Hilltop Life Adjustment Program

A licensure complaint, prompted by #CO38679, was completed on 4/22/25. A deficiency was cited. Based upon record review and interview, the residence failed to ensure medication cart audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting 48 current residents.Findings include1. Record ReviewOn 4/22/25 at approximately 12:00 p.m., documentation of quarterly medication audits were reviewed, and there was no evidence that the administrator participated in the audit. 2. Interviews On 4/22/25 at approximately 1:49 p.m., the resident care coordinator stated she and the assistant director completed quarterly medication audits together; the administrator does not participate in the audits. On 4/22/25 at 3:01 p.m., the administrator stated she does not participate in quarterly medication audits and acknowledges the requirement that the administrator and qualified medication administration personnel (QMAP) must complete the audits together.

A relicensure survey with complaint #CO33328 was completed on 1/24/24. A deficiency was cited. Based on record review and interview, the residence failed to follow occurrence reporting requirements outlined in Chapter 2, part 4.2, affecting two of two sample residents (#3, #7) who experienced physical abuse. Findings include: 1. References and Residence Policy a. Chapter II regulations governing assisted living residences, part 4.2.2, requires that 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:(D) Any occurrence involving physical, sexual, or verbal abuse of a client, as described in sections 18-3-202, 18-3-203, 18-3-204, 18-3-206, 18-3-402, 18-3-403, as it existed prior to July 1, 2000, 18-3-404, or 18-3-405, C.R.S., by another client, an employee of the licensee or a visitor to the facility or agency;b. According to the HFEMSD Occurrence Reporting Manual, "Any allegation of an occurrence involving physical...abuse of a patient or resident ... Two elements needed: Intent OR Knowingly OR RecklesslyAND Bodily injury and/or serious bodily injury." HFEMSD, (2018), retrieved from: https://cdphe.colorado.gov/health-facility-reported-incidentsc. The residence' s Critical Incident & Occurrence Reporting policy, dated 9/20/23, read in part: "Critical incidents that may constitute an occurrence are also reported to the Colorado Department of Human Services per 6 CCR 1011-1 Chap 07 ... The following are critical incidents: Abuse: includes actions that result in bodily harm, pain, or mental distress.2. Record Reviewa. Resident #3 was admitted to the residence on 11/10/14 with diagnoses including intracranial injury and bipolar disorder. The resident summary template (RST), dated 1/24/24, read in part: "(Resident #3) has poor judgment and cognitive impairment. If (Resident #3) is frustrated, cue to a quiet area away from any audience. If unable to redirect, take 10 mins and have a different staff approach for redirection. He often responds to asking him ' how he feels a vete..