written practitioner's order, dated 1/9/23, directed the residence to administer Seroquel 25 mg twice daily. However, the January 2023 eMAR read the medication was not administered on 1/21/23 as the medication was not available, for a total of one missed dose. On 1/25/23 at 3:45 p.m., the assisted living director (ALD) stated that she pulled a medication report weekly and then gave the report to the HSD to investigate the errors. On 1/25/23 at 6:32 p.m., the administrator stated the residence was not on a cycle fill for medications. He stated the QMAPs were currently ordering all refills and he expected them to request the refill five days prior to running out.

A licensure revisit was completed on 1/27/23 for all previous deficiencies cited on 4/27/22. The residence is in compliance with all regulations surveyed.