Fountains of Hilltop, the

A revisit survey was completed on 3/24/25 for all previous deficiencies cited on 11/18/24. 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 #CO36477 was completed on 11/18/24. Deficiencies were cited. Based on interview and record review, the residence failed to develop and implement an internal process to ensure the routine and prompt handling of grievances or complaints brought by residents, family members, or advocates, affecting two of five sample residents (#21, #22).Findings include:1. Resident #21 was admitted to the residence on 3/7/22 with diagnoses of unilateral primary osteoarthritis and dementia.a. Record ReviewAn electronic message, dated 6/18/24 to the director from Resident #22, read in part that staff had served Resident #21 a sandwich that contained poison from the residence' s kitchen resulting in loose stools and vomiting. b. InterviewsOn 11/13/24 at 12:24 p.m., the nurse stated that on 9/27/24, Resident #21 expressed concern about eating a sandwich prepared in the kitchen, claiming that it contained poison and made her ill. The nurse confirmed that both she and the administrator were present when Resident #21 voiced this concern. However, the nurse stated that neither of them .. Based on interview and record review, the residence failed to ensure each resident care plan reflected current personal services needs and preferences along with staff tasks necessary to meet the needs of the resident, affecting two of two sample residents (#19 and 22) who required updates to the care plans. Findings include:1. Resident #19 was admitted to the residence on 4/11/22 with a diagnosis of urinary incontinence.a. Record ReviewThe residence' s fall report, dated 10/18/24-10/29/24, revealed Resident #19 had fallen on 10/18/24, 10/27/24, and twice on 10/29/24. The fall report indicated Resident #19 hit her head, had knee pain, and was sent to the local hospital after she fell on 10/27/24. Clinical notes for Resident #19 revealed that staff documented the initial fall report clinic note; however, the staff did not document any follow-up, including fall interventions for the falls Resident #19 had on 10/18/24, 10/27/24 and for both falls on 10/29/24.The care plan dated, 9/20/23, revealed that the residence failed.. 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 2.4.2.2 (B)(1) The following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department: (B) Any occurrence that results in any of the following serious injuries to a client: (1) Brain or spinal cord injuries; 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..

A licensure and complaint revisit was completed on 11/18/24 for all previous deficiencies cited on 3/15/22. A deficiency was cited. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24. Based on record review and interview, the residence failed to detail in each residents' care plan the individualized approach necessary to address fall risk related to deficits in strength and balance, affecting one of five sample residents (#19). This deficiency was cited previously during a state licensure survey on 3/15/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewResident #19 was admitted to the residence on 4/11/22.The residence' s fall report, dated 10/18/24-10/29/24, revealed Resident #19 fell on 10/18/24, 10/27/24, and twice on 10/29/24. The fall report indicated Resident #19 hit her head, had knee pain, and was sent to the local hospital after her fall on 10/27/24. Clinical notes for Resident #19 revealed that staff documented the initial fall report clinic note; however, the staff did not document any follow-up, including fall interventions for the falls Resident #19 had on 10/18/24, 10/27/24 and for both falls on 10/29/24. The care plan dated, 9/20/23, revealed that the residence failed to update the care plan after Resident #16 fell on 8/27/24, 10/18/24, 10/27/24, and two times on 10/29/24. The staff did not implement any additional interventions to prevent additional falls related to deficits in balance and strength, nor did the care plan include individual approaches necessary to address Resident #19' s increased falls.2. Interviews On 11/14/24 at 11:30 a.m., the assisted living nurse (ALN) stated the residence had not updated the care plan for Resident #19 ' s since 9/20/23. She stated that although the residence created a fall management spreadsheet, the residence did not create a fall management plan in an attempt to mitigate future falls.On 11/18/24 at 12:13 p.m., the administrator acknowledged the residence failed to follow their fall procedures after Resident #19 ' s falls in October 2024 due to tenured staff turnover in the care department.

A recertification survey with complaint #CO36478 was completed on 11/18/24. No deficiencies were cited.