Argyle, the

A licensure complaint, prompted by #CO41607 was completed on 2/12/26. Deficiencies were cited. Based on observation, interview, and record review, the residence failed to require all staff certified in cardiopulmonary resuscitation (CPR) to provide CPR services promptly in accordance with their training, affecting 125 current residents. (Cross-reference U2722)Specifically, Former Resident #1 was admitted to the residence on 8/18/22 with a diagnosis of hypertension. On 1/6/26 at 8:37 p.m., Former Resident #1 had gone out to the unmonitored designated smoking area. Approximately two minutes later, the resident had begun to slump over in his wheelchair, and he fell out of the wheelchair onto his head. The former resident had been on the ground for approximately eight minutes with no staff present before another resident found him and obtained staff assistance. Former Staff #3 and Staff #5 went outside to the designated smoking area to evaluate Former Resident #1. Former Staff #3 was unaware of how to respond and called for staff assistance while Staff #5 telephoned Emergency Medical Services (EMS). After receiving Former Staff #3' s call for assistance, Staff #4 and #6 responded, and Staff #5 asked they move Former Resident #1 out of the rocks. After moving the former resident, Staff #4 and #6 asked about the former resident' s advance directive. Former Staff #3 was unaware of where to locate an advance directive, and Staff #5 had not confir.. Based on observations, record review, and interviews, the residence failed to ensure the outdoor smoking area was monitored when residents were present, affecting 125 current residents. (Cross-reference U0740)Findings Include:The residence' s undated "Smoking" policy, had no mention of the DSA being monitored by staff when residents were present. Observations of the designated smoking area (DSA) on 2/12/26 from approximately 7:45 a.m. to 4:15 p.m. revealed as follows:Two different residents were observed smoking. No staff were present during both times. On 2/12/26 at approximately 10:00 a.m., Staff #1 and Staff #2 stated they had never been told they needed to monitor residents when residents were present in the DSA. They stated they had never done so. On 2/12/26 at approximately 10:30 a.m., the administrator confirmed that no official process was in place to monitor the DSA. He stated he was not aware of the state regulation, and confirmed the residence did not monitor the DSA. He added he did not have enough staff to monitor the DSA.

A licensure complaint, prompted by #CO41454, #CO41455, and #CO41456, was completed on 2/4/26. A deficiency was cited. Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration for one of four sample residents whose medications were reviewed (#27). Findings include:1. Record reviewResident #27 was admitted to the residence on 10/13/25, with diagnoses including epilepsy and hypothyroidism.A signed practitioner' s order, dated 9/17/25, instructed the residence to administer hydralazine oral tablets 100 mg three times a day. The December 2025 and January 2026 medication administration record (MAR) read hydralazine oral tablets were to be administered to Resident #27 daily at 6:00 a.m., 2:00 p.m., and 8:00 p.m.The December 2025 MAR read in part: Resident #27 was not administered hydralazine oral tablets at 2:00 p.m. on 11 of 31 days in December of 2025, only receiving two of the three doses, because she [Resident #27] was absent from the home without medication.The January 2026 MAR read in part: Resident #27 was not administered hydralazine oral tablets at 2:00 p.m. on 10 of 31 days in January of 2026, only receiving two of the three doses, because she [Resident #27] was absent from the home without medication.2. InterviewsOn 2/4/26 at 3:30 p.m., the clinical manager said Resident #27 went to dialysis three days a week and was not administered the 2:00 p.m. dose of hydralazine on those days she was absent from the residence. The clinical manager said the residence was not following the practitioner' s order for the medication consistently due to Resident #27 only receiving two of the scheduled three doses of hydralazine on dialysis days. The clinical manager said she had contacted the practitioner to discuss missing doses on dialysis days, but was not able to provide documentation.On 2/4/26 at approximately 4:00 p.m., the administrator said he [administrator] was not in agreement that the residence was not following practitioner orders; however, acknowledged the residence could document conversations with the practitioner better about changing the order. Th..

A complaint revisit was completed on 2/4/26 for all previous deficiencies cited on 5/8/25. A deficiency was cited.The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/25. Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration for one of four sample residents whose medications were reviewed (#27). This deficiency was cited previously during a state licensure survey 5/8/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Record reviewResident #27 was admitted to the residence on 10/13/25, with diagnoses including epilepsy and hypothyroidism.A signed practitioner' s order, dated 9/17/25, instructed the residence to administer hydralazine oral tablets 100 mg three times a day. The December 2025 and January 2026 medication administration record (MAR) read hydralazine oral tablets were to be administered to Resident #27 daily at 6:00 a.m., 2:00 p.m., and 8:00 p.m.The December 2025 MAR read in part: Resident #27 was not administered hydralazine oral tablets at 2:00 p.m. on 11 of 31 days in December of 2025, only receiving two of the three doses, because she [Resident #27] was absent from the home without medication.The January 2026 MAR read in part: Resident #27 was not administered hydralazine oral tablets at 2:00 p.m. on 10 of 31 days in January of 2026, only receiving two of the three doses, because she [Resident #27] was absent from the home without medication.2. InterviewsOn 2/4/26 at 3:30 p.m., the clinical manager said Resident #27 went to dialysis three days a week and was not administered the 2:00 p.m. dose of hydralazine on those days she was absent from the residence. The clinical manager said the residence was not following the practitioner' s order for the medication consistently due to Resident #27 only receiving two of the scheduled three doses of hydralazine on dialysis days. The clinical manager said she had contacted the practitioner to discuss missing doses on dialysis days, but was not able to provide documentation.On 2/4/26 at approximately 4:00 p.m., the administrator s..

