Aspen Leaf Assisted Living-Limon 6th Co

A licensure complaint prompted by #CO34780, was completed on 2/15/24. Deficiences were cited. Based on observation, interviews and record review, the residence failed to implement a fall management 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 three of four sample residents who fell (#1 #2, #4) and one former resident (#6). Specifically, former Resident #6 had documented falls on 4/23, twice on 9/3, and 9/4. The residence failed to update former Resident #6' s care plan to include individualized approaches necessary to address the resident' s fall risk since 3/15/23. The fall on 4/23/23 resulted in no injury. Subsequently, former Resident #6 sustained a fall on 9/3/23 at 5:17 a.m., which resulted in a skin tear to the right hand and on 9/3/23 at 10:44 p.m., which resulted in skin tears to the resident' s elbow and both hands. On 9/4/23 the resident sustained another fall without injury; however, on 9/5 and 9/6/23 the resident experienced rib and hip pain and required two person assistance with all transfers. The resident was transported to the hospital and found to have a fractured hip due to the fall on 9/3 or 9/4/24.Findings include:1. Residence policyThe residence' s Fall Management policy, dated 10/2/21, read in part: "the (residence) has developed policies and procedures to establish a fall management program. The program includes &n.. Based on record review and interview, the residence failed to complete a comprehensive assessment that included all required information, affecting two of three sample residents who had unique food and dining preferences or restrictions (#1, #3).Findings include: 1. Resident #1 was admitted to the residence on 1/23/23.An alternate menu read the meal choices were leftovers from a previous meal, a cheese sandwich, peanut butter and jelly sandwich and a choice side with all entrees of vegetable medley, soup du jour (chef' s choice), or regularly scheduled meal sides.A progress note dated 4/10/23 read the resident had dental surgery. A progress note dated 4/11/23, read Resident #1 was in pain that all her teeth were taken out.The residence' s most recent assessment for Resident #1, dated 10/24/23, read the resident had peanut allergies. Under "dietary preferences" Resident #1' s care plan read there were no concerns. On 2/15/24 at 7:15 a.m., Staff #2 stated the owner took grilled cheese off the menu and replaced it with a cheese sandwich due to Resident #1' s frequent requests for grilled cheese. Staff #2 stated she was one of the cooks at the residence and had no problem making grilled cheese as an alternate, and would still do so on occasion since she did not like telling Resident #1 "no." Staff #2 stated Resident #1 did not have orders for a modified diet; ho..

A certification complaint prompted by #CO34781, was completed on 2/15/24. A deficiency was cited. Based on interview and record review, the facility (residence) failed to document in the assessment that the residence was able to support a resident' s needs, affecting two of four sample residents (#1, #3).Findings include: 1. Resident #1 was admitted to the residence on 1/23/23.An alternate menu read the meal choices were leftovers from a previous meal, a cheese sandwich, peanut butter and jelly sandwich and a choice side with all entrees of vegetable medley, soup du jour (chef' s choice), or regularly scheduled meal sides.A progress note dated 4/10/23 read the resident had dental surgery. A progress note dated 4/11/23, read Resident #1 was in pain that all her teeth were taken out.The residence' s most recent assessment for Resident #1, dated 10/24/23, read the resident had peanut allergies. Under "dietary preferences" Resident #1' s care plan read there were no concerns. On 2/15/24 at 7:15 a.m., Staff #2 stated the owner took grilled cheese off the menu and replaced it with a cheese sandwich due to Resident #1' s frequent requests for grilled cheese. Staff #2 stated she was one of the cooks at the residence and had no problem making grilled cheese as an alternate, and would still do so on occasion since she did not like telling Resident #1 "no." Staff #2 stated Resident #1 did not have orders for a modified diet; however, stated she did not have all her teeth and it was easier for her to eat soft foods, and had a strong preference for grilled cheese specifically. On 2/15/24 at 7:24 a.m., Staff #1 stated the last time Resident #1 asked for a grilled cheese sandwich was on 2/14/24, and stated she would frequently ask for grilled cheese when she did not like the meal that was served or had difficulty eating it. On 2/15/24 at 7:29 a.m., Resident #1 stated grilled cheese was one of her favorite foods and was easiest for her to eat out of the foods on the alternate menu, because the bread was flaky and did not stick to her mouth like the cheese sandwich or peanut butter and jelly sandwich did. Resident #1 stated it had been difficult to eat since she had her te..