Arbors of San Marino

A licensure complaint, prompted by #CO41075, #CO41225, #CO41238, and #CO41239, was completed on 1/6/26. Deficiencies were cited. Based on record review and interview, the residence failed to comply with the authorized practitioner' s orders associated with medication administration, affecting one of seven sample residents (#3).Findings include:1. Resident #3 was admitted to the residence on 12/31/21.a. AcetaminophenA written practitioner' s order dated 11/1/25 directed the residence to administer two 500mg tablets orally three times per day; however, the December 2025 medication .. Based on record review and interview, the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting one of seven sample residents (#1). Findings include:1. Resident #1 was admitted to the residence on 4/28/22.The September 2025 medication administration record (MAR) read the following medications were being administered with no signed and dated practitioner' s orders .. Based on record review and interviews, the residence failed to implement policies and procedures to establish a fall management program, specifically providing staff training related to fall prevention affecting 61 current residents.Findings Include:1. Record ReviewThe residence' s undated fall management policy, read in part, staff will be educated and trained on fall prevention strategies, proper response following a fall, and implementation of individua.. Based on records review and interview, the residence failed to ensure that two qualified medication administration persons (QMAPs) jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time the count occurred, for three of eight residents (#1-#3) who resided in the secure environment. Findings Include:A review of the controlled substance shift count sheets from 8/1/25 to 1/2/25 reveale.. Based on records review and interview, the residence failed to ensure the qualified medication administration person (QMAP) supervisor conducted a competency assessment with direct observation of all medication administration tasks that the QMAP will be assigned to perform, before initial assignment for one of six sample staff (#5) were scheduled as QMAP for 18 of 31 days in October.Findings Include:A review of the October 2025 staff schedule revealed that Staff #.. Based on records review and interviews, the residence failed to ensure staff accurately documented each medication administration event at the time the event was completed, affecting three of seven sample residents (#1-#3).Findings include1. Record ReviewResident #1 was admitted to the residence on 4/28/22.a. Hydrocodone-ACET A written practitioner' s order dated 6/16/25, directed the residence to administer one 5/325mg tablet by mouth twice a day. .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.(U0910) 10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments, and emergency contact information, along with a facility diagram showing..

A licensure complaint, prompted by #CO40594, #CO40925 and CO40966, was completed on 9/23/25. A deficiency was cited. Based on interview and record review the residence failed to make available, either directly or indirectly through a resident agreement, protective oversight included but not limited to, taking appropriate measures when confronted with an unanticipated situation or event involving one or more residents and the identification of urgent issues or concerns that require an immediate individualized approach, affecting one of one sample resident (#45). Specifically, Resident #45 had participated in a fire drill on the afternoon of 8/27/25. Resident #45 was assisted to the bridge between the assisted living and independent living, which was the designated fire drill area for all residents located on the second floor. After the fire drill had been completed, staff members had assisted residents back to their rooms; however, Resident #45 was left unattended in her wheelchair near a decline. Resident #45 was found on the floor against the wall of the decline with skin tears to her hands and an abrasion on her head.Findings include: Resident #45 was admitted to the residence on 7/31/21 with a diagnosis consistent with hypothyroidism and Orthostatic Hypotension.A progress note dated 8/27/25 read in pertinent part, Resident #45 was found on the floor of the bridge to the independent and assisted living after a fire drill on her left side. Resident #45 fell forward, noted abrasions to the left forehead and knuckles of both hands. Bruising to the left side of her forehead with some swelling and a skin tear with flap formation above her elbow. An outside provider note dated 8/27/25 read in pertinent part, Resident #45 had a fall, contusions to the forehead, abrasions, and a skin tear to the forehead. Wound orders obtained and completed. On 9/23/25 at approximately 11:30 a.m., during an environmental tour, the area where Resident #45 had fallen as a transitional ramp connecting two hallways together with different floor elevations. The decline was noticeably continuous without a clear landing or break point, the slope behind immediately after a transition strip an..

A licensure complaint revisit was completed on 4/21/25 for the previous deficiencies cited on 7/26/22. Deficiencies were cited. Based on interview and record review, the residence failed to establish a fall management program which included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting two sample residents who sustained injuries from falls (#38 and #39). (Cross-reference S1146)Specifically, resident #39 had 10 falls in four months, most had resulted in injury that included bumps, bruises along with hitting her head. The residence failed to update Resident #39' s care plan to include individualized approaches necessary to address the resident' s fall risk after each fall. The most updated care plan dated, 4/10/25 had no fall interventions added since 2/11/25, which read, "reminded resident #39 not to walk backwards". The care plan was only updated for the care staff to perform safety checks more often. The care staff were not aware of the fall risks for Resident #39. Specifically, Resident #38 had documented falls on 4/3, 4/16 and 4/20/25. The resi.. Based on interview and record review, the residence failed to update comprehensive assessments whenever a resident' s condition changed from baseline status, affecting two of six sample residents (#38 and #39).This deficiency was cited previously during a state licensure survey on 7/26/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: Resident #39 was admitted to the residence on 5/31/23 with a diagnosis of Parkinson' s. The most recent assessment for Resident #39 dated 8/8/24 was not updated after a change in condition after the resident sustained multiple falls since 1/22/25, most of which resulted in injury. A progress note, dated 1/22/25, read in part: Resident #39 had an unwitnessed fall in her room where she struck her head and sustained a large plump sized lump, found to her upper mid back and scalp. The resident was sent to the emergency department (ED) for evaluation. A pr.. 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 was completed on 4/21/25. Deficiencies were cited. 9999 INFORMATIONAL ADVISMENTTHIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7."12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the reside.. Based on interview and record review, the residence failed to ensure each staff member completed training relevant to their specific duties and responsibilities prior to working independently, affecting 75 current residents. (Cross-reference S1146, S1180)Findings include:On 4/21/24 at approximately 2:15 p.m., Staff # 14 and Staff #15 were observed working with Resident #39. A review of Staff #14 and #15' s personnel files revealed no evidence of training .. Based on interview and record review, the residence failed to establish a fall management program which included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting two sample residents who sustained injuries from falls (#38 and #39). (Cross-reference S648, S1146)Specifically, resident #39 had 10 falls in four months, most had resulted in injury that included bumps, b.. Based on interview and record review, the residence failed to update comprehensive assessments whenever a resident' s condition changed from baseline status, affecting two of six sample residents (#38 and #39).Findings include: Resident #39 was admitted to the residence on 5/31/23 with a diagnosis of Parkinson' s. The most recent assessment for Resident #39 dated 8/8/24 was not updated after a change in condition after the resident sustained .. Based on observation and interview, the residence failed to ensure the residence grounds were maintained to protect residents from slopes and hazards, affecting 75 current residents. Findings include:On 4/21/25 at approximately 7:00 a.m., 7:42 a.m., 12:00 p.m., and 2:50 p.m., environmental tours revealed the residence had several walking paths or sidewalks that had ledges and drop-offs as follows: At the entrance of the residence, an area adjace.. Based on record review and interview, the residence failed to develop and follow written policies and procedures to endure the continuation of necessary care to all residents for at least 72 hours immediately following an emergency including, but not limited to, a long power failure, affecting 75 current residents. Findings include: The residents emergency preparedness plan failed to include a detailed documented plan to ensure the continuation of care to all .. Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting 75 current residents.Findings include:The residence' s emergency plan failed to include policies that address a plan that ensures the availability of, or access to, emergency power for essential functions and all residents-required medical devices or auxiliary aids. The emergency ..