Divine Care Homes LLC

A complaint survey, prompted by #CO41474, was completed on 1/28/26. Deficiencies were cited. Based on interview and record review, the residence failed to reflect the most current assessment information and the staff tasks necessary to meet needs in the resident care plan, affecting two of three current residents (#1, #2).Findings include:1. Resident #1 was admitted to the residence on 11/14/25 with a diagnosis including chemotherapy induced peripheral neuropathy.A care plan, dated 11/14/25, read Resident #1 was independent with eating, ambulation, and showering, along with bowel and bladder needs. No fall prevention and management, increased weakness, hospitalization assessments, or smoking was listed in the care plan. On 1/29/26, after survey exit, the administrator provided an updated care plan dated 1/29/26. A progress note, dated 11/14/25, read Resident #1 had fallen while attempting to transfer himself to his wheelchair to use the bathroom. A progress note, dated 12/23/25, read Resident #1 had fallen attempting to transfer himself to his wheelchair to go to the bath.. Based on record review and interview, the residence failed to contact the authorized practitioner for clarification of unclear orders and failed to obtain new orders in writing, affecting two of three current residents (#1, #2).Findings Include:1. Record Reviewa. Humulin R U-500 Injectable PenResident #2 was admitted to the residence on 11/15/23 with a diagnosis including diabetes mellitus. A practitioner' s order, dated 11/21/25, directed the residence to administer 20 units of Humulin R U-500 under the skin in the morning and 20 units before bedtime. Lunch and dinner doses were to be determined by a sliding scale, which read add two units if blood sugar is between 200 and 299, add three units if blood sugar is between 300 and 400, and if blood sugar level is greater than 401, add five units. The December 2025 medication administration record (MAR), directed the residence to administer 18 units of HumulinR U-500 under the skin for the scheduled morning dose. All insulin for Resident #2 did not indicate medication was to b.. 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 VII.14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence ' s Quality Management Program assessment and review.

A licensure complaint, prompted by #CO38193 and #CO39279 was completed on 4/2/25. Deficiencies were cited.A change of ownership occurred on 1/9/25. Based on record review and interview the residence failed to ensure that it had trained staff available to physically perform lift assistance when determined appropriate instead of relying on emergency medical responders, affecting three current residents (#1, #2, #3) and former resident (#4). (Cross-reference S1190) Findings include:Former Resident #4 was admitted to the residence on 11/22/23 with unknown diagnosis. A progress note, dated 1/11/25, read in part Former Resident #4 was in the emergency department (ED) and an incident report had been filed and management was notified. An incident report, dated 1/11/25, read in part Former Resident #4 had fallen outside of the residence. Another resident let Contracted Staff #1 know and when she went outside the Former Resident #4 was on the ground with his daughter with him. Bruising to his elbow was observed and he was unable to get up. The former resident was also refusing any assistance from the daughter and the staff. The former resident crawled to a chair to get himself up, where Contracted Staff #1 asked him to stay until emergency medical services (EMS) arrived. On 3/2/25 at 12:30 p.m., Contracted Staff #1 stated she was alerted that a resident had been on the ground outside of the residence. She stated Former Resident #4 was found on the ground with his daughter. Contracted Staff #1 stated .. Based on record review and interview, the residence failed to direct staff to assist residents who have fallen or are otherwise unable to get up off the floor independently, affecting three current residents. (Cross-reference S1192)Findings include:The residence' s Lift Assist Policy revised on 11/20/12 directed staff when to lift residents. However, the policy did not direct staff to assist residents who have fallen or were otherwise unable to get up off the floor independently. Staff were required to contact the nurse or Emergency Medical Services (EMS). On 4/2/25 at 12:30 p.m., Contracted Staff #1 stated she was not trained to know the residence' s policy on lifting a resident off the floor. She stated she was told by the administrator to read the residence' s policy binder when on shift. She also stated she would contact the administrator for direction if a resident were to be on the ground for any reason. On 4/2/25 at approximately 12:45 p.m., the administrator stated the staff was not to perform a lift assist on their own, they were to contact the on call person or EMS for assistance. On 4/2/25 at approximately 1:20 p.m., the administrator acknowledged the residence was required to provide lift assist and the residence' s lift assist policy was incorrect.

A relicensure survey was completed on 10/17/24. No deficiencies were cited. 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 7.8.8 Each assisted living residence shall place in a visible location a list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times. The list shall be kept up to date and indicate by staff person whether the certification is in first aid or CPR or both. 10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.13.4 The house rules shall list all possible actions which may be taken by the assisted living residence if any rule is knowingly violated by a resident. House rules shall not supersede or contradict any regulation herein, or in any way discourage or hinder a resident ' s exercise of his or her rights.