A complaint survey, prompted by #CO40918, #CO40324 and #CO40250, was completed on 9/11/25.A deficiency was cited. Based on observation, interview and record review, the residence failed to ensure qualified medication administration personnel (QMAP) did not pre-pour medication, affecting four of four sample residents (#29-#31 and #33).Observation and interviewOn 9/11/25 at 8:26 a.m., a drawer within a portable work station contained a stack of three small, clear cups, labeled with various numbers on them. Each cup contained one medication each. Staff #9, who was utilizing the work station for med pass, said the cups contained medications for residents with correlating room numbers Resident' s (#29, #30 and #31). Staff #9 said he had pre-poured medications because he was running behind on med pass. Staff #9 said pre-pouring medication was not allowed. On 9/11/25 at 3:30 p.m., the executive director (ED) said it was not acceptable for QMAPS to pre-pour any medications and that staff were aware. Similar deficient practice was found for Resident #33.

A licensure complaint, prompted by #CO38225 and #CO40011, was completed on 5/8/25. Deficiencies were cited. Based on interview and record review the residence failed to comply with practitioner' s orders, affecting six of six sample residents for whom medications were reviewed (#2, #12, #16, #17, #20, and #21). (Cross-Reference T1110, T1142, T1604, B0710)Specifically, a practitioner' s order for Resident #12, dated 1/17/25, directed the residence to a.. Based on interview and record review the residence failed to ensure residents' comprehensive assessment included information regarding the resident' s overall health and physical functioning ability, reactions to the environment and others, safety awareness and the types of physical, mental, and social support required by the resident, affecting se.. Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records, affecting six of six sample residents for whom medications were reviewed (#2, #12, #16, #17, #20, and #21). (Cross-Reference T1568)Findings include:On 5/6/25-5/8/25, during.. Based on interview and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident. Further, the residence failed to ensure that the residents' records contained practitioner orders and documentation provided by external service providers (ESP), affe.. Based on record review and interview, the residence failed to either directly or indirectly, through a resident agreement, provide personal services sufficient to meet the needs of the resident, affecting one sample resident (#20) (Cross-reference T1142 and T1568)Specifically, the residence identified through assessments that Resident #20 requir.. Based on record review and interview, the residence failed to ensure that residents' practitioner was promptly notified of a residents' pattern of refusal; or a resident' s repetitive request for and use of pro nata (PRN) medication, affecting three of six sample residents for whom medications were reviewed (#2, #17, and #21). (Cross-reference T1142, T156.. Based on record review and interview, the residence failed to evaluate a resident transferred to another healthcare entity prior to re-admission, affecting three of three sample residents who were transferred to another healthcare entity and then re-admitted to the residence (#2, #18, and #31). (Cross-reference B0710, T1568, T2230) Findings incl.. Based upon interview and record review, the residence failed to ensure new orders from an authorized practitioner were obtained when three of six sample resident (#2, #18, #21) returned to the residence after an inpatient hospitalization. (Cross-reference T1068 and T1568).Findings include:Resident #2 was admitted to the residence on 2/.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.11 Only medication that has been ordered by an authorized practitioner shall be prepare..

A relicensure survey with complaint revisit was completed on 5/8/25 for the previous deficiencies cited on 9/24/24. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter 7 was implemented on 3/17/25. Based on interview and record review the residence failed to ensure residents' comprehensive assessment included information regarding the resident' s overall health and physical functioning ability, reactions to the environment and others, safety awareness and the types of physical, mental, and social support required by the resident, affecting seven of eight sample residents (#2, #12, #16-#20). (Cross-reference T1068, T1110, T1568, T1433).This deficiency was cited previously during a state licensure survey on 9/24/24. Although the residence corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:The residence' s undated Resident Assessment Policy read in part that the residence completed a comprehensive assessment annually, or when a resident had a change in condition.Resident #12 was admitted to the residence on 6/3/19 with diagnoses including unspecified pain in the hip and neuropathy. Progress notes, dated 3/8/25-4/25/25, read in part:On 3/8, a representative from the resident' s practitioner' s office reported the resident experienced increased pain between 2:00 a.m. and 4:00 a.m., and asked the residence if they were administering medications correctly. On 4/25, the resident experienced pain that woke him.The most recent comprehensive assessment, dated 4/17/24, contained no information regarding the resident' s history of pain other than his most recent pain level, dated 3/29/22, which was a six on an undisclosed scale. 3. InterviewsOn 5/6/25 at 9:28 a.m., the assistant administrator (AA) stated that the former health and wellness director (HWD) completed most assessments. She stated that the residence became aware in mid-April 2025 of multiple failures by the former HWD, and she no longer worked at the residence. The AA stated that the former HWD failed to address Resident #12' s uncontrolled pain. In a later interview, on 5/8/25 at 10:06 a.m., the AA stated that the residence was required to ensure all assessments contained all of th..