Continuing Care at Wind Crest

A revisit survey was completed on 1/22/25 for all previous deficiencies cited on 12/11/24. 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 complaint #CO38060, in response to an application to increase bed capacity was completed on 12/11/24. The bed capacity was increased from 108 to 272. A deficiency was cited. Based on record review and interview, the residence failed to complete a pre-admission assessment to determine the appropriateness and need for secure environment residency with the required elements, affecting six of six sample residents (#1-#6) who resided in the secure environment. Findings include:Residents #1-#6 each had documents titled Secured Neighborhood Physician Acknowledgment Forms in the records. The forms only included current diagnoses and practitioner' s signature and date. There was no information that described the residents medical condition, cognitive deficits that contributed to wandering, compromised safety awareness and other types of conduct. Additionally, the forms did not include detailed information from the resident' s family concerning relevant history and patterns of reduced safety awareness and wandering, along with strategies used to prevent unsafe wandering or successful exiting.On 12/11/24 at approximately 12:00 p.m., the administrator acknowledged the pre-admission assessments for Resident #1-#6 did not meet the regulation, as required. 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 7.7.3 If the assisted living residence becomes aware of information that indicates a current administrator, individual appointed as an interim administrator, staff member, or volunteer could pose a risk to the health, safety, and welfare of the residents and/or that such individual is not of good, moral, and responsible character, the assisted living residence shall request an updated criminal history and adult protective services record check for such individual from the CBI and/or other relevant law enforcement agency. 10.6 Each assisted living residence' s emergency policies shall address, at a minimum, all of the following items: I. In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies.

A revisit survey was completed on 2/14/24 for all previous deficiencies cited on 11/9/23. 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

A revisit survey was completed on 11/9/23 for all previous deficiencies cited on 5/24/23. A deficiency was cited. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of five sample residents (#1, #2, #11) whose medications were reviewed.Findings include:1. Residence PolicyThe residence' s Medication Administration policy, dated October 2023, read in part, "Medication management ... will include ordering ... and safe administration of residents' medications by authorized staff consistent with state requirements."2. Resident #2 was admitted to the residence on 11/7/19.a. Lidocaine patchA written practitioner' s order, dated 10/2/23, directed the residence to administer lidocaine 4% topical patch one daily and remove in the evening. However, the October 2023 electronic medication administration record (eMAR), read lidocaine was unavailable and was not administered on 10/2-10/4/23, for a total of three missed doses. b. BupropionA written practitioner' s order, dated 10/2/23, directed the residence to administer bupropion 150 mg twice daily. However, the October 2023 eMAR, read bupropion was unavailable and was not administered on 10/17/23 in the evening, for a total of one missed dose. On 11/9/23 at approximately 4:40 p.m., the assistant director of nursing (ADON) stated Resident #2' s lidocaine and bupropion are ordered by Resident #2' s external hospice provide.. 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 #CO28335, #CO30156, #CO30286, #CO32151 was completed on 5/24/23. Deficiencies were cited. Based on interview and observation, the residence failed to ensure resident records contained progress notes as well as documentation regarding any out of the ordinary event, affecting one of nine sample residents (#1).Findings include:Resident #1 was admitted to the residence on 10/13/22 with diagnosis including chronic urinary tract infections (UTI).Hospital discharge paperwork, dated 3/30/23, revealed the residence was admitted to the hospital for a UTI on 3/28-3/30/23 then discharged to a skilled nursing facility for physical therapy rehabilitation.A sticky note, .. Based on interview and record review, the residence failed to comply with authorized practitioner orders, affecting three of five sample residents (#1, #2, #4).Findings include:1. Residence policy The residence' s Medication Administration policy, dated May 2021, read in part that the residence would comply with practitioner orders.2. Resident #4 was admitted to the residence on 4/10/22 with diagnoses including atrial fibrillation.a. EliquisA written practitioner order, dated 3/29/23, directed the residence to administer Eliquis 5 mg twice daily. However, a progres.. Based on interview and record review, the residence failed to ensure personnel files were readily available onsite for department review, for two of three staff (#2, #3), affecting nine of nine sample residents (#1-#9).Findings include:1. ReferencesChapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff' does not include individuals providing external services, as defined herein.Chapter VII regulations governing assisted living.. Based on interview and record review, the residence failed to ensure residents were free of neglect and failed to ensure residents were treated with dignity and respect, affecting four of nine sample residents (#6-#9) and one Former Resident (#10).Findings include:1. Residence policy and referencesa. The residence' s Resident Rights policy, dated June 2021, read in part, residents would be free from neglect and treated with dignity and respect.b. Chapter VII regulations governing assisted living residences, part 2.7, defined "At-risk person" as any person who is 70 years of.. Based on interview and record review, the residence failed to have a roster of current residents that included their emergency contact information, along with a residence diagram showing room locations, affecting 90 current residents. Findings include:On 5/23/23 at approximately 8:00 a.m. the resident roster was requested and provided. However, the resident roster did not include the residents' emergency contact information, along with a residence diagram showing room locations.On 5/24/23 at approximately 1:09 p.m., the administrator stated she was not sure .. 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 7.14.7 The assisted living residence shall ensure that each resident receives proper administration and/or monitoring of medications.