Lodge at Greeley, the

A change of ownership survey with a licensure complaint, #CO36968, was completed on 4/30/25. A deficiency was cited. A change of ownership survey occurred on 10/7/24. Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration affecting one of five sample residents whose medications were reviewed (#1). Findings include:1. Resident #1 was admitted to the residence on 4/18/24 with a cerebrovascular accident (CVA, also known as a stroke), neurocognitive disorder, and a paroxysmal atrial fibrillation (AFib).A written practitioner' s order dated 4/22/24 directed the residence to administer dabigatran etexilate 150 mg twice daily. However, the March 2025 medication administration record (MAR) revealed that staff did not administer the medication on the mornings of: 3/7/25 to 3/13/25 and the evenings of 3/7/25 to 3/12/25, for a total of 13 missed doses.On 4/30/25 at 4:26 p.m., the administrator confirmed that when Resident #1' s MAR read "medication not available," the medication was not in stock and the resident did not receive it. She later stated that the gap in the MAR meant the residence did not comply with practitioner orders.

A revisit survey was completed on 11/14/24 for all previous deficiencies cited on 7/17/24. 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 licensure revisit was completed on 7/17/24 for all previous deficiencies cited on 4/5/23. Deficiencies were cited.The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 1/14/24. Based on record review and interview the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting four of six sample residents (#18, #20, #21, #23).This deficiency was cited previously during a complaint survey on 4/5/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #21 was admitted to the residence on 11/2/21 with diagnoses including glaucoma.Brimonidine TimololA written practitioner' s order, dated 5/2/24, directed the residence to administer brimonidine timolol one drop in both eyes twice daily. However, the July 2024 medication administration record for Resident #21 read the medication was not in stock and not administered on 7/14 in the evening and 7/15 morning and evening doses, for a total of three missed doses.A progress note in Resident #21' s record revealed on 7/15/24 Resident #21 was not administered brimonidine timolol due to medication being in-route to the building.On 7/16/24 at 7:49 a.m., Staff #27 stated that the weekend before the onsite visit on 7/16/24, Resident #21 was not administered her eye drops because they were out of stock.On 7/17/24 at 8:29 a.m., .. Based on record review and interview, the residence failed to establish a fall management program that included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting two of four sample residents who fell (#20, #23).This deficiency was cited previously during a complaint survey on 4/5/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #20 was admitted to the residence on 5/1/22 with a diagnosis of transient cerebral ischemic attack. The progress notes for Resident #20 in July 2024 revealed the following:On 7/4/24, Resident #20 was found on the floor of her bathroom with no injuries. Additionally, "Resident had no injuries (from a fall on 7/3) only bruising and skin tear from the night before."There were no additional care plan updates in Resident #20' s record after 6/18/24 that included details of the approaches necessary to address fall risks related to deficits after Resident #20 fell on 7/3 and 7/4/24.2. Interviews On 7/17/24 at 12:45 p.m., Staff #24 stated they were unaware of any new care plan updates that detailed the approaches necessary to address fall risks related to deficits after Resident #20 fell on 7/3 and 7/4/24.On 7/17/24 at..

A relicensure survey with complaint #CO33755 and #CO33175 were completed on 7/17/24. Deficiencies were cited. Based on observation and interview the residence failed to keep grounds maintained to protect residents from slopes, holes or other hazards, and shall be consistent with any landscape plan approved by the local jurisdiction in the secure environment outdoor courtyard, affecting 24 residents in the secure environment.Findings include:During an environmental tour on 7/16 and7/17/24 in the outdoor courtyard of the secure environment there was a three inch d.. Based on observation and interview the residence failed to post weekly menus that are readily available for residents and public viewing no less than 24 hours prior to serving, affecting 24 residents in the secure environment.Findings include:On 7/16 and 7/17/24 from approximately 7:30 a.m. to 3:30 p.m., the secure environment common areas included no menu posting of meals being served that week for public viewing.On 7/16/24 at approximately 4:30 p.m... Based on record review and interview the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting four of six sample residents (#18, #20, #21, #23).Findings include:1. Resident #21 was admitted to the residence on 11/2/21 with diagnoses including glaucoma.Brimonidine TimololA written practitioner' s order, dated 5/.. Based on record review and interview the residence failed to develop and implement policies and procedures with all of the required elements for the identification, reports, and investigation of injuries of unknown origin, affecting one of seven sample residents residing in the secure environment. Findings include:1. Resident #22 was admitted to the residence on 8/24/20.A progress note in Resident #22' s record, dated 6/6/24 read staff found a skin tear on Resident.. Based on record review and interview, the residence failed to establish a fall management program that included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting two of four sample residents who fell (#20, #23).Findings include:1. Resident #20 was admitted to the residence on 5/1/22 with a diagnosis of transient cerebral ischemic attack. The progress notes for R.. Based on record review and interview, the residence failed to observe residents' right to private, consensual sexual activity, affecting two of two sample residents (#25, #26).Findings include:1. Residence PolicyThe residence' s posted Resident Rights read, in part: Residents had the right to privacy and confidentiality, including the right to have visitors anytime