Colorado Springs Senior Homes

A certification complaint, prompted by #CO36715 was completed on 8/6/24. Deficiencies were cited. Based on record review and interview, the residence failed to ensure the residents' right to be treated with dignity and respect, affecting one (#2) of two sample residents.Findings include:1 Residence PolicyThe residence' s undated residence rights policy read in part, "The right to civil and religious liberties, including, the right to be treated with dignity and respect."2. Record ReviewResident #2 was admitted to the residence on 11/3/05 with diagnoses of schizophrenia, seizure disorder, hypothyroidism and depression.A functional assessment and assistance care document dated 9/29/23, indicated that the resident required assistance with activities of daily living (ADLs) such as dressing, grooming, and meals. The document also read, "staff need to remind Resident #2 to use (a) walker and to keep (the) walker close by (to) prevent falls." An investigation report, dated 6/14/24, revealed Resident #2 reported Staff #5 grabbed and hit her, which caused bruises. Resident #2 also reported that Staff #5 did not assist her with her ADLs and refused to provide her with assistance when she fell.3. InterviewsOn 8/6/24 at 1:00 p.m., the administrator confirmed that the residence assessed Resident #2 when bruises were discovered on her arm; she added an investigation was conducted with Staff #5 which resulted in the residence' s decision by to move Staff #5 to a differen.. Findings include:1. Residence PolicyThe right to choice and personal involvement regarding care and services, including:The right to be informed and participate in decision making regarding your care and services, in coordination with family members who may have different opinions;The right to be informed about and formulate advance directives;The right to freedom of choice in selecting a health care service or provider; andThe right to expect the cooperation of the residence in achieving the maximum degree of benefit from services we provide you. If you have limited English proficiency or impairments that inhibit communication, residence will find a way to facilitate communication of care needs.2. Record ReviewResident #1 was admitted to the residence on 12/18/23 with diagnoses of delusions and paranoia, a history of medical treatment noncompliance, and diabetes mellitus II.The resident record for Resident #1 contained a care plan created by the resident' s external service provider.On 8/6/24 at 8:46 a.m., a care plan for Resident #1 was requested. However, the administrator was unable to provide the requested document.3. InterviewOn 8/6/24 at 4:20 p.m., the administrator acknowledged the residence did not maintain a documented care plan of current personal services needs and preferences along with staff tasks necessary to meet R..

A licensure complaint, prompted by #CO36713, was completed on 8/6/24. Deficiencies were cited. Based on interview and record review, the residence failed to maintain a documented care plan of current personal services needs and preferences along with staff tasks necessary to meet the needs of residents, affecting one (#1) of two sample residents whose care plans were reviewed.Findings include:1. Residence PolicyThe right to choice and personal involvement regarding care and services, including:The right to be informed and participate in decision making regarding your care and services, in coordination with family members who may have different opinions;The right to be informed about and formulate advance directives;The right to freedom of choice in selecting a health care service or provider; andThe right to expect the cooperation of the residence in achieving the maximum degree of be.. Based on observation, record review and interview, the residence failed to ensure a comprehensive assessment was completed, documented in writing and kept in the resident' s record, affecting one of two sample residents (#1).Finding include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences in part 12.6 requires that at the time a new resident moves in, the assisted living residence shall complete a comprehensive assessment that reflects information requested and received from the resident, the resident' s representative if requested by the resident, and a practitioner. Information from the comprehensive assessment shall be used to establish an individualized care plan.b. The residence' s Admission and Continued Stay policy, dated 7/1/2.. Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one of two sample residents (#1).Findings include:1. Reference and Residence Policya. According to the Health Facilities and Emergency Medical Services Division Occurrence Reporting Manual (2018), the residence was required to report "Any occurrence involving sexual ... abuse of a patient or resident, as described in section ...18-3-402, 18-3-403, 18-3-404, or 18-3-405 C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility." Section 25-1-124 (2)(d) C.R.S.b. The residence' s Occurrence and Critical Incident Reporting policy, dated 7/1/23, read in part, "In accordance with Colorado regulations, reportable occurrences must be report.. Based on record review and interview, the residence failed to ensure the residents' right to be treated with dignity and respect, affecting one (#2) of two sample residents.Findings include:1 Residence PolicyThe residence' s undated residence rights policy read in part, "The right to civil and religious liberties, including, the right to be treated with dignity and respect."2. Record ReviewResident #2 was admitted to the residence on 11/3/05 with diagnoses of schizophrenia, seizure disorder, hypothyroidism and depression.A functional assessment and assistance care document dated 9/29/23, indicated that the resident required assistance with activities of daily living (ADLs) such as dressing, grooming, and meals. The document also read, "staff need to remind Resident #2 to use (a) walker and to keep (the) ..

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 10/11/23. 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

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 10/11/23. 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

A recertification survey with complaint #CO30402 was completed on 10/11/23. A deficiency was cited.The facility was comprised of four free-standing buildings (#2, #4, #6, #8). Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting three of three sample residents (#1-#3). Findings include:1. Chapter VII regulations governing assisted living residents part 14.11, requires only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.Findings include:a. Residence PolicyThe residence' s medication policy, dated 7/26/23, read in part that the residence did not administer any medications without a valid written order from a practitioner. All medication orders included the date, medication, strength, dosage, frequency, route and a valid written or electronic signature by a physician or other authorized provider.b. Resident #3 was admitted to the residence on 12/15/21.The September and October 2023 medication administration records (MARs) revealed the residence administered medications to Resident #3 as follows:Atorvastatin 10 mg at bedtime on 9/1-9/30 and 10/3-10/7/23Benztropine 1 mg twice daily on 9/1-9/30 and 10/4-10/7/23Miralax 17 gm at bedtime on 9/1, 9/14-9/16, 9/21, 9/27, 10/3, and 10/10/23Metamucil one packet daily on 9/1-9/13, 9/15-10/1, and.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.400.8.495.6(I)(2) 2. Staffing at a facility shall be no less than the following standards:a. A minimum of 1 staff to 10 participants during the daytime.b. A minimum of 1 staff to 16 participants during the nighttime.

A relicensure survey with complaint #CO30401 was completed on 10/11/23. Deficiencies were cited.The residence was comprised of four free-standing buildings (#2, #4, #6, #8). Based on interview and observation, the residence failed to have a current list of all staff who have current first aid and/or cardiopulmonary resuscitation (CPR) certifications, readily available at all times and in a visible location affe.. Based on interview and record review, the administrator and the qualified medication administration person (QMAP) supervisor failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration reco.. Based on interview and record review, the residence failed to ensure that each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event wa.. Based on interview and record review, the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting two of three sample residents (#1, #3). (Cros.. Based on interview and record review, the residence failed to ensure that resident records included progress notes which contained information on resident status and wellbeing, as well as documentation regarding any out of the ord.. Based on interview and record review, the residence failed to ensure that staff members were of good, moral, and responsible character by not obtaining a name-based criminal history report, conducted by the Colorado Bureau of In.. Based on observation and interview, the residence failed to ensure that resident rooms occupied by smokers had fire resistant wastebaskets, affecting 10 of 12 current residents (#2-#4, #6, #9, and #11-#15) identified as smokers.Findin.. Based on observation and interview, the residence failed to post a conspicuous "No Smoking" sign in areas where oxygen was stored and/or used, affecting eight current residents identified as requiring oxygen (#2, #4-#10).Findings .. Based on observation, record review and interview, the residence failed to retain in employee' s personnel files, who were qualified medication administration persons (QMAPs), documentation that the individual' s names appeared on t.. Based on observation, record review, and interview, the residence failed to maintain the residence' s water temperature, which was accessible by residents, at or below 120 degrees Fahrenheit (F) at taps, affecting eight of ei.. Based on record review and interview, the residence failed to ensure applicants complied with Colorado Adult Protective Service Data Systems (CAPS) requirements prior to hiring staff who provided care to the residents, affecti.. 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 a..