Beehive Homes of Pagosa Springs

A licensure complaint, prompted by #CO39411, was completed on 3/11/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure the resident' s medication administration record (MAR) contained accurate information, affecting two of two sample residents (#1, #2) and one former resident (#3).Findings include:1. Record ReviewFormer Resident #3 was admitted to the residence on 2/15/22 with a diagnosis of repeated falls, cerebrovascular disease, and dementia due to another medical condition which was behavioral disturbance.A written practitioner' s order dated 8/13/24 directed the residence to administer quetiapine 25 mg at bedtime, however, the January 2025 MAR revealed a blank space at the time of administration on 1/1, 1/2, 1/7-1/9/.. Based on record review and interview the residence failed to be responsible for the coordination of resident care services with known external service providers (ESPs), affecting one former resident (#3). (Cross-reference S1180, S1568)Specifically, Former Resident #3 was admitted to the residence on 2/15/22 with a diagnosis of repeated falls, cerebrovascular disease, and dementia due to another medical condition which was behavioral disturbance. Former Resident #3 fell on 1/27/25 which resulted in requiring emergency services. The emergency department discharge paperwork dated 1/28/25 read in part, "Former Resident #3 had a diagnosis of dementia and a compression fracture .. Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of two sample residents (#2) and one former resident (#3). (Cross-reference S1160) Findings include:1. Record ReviewFormer Resident #3 was admitted to the residence on 2/15/22 with a diagnosis of repeated falls, cerebrovascular disease, and dementia due to another medical condition which was behavioral disturbance. A written practitioner' s order dated 2/8/25 directed the residence to administer lorazepam 0.5 mL by mouth at bedtime. However, the February 2025 medication administration record (MAR) for For.. Based on record review and interview, the residence failed to maintain a fall management program which included detailing in each resident' s care plan the individualized approaches necessary to address fall risks, affecting one of two sample residents (#1) and one former resident (#3).Specifically, Former Resident #3 was admitted to the residence on 2/15/22 with diagnoses including repeated falls, cerebrovascular disease, and dementia due to another medical condition which was behavioral disturbance. Record review revealed the former resident fell on 10/22/24, 11/2/24, and 1/27/25 in which all three falls resulted in injuries such as losing consciousness, hip pain, bump on the head, an.. 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 7.6.8 The administrator, or individual appointed as an interim administrator, shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (A) Managing the day-to-day delivery of services to ensure residents receive the care that is described in the resident agreement, the comprehensive resident assessment, and the resident care plan;(B) Organizing and directing the assis..

A revisit survey was completed on 12/17/24 for all previous deficiencies cited on 9/18/24. 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 was completed on 09/18/24. A deficiency was cited. Based on interview and record review, the residence failed to ensure there was at least one staff member on-site at all times with current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization, affecting 10 current residents.Findings include:1. Record ReviewOn 9/18/24 at approximately 11:30 a.m., CPR certifications were provided. However, the CPR certifications revealed the administrator, Staff #1 and Staff #2 did not have certification from a nationally recognized organization.The August 2024 and September 2024 staff schedules revealed the residence did not ensure there was at least one staff member with current CPR certification from a nationally recognized organization for 71 shifts.2. InterviewOn 9/18/24, at 12:30 p.m., the administrator stated that he only had two CPR-trained staff members. Furthermore, he indicated that he was aware he needed to have at least one staff member with current CPR certification from a nationally recognized organization. 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 7.12.13 An assisted living residence shall not use restraints of any kind or deprive a resident of his or her liberty for purposes of care or safety.

A revisit survey was completed on 5/14/24 for all previous deficiencies cited on 8/9/23. 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

PLEASE NOTE: The emergency rules regarding COVID-19 Vaccination were suspended effective 7/14/22. As such, a revisit could not be conducted for this event to determine compliance with the cited deficiencies.

A licensure revisit was completed on 8/9/23 for all previous deficiencies cited on 2/9/22. A deficiency was cited. Based on interviews and record review, the residence failed to update the comprehensive assessment whenever the resident' s condition changed from baseline status, affecting two of five sample residents (#7 and #8). This deficiency was cited previously during a state licensure survey on 2/9/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with regulatory requirements. Findings include: 1. Residence Policies and Referencea. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(A) Information from the comprehensive pre-admission assessment described in Part 11.1;(B) Information regarding the resident ' s overall health and physical functioning ability;(J) History and circumstances of recent falls and any known approaches to prevent future falls;(K) Safety awareness.b. The residence' s undated Resident Assessment Policy, read: "The nursing assessments will be performed every six months by a registered nurse or as needed based on significant change in condition."c. The residence' s undated Resident Agreement, read in part: "Should a resident' s condition change significantly, a licensed health-care professional must conduct a re-assessment of the resident' s needs."2. Resident #8 was admitted to the re.. 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