Eqc Silver Rose, Incorporated

A certification complaint, prompted by #CO39970, was completed on 5/2/25. Deficiencies were cited. Based on record review and interview, the facility (residence) failed to have staffing sufficient in number to provide services described in the provider care plan, affecting three (#1, #3, #6) of three members (residents) who were left unattended at the residence.Findings include:The residence' s staffing policy, dated July 2004, read in part that the residence ensured that at least one staff member with the required qualifications and training, and who was at least 18 years old, was present in the residence when one or more residents was present.On 5/2/25 at 1:15 p.m., the acting administrator (AA) stated that on 5/1/25, she had left the residence at approximately 2:30 p.m. or 3:00 p.m. She stated Staff #3 was present at the residence when she left. The AA stated that while she was gone, she placed an order for food delivery for the residence' s dinner. She added that because the delivery time was going to be too long, she telephoned the residence, spoke with Resident #6 who answered the phone, and told the resident to instruct Staff #3 to pick up the food from the restaurant. The AA further stated that she coordinated a transport company to provide transportation for Staff #3 to get to the restaurant and back. She stated that while Staff #3 was out of the residence, an outside agency representative (OAR) telephoned her to let her know that there were no staff present at the resid.. Based on record review and interview, the facility (residence) failed to maintain a personnel record for Staff #3, affecting six current members (residents).Findings include: On 5/2/25 at approximately 1:30 p.m., the personnel file for Staff #3 was requested but was not provided at any time during the onsite investigation.On 5/2/25 at 2:38 p.m., the acting administrator stated that she was unable to provide a personnel file for Staff #3 because she could not find one.

A licensure complaint, prompted by #CO39971, was completed on 5/2/25. Deficiencies were cited. Based on record review and interview, the residence failed to ensure there was at least one staff member present in the assisted living residence when there were residents present, affecting three (#1, #3, #6) of three residents who were left unattended at the residence.Findings include:The residence' s staffing policy, dated July 2004, read in part that the residence ensured that at least one staff member with the required qualifications and training, and who was at least 18 years old, was present in the residence when one or more residents was present.On 5/2/25 at 1:15 p.m., the acting administrator (AA) stated that on 5/1/25, she had left the residence at approximately 2:30 p.m. or 3:00 p.m. She stated Staff #3 was present at the residence when she left. The AA stated that while she was gone, she placed an order for food delivery for the residence' s dinner. She added that because the delivery time was going to be too long, she telephoned the residence, spoke with Resident #6 who answered the phone, and told the resident to instruct Staff #3 to pick up the food from the restaurant. The AA further stated that she coordinated a transport company to provide transportation for Staff #3 to get to the restaurant and back. She stated that while Staff #3 was out of the residence, an outside agency representative (OAR) telephoned her to let her know that there were no staf.. Based on record review and interview, the residence failed to maintain a personnel file for Staff #3, affecting six current residents.Findings include: On 5/2/25 at approximately 1:30 p.m., the personnel file for Staff #3 was requested but was not provided at any time during the onsite investigation.On 5/2/25 at 2:38 p.m., the acting administrator stated that she was unable to provide a personnel file for Staff #3 because she could not find one.

A complaint revisit was completed on 5/2/25 for the previous deficiencies cited on 11/14/24. Deficiencies were cited.The deficiencies cited for Event B3CB11 were cited prior to the regulation revision that was implemented on 3/17/25. Based on observation and interview, the residence failed to ensure that weekly menus were readily available for residents and public viewing no less than 24 hours prior to serving, affecting six current residents.This deficiency was cited previously during a state licensure survey on 11/14/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 5/2/25, throughout the onsite visit, a dry erase board on a wall adjacent to the residence' s kitchen read "Menu." However, there was no additional menu information available on the white board or anywhere else throughout the residence. On 5/2/25 at 1:50 p.m., the acting administrator stated that the residence did not provide a weekly menu, and (contrary to the above observation) staff hand wrote the menu on the dry erase board. She stated this deficiency that was previously cited was not corrected because she was unaware of the requirement to have a menu posted 24 hours prior to serving.On 5/2/25 at 2:15 p.m., Resident #5 stated that sometimes staff informed the residents of the menu 24 hours in advance, but sometimes they did not.On 5/2/25 at approximately 2:20 p.m., an outside agency representative (OAR) stated that while she visited the residence on 5/1/25, she looked for a menu to .. Based on record review and interview, the residence failed to ensure staff documented, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them, affecting one of three sample residents (#6).This deficiency was cited previously during a state licensure survey on 11/14/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:The resident record for Resident #6 contained no progress notes at all.On 5/2/25 at approximately 1:58 p.m., Resident #6 was observed lying in his bed wearing an orthopedic boot on one foot.On 5/2/25 at 1:58 p.m., Resident #6 stated he fell on 4/30/25. He stated he went to the emergency department (ED) on 5/1/25 and discovered that he had broken his foot.On 5/2/25 at 3:03 p.m., the acting administrator stated that Resident #6 fell two days prior to the onsite visit and was transported to the ED 5/1/25. She stated that she did not document in progress notes, adding that she was aware of the requirement and should have done so.