Beatrice Hover Assisted Living Residence

A revisit survey was completed on 4/2/25 for all previous deficiencies cited on 9/25/24. The facility is in compliance with all deficiencies that were cited. 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 with complaints #CO31569, #CO37102, and #CO37645 were completed on 9/25/24. Deficiencies were cited. Based on record review and interview, the residence failed to document and implement effective actions that were to be taken by staff to prevent reoccurrence of falls for three of four sample residents (#1, #3, #4) with repeated falls. (Cross-reference S0720)Findings include:The residence' s Lift Assistance policy, dated 12/1/20, read in part that after a resident fell, the residence staff documented the action taken by staff and ongoing efforts to prevent a reoccurrence of the situation in the future. Resident #3 was admitted to the residence on 9/14/22 with a diagnosis of cerebral palsy.A progress note, dated 9/15/24, read in part: "Resident stated she had a fall while getting (incontinence product) for her bed. She was sitting on her bed when (Staff #7) answered her call light. She had a cut to her chin an.. Based on record review and interview, the residence failed to ensure appropriate routine staffing levels considering the acuity and needs of the residents, the services outlined in the care plan, and services set forth in the resident agreement, affecting 49 current residents. (Cross-reference S1192, S1194)Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 8.4, requires that staff shall be sufficient in number to help residents needing or potentially needing assistance, considering individual needs such as the risk of accident, hazards, or other challenging events.b. Chapter VII regulations governing assisted living residences, part 12.9, requires the comprehensive assessment shall be updated for each resident at least annually and whenever the r.. Based on record review and interview, the residence failed to ensure staff were available to evaluate residents who had fallen to determine if the resident could be assisted in a safe manner, such as when the resident had no pain, or there was no change from baseline, affecting two of four sample residents with recurrent falls (#1 and #2). (Cross-reference S0720)Specifically, the residence staff lifted Resident #1 on 8/30/24 after she fell from her bed despite the resident experiencing pain. The resident continued to vocalize pain. Findings include: 1. Residence Policy The residence Lift Assistance policy, dated 12/1/20, read in part that the residence required staff to lift a resident if the resident had no pain and the residence staff was able to lift the resident safely.2. Resident #1 was admitted to t.. 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 7.12.1 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 residents: A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population; 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the followin..