Florence Care Home

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, Section 8.7000.8.7001 B.2. a. All HCBS Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.7001.B.4: iii. The setting ensures an individual' s rights of privacy, dignity, and respect, and freedom from coercion and Restraint. 2) The right of privacy includes the right not to have one' s name or other confidential items of information posted in common areas of the setting. A recertification survey with complaint #CO40843 was completed on 9/10/25. A deficiency was cited. Based on observation and interview, the facility (residence) failed to ensure the right of privacy, including the right to be free of cameras for all 10 current members (residents).Findings include:During the environmental tour on 9/9/25, it was revealed the residence had three cameras hung in common areas. One camera was pointed toward the dining room table and hallway, where residents enter and exit their rooms. The second camera was posted in the laundry room area, where the exit was for residents to go to the back yard and designated smoking area was, as well as where the hair salon station was, and where residents had to go through to go to the kitchen (to grab snacks) and go to the living room. The third camera was placed in the living room where the residents build puzzles, watch television, or go to the sun room. On 9/10/25 at approximately 4:40 p.m., the administrator stated the cameras were put in about a year ago, and before the cameras were put up, the residence had a verbal discussion with the residents. She continued to say no resident had brought up a concern about the camera and would add it to the resident council meeting agenda to discuss with them on 9/19/25. The administrator was then asked if she was aware that a rights modification was needed in order to have cameras posted. She stated she was unaware and thought the..

A relicensure survey with complaint #CO40497 and #CO40842 was completed on 9/10/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure the administrator completed the 40 hours of administrator training before assuming an administrator position within 30 days of appointment as required, affecting 10 current residents. Findings include: On 9/9/25 at 9:15 a.m., the 40-hour administrator training certification was requested. However, the administrator training certification provided her nursing home administrator (NHA) license and a 10-hour bridge course. On 9/9/25 at 9:26 a.m., the administrator stated she had her NHA so she did not take the 40 hour certification training. On 9/10/25 at approximately 4:30 p.m., the administrator confirmed that she only had her NHA and a 10-hour bridge certification course. She continued to say that she believed that since her NHA was a .. Based on record review and interview, the residence failed to comply with authorized practitioner' s ordersassociated with medication administration except for those medications which a resident self-administers, affecting one (#1) of three sample residents. Resident #1 admitted to the residence on 31/11/23 with a diagnosis including hemoplagia, hypertension, myocardial infarction and cardiomegaly. A written practitioner' s order, initially dated 8/6/25, directed the residence to discontinue lisinopril 40mg. Updated orders sent on 8/6/25, directed the residence to start administering lisinopril 5mg once daily for Resident #1' s hypertension. However, the August 2025 medication administration records (MAR) showed the medication was no longer on the electronic medication record (MAR), there.. Based on record review and interview, the residence failed to update resident' s comprehensive assessment whenever the resident' s baseline status changed, affecting one of three sample residents (#2). Findings include:1. Record ReviewResident #2 was admitted to the residence on 8/3/23 with a diagnosis of generalized muscle weakness.An incident report dated 8/13/25 read that Resident #2 fell during a transfer to his wheelchair and ' claimed' to hit his head. An external service unit was dispatched, and he was not taken to the hospital. An initial assessment, dated 3/28/25, and a bowel assessment, dated 5/6/25, were provided; no other assessments were provided for Resident #2 when requested. 2. InterviewsOn 9/10/25 at 1:02 p.m., the administrator stated that Resident #2 did no.. 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 7.9.2. The assisted living residence shall have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S. Such policies and procedures shall: (A) Set forth the visitation rights of the resident, consistent with 42 CFR 482.13(h); 42 U.S.C. 1396r(c)(3)(C); 42 U.S.C. 1395i(c)(3)(C); 42 CFR483.10(a), (b), and (f); and Section 2527-104, C.R.S., as applicable to the facility type; (B) Describe any restriction or limitation necessary to ensure the health and safety of residents, staff, or visitors and the..