Cappella of Grand Junction

A revisit survey was completed on 6/2/23 for all previous deficiencies cited on 12/14/22. No deficiencies 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 licensure complaint, prompted by #CO30510, was completed on 1/5/23. Deficiencies were cited. Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated when the resident' s condition changed from baseline status, affecting two of three sample residents (#1, #3). (Cross-reference Q1180)Findings include: 1. Residence Policy The residence' s Change of Condition policy, dated November 2021, read in part: "Documentation in the medical record will include notifications, new interventions and provided support, assessment findings, resident' s response to changes and residents/families communication." 2. Resident #1 was admitted to the residence on 12/12/19 with a diagnosis of Alzheimer' s disease.Residence incident reports read Resident #1 had falls on 11/11, 12/6, 12/13/22, and 1/1/23. Additionally, the reports read Resident #1 was hospitalized on 12/22/22.Residence progress notes for Resident #1 read as follows: 11/9/22: Resident #1 showed confusion on where he was and staff offered to show resident where his room was 11/11/22: Resident #1 was found laying on floor of bedroom after sliding from bed 11/21/22: Resident #1 asked why he was by the dining room as the resident was unsure why he was there. Staff returned Resident #1 to his apartment. Later that day, the resident had trouble walking down to breakfast. 12/1/22: The resident' s foot hurt and swollen. 12/6/22: Resident #1 .. Based on record review and interview, the residence failed to establish a fall management program that 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 of three sample residents (#1, #3). (Cross-Reference Q1146)Specifically, Resident #1 had falls on 11/11, 12/6, and 12/13/22. The 12/13/22 fall resulted in pain and bruising over the left side of the resident' s body. The residence failed to update the care plan for Resident #1 for the falls on 11/11, 12/6, and 12/13/22 detailing the individualized approach necessary to address fall risks. On 12/27/22 the residence updated the care plan for Resident #1; however, it was not updated after the resident sustained another fall on 1/1/23. Findings include: 1. Residence Policy The residence' s fall management policy, dated December 2021, read in part: "The health and wellness director/assisted living director or designee will investigate the fall with the intention of preventing further falls for the person who fell and for other people who may be in a similar situation. Changes to service plans will be made, as needed." 2. Resident #1 was admitted to the residence on 12/12/19 with a diagnosis of Alzheimer' s disease. Residence incident reports read Resident #1 had falls on 11/11, 12/6, 12/13/22, and 1/1/23. Additionally, t..