Dayspring Villa

A Certification Complaint, prompted by #CO40124 was completed on 5/20/25. Deficiencies were cited. Based on record review and interview, the facility failed to coordinate care and medication administration with external providers affecting one (#1) of five sample members. Findings include:1. Record reviewResident #1 admitted to the facility on 7/14/21 with a diagnosis of type 1 diabetes. The May 2025 medication administration record (MAR) read in part: Start date 8/29/24. Trulicity 1.5 MG/0.5 ML PEN Inject 1.5 mg subcutaneously one time a day weekly related to diabetes. Home health to administer. A progress note, dated 5/6/25, written by the resident care coordinator (RCC) read in part: Home health nurse for Member #1 reported switching home health agencies and provided the RCC with new agency contact information. Progress note, dated 5/13/25, read: Two home health nurses from different home health agencies arrived at the residence to provide Member #1 with his weekly insulin injection. An internal document, dated 5/15/25, read in part: Home health nurse for Member #1 went to the office of the RCC last week, informed the RCC she (nurse) was switching agencies and Member #1 would be switching home health agencies to keep her as his nurse. The RCC reported asking the home health nurse if Member #1 had signed a contract and if a physician' s order was obtained for services and the home health nurse said there was. 2. InterviewOn 5/20/2.. Based on record review and interviews the facility failed to ensure each member care plan identified all external service providers and detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting three (#1, #3 and #4) of five sample members. Findings include:1. Record reviewMember #3 was admitted to the facility on 12/1/2021 with a diagnosis of type 2 diabetes. A referral, dated 9/25/24, to a home health agency read in part: Member #3 was referred for a nursing evaluation and treatment of weekly injection.The May 2025 medication administration record (MAR) read in part: Semaglutide-subcutaneous solution peninjector 2 MG/3ML (Semaglutide). Inject 0.25 mg subcutaneously one time a day every 7 day(s). Home health agency to administer. Start date 9/27/24.2. InterviewOn 5/20/25 at 12:10 pm- ED said member care plans should be individualized, to include, identifying external providers. The ED said she recently became aware of this missing information and care plans were being updated. 3. Similar deficient practice was found for Member' s #1 and #2.

A Licensure Complaint, prompted by #CO40126 was completed on 5/20/25. Deficiencies were cited Based on observation interview and record review, the residence failed to have documentation of on-going services provided by external service providers, affecting five sample residents (#1 - #5). (Cross-reference 14.22)Findings include:On 5/20/25 a list of residents receiving external services identified Resident' s (#1 - #5) were receiving home health services from various agencies. However, the residence had no documentation on-site from the various home health agencies.On 5/20/25 at 10:23 a.m., the executive director (ED) said she was aware resident records needed to include documentation of on-going services provided by external service providers. The ED said she became aware of the missing documentation 5/13/25 and was working to implement a better system. Based on record review and interview, the residence failed to coordinate care and medication administration with external providers affecting one (#1) of five sample residents. (Cross-reference 18.8) Findings include:1. Record reviewResident #1 was admitted to the residence on 7/14/21 with a diagnosis of type 1 diabetes. The May 2025 medication administration record (MAR) read in part: Start date 8/29/24. Trulicity 1.5 MG/0.5 ML PEN Inject 1.5 mg subcutaneously one time a day weekly related to diabetes. Home health to administer. A progress note, dated 5/6/25, written by the resident care coordinator (RCC) read in part: Home health nurse for Resident #1 reported switching home health agencies and provided the RCC with new agency contact information. Progress note, dated 5/13/25, read: Two home health nurses from different home health agencies arrived at the residence to provide Resident #1 with his weekly insulin injection. An internal document, dated 5/15/25, read in part: Home health nurse for Resident.. Based on record review and interviews the residence failed to ensure each resident care plan identified all external service providers and detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting three (#1, #3 and #4) of five sample residents. Findings include:1. Record reviewResident #3 was admitted to the resident on 12/1/2021 with a diagnosis of Type 2 diabetes. A referral, dated 9/25/24, to a home health agency read in part: Resident #3 was being referred for a nursing evaluation and treatment of weekly injection.The May 2025 medication administration record (MAR) read in part: Semaglutide-subcutaneous solution peninjector 2 MG/3ML (Semaglutide). Inject 0.25 mg subcutaneously one time a day every 7 day(s) for per provider. Home health agency to administer. Start date 9/27/24.The care plan, dated 1/21/25, did not indicate Resident #3 was receiving home health services.2. InterviewOn 5/20/25 at 7:30 a.m., Staff #1 said she could recall four residents bei..

A recertification revisit was completed on 1/18/24 for the previous deficiency cited on 10/31/23. A deficiency was cited. 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 two of six sample participants (residents) (#5, #13).This deficiency was cited previously during a state licensure survey on 1/11/21. Although the residence corrected this deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires that the assisted living residence comply with authorized practitioner' s orders associated with medication administration except for those medications which a resident self-administers.a. Residence PolicyThe residences medication policy, dated December 2022, read in part that the residence trained staff to provide medication administration services to residents according to state regulations. Staff administered medications to residents as ordered.b. Resident #13 was admitted to the residence on 1/20/23 with diagnoses including type II diabetes.A written practitioner' s order, dated 12/5/23, directed the residence to administer dapagliflozin propanediol 10 mg daily. However, the January 2024 medication administration record read that the residence failed to administer the medication on 1/2, 1/3, and 1/7-1/10/24 because the medication was unavailable, for a total of six missed doses.On 1/18/24 at 12:10 p.m., Resident #13 stated that the residence did not have the medication because the pharmacy did not deliver it before she ran out of the medication. She stated that the staff tried their best to get the medication delivered timely, but they were unable to.On 1/18/24 at 12:47 p.m., the administrator stated that when staff documented that a medication was unavailable in the MAR, it meant that the residence did not administer the medication as ordered.On 1/18/24 at 12:47 p.m., the resident care ..