A Change of Seasons Assisted Living LLC

A certification complaint, prompted by #CO38017, was completed on 11/6/24. A deficiency was cited. Based on record review and interview the residence failed to comply with Chapter 7, Part 11 by not providing a written notice of involuntary discharge, affecting one former member (#4).References:11.17 Written notice of involuntary discharge must include the following: (A) A detailed explanation of the reason or reasons for the discharge, including, at a minimum: (1) Facts and evidence supporting each reason given by the residence, and (2) A recounting of events leading to the involuntary discharge, including interactions with the resident over a period of time prior to the notice and actions taken to avoid discharge, specifying the timing of the events and actions. (B) Statements conveying the following information: (1) That the individual receiving the notice has the right to file a grievance with the residence challenging the involuntary discharge within 14 days of the written notice, regardless of whether the resident has already been removed from the assisted living residence, (2) That if a grievance is filed, the assisted living residence must provide a response to the grievance within five business days, and (3) If the resident or person filing the grievance is dissatisfied with the response, that the resident or person filing the grievance may appeal to the executive director of the Colorado Department of Public Health and Environment or their designee. (C) Names and contact information, including phone numbers, physical addresses, and email addresses, for the state long-term care ombudsman, the designated local ombudsman, and the Colorado Department of Public Health and Environment. (D) If the involuntary discharge is initiated due to a medical or physical condition resulting in a required level of care that cannot be treated with medication or services routinely provided by the residence ' s staff or an external service provider, the notice must also include an assessment by the resident ' s applicable health-care or behavioral health provider of the resident ' s current needs in relation to the resident ' s medical and physical conditi..

A licensure complaint, prompted by #CO38016, was completed on 11/6/24. Deficiencies were cited. Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy which included all required elements, affecting 10 current residents.Findings include:The residence' s involuntary discharge section of the resident agreement failed to include the following required elements:1. The individual designated by the assisted living residence to receive involuntary discharge grievances. 2. The ability of any of the persons in the assisted living residence is required to notify under Part 11.16 to file a grievance challenging the involuntary discharge and reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after the assisted living residence provides written notice of the involuntary discharge. 3. The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence. 4. A requirement that grievances related to involuntary disch.. Based on record review and interview the residence failed to provide a copy of an involuntary discharge notice to the state long-term care ombudsman, affecting one former resident (#4). (Cross-reference S1072)Findings include:Former Resident #4 was admitted to the residence on 8/24/24 with a diagnosis of dementia. A progress note dated 9/17/24 read in part, communication from former Resident #4' s legal representative about an appointment. Former Resident #4 and the legal representative left the residence at 11:30 a.m. The residence did not document anything further for former Resident #4.On 11/6/24 at 12:30 p.m., the administrator stated she did not send a copy of the written involuntary discharge notice to the local or state long-term ombudsman because one was never written. She did explain that she was not aware this was a requirement. Based on record review and interview the residence failed to provide a written notice of involuntary discharge which includes all required elements, affecting one former resident (#4). (Cross-reference S1074)Findings include:Former Resident #4 was admitted to the residence on 8/24/24 with a diagnosis of dementia. A progress note dated 9/17/24 read in part, communication from former Resident #4' s legal representative about an appointment. Former Resident #4 and her legal representative left the residence at 11:30 a.m. The residence did not document anything further for former Resident #4.On 11/6/24 at 8:15 a.m., the administrator stated former Resident #4 only lived at the residence for a few weeks. She also stated the former resident was admitted to the residence with external hospice services to support her for various reasons; especially difficult behaviors, which include but are not limited to physical aggression, verbal aggression, refusal of care and treatment, and urinating and defecating on the floor. The administrator explai..

A relicensure survey was completed on 12/28/23. Deficiencies were cited. Based on record review and interview, the residence failed to ensure medication audits were completed and documented by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting eight current residents.Findings include:On 12/28/23 at 7:45 a.m., the administrator was requested to provide the residence' s quarterly medication cart audits; however, she was unable to provide the documentation. On 12/28/23 at 8:30 a.m., the administrator stated she conducted medication cart audits; however, she had not documented the results of the audits. The administrator confirmed there was no documentation for the medication cart audits. Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents for two of three sample staff (#1, #2), affecting eight current residents. Findings include: 1. References a. According to Colorado Revised Statutes (2020) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult." Justia US Law (2018), 2018 Colorado Revised Statutes Title 26 - Human Services Code Article 3.1 - Protective Services for Adults at Risk of Mistreatment or Self-Neglect Part 1 - Protective Services for At-Risk Adults § 26-3.1-111. Access to CAPS - employme..

A recertification survey was completed on 12/28/23. A deficiency was cited. Based on observation, record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting eight current participants (residents).Findings include: Chapter VII regulations governing assisted living residences, part 14.31, requires the administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence' s Quality Management Program assessment and review. On 12/28/23 at 7:45 a.m., the administrator was requested to provide the residence' s quarterly medication cart audits; however, she was unable to provide the documentation. On 12/28/23 at 8:30 a.m., the administrator stated she conducted medication cart audits; however, she had not documented the results of the audits. The administrator confirmed there was no documentation for the medication cart audits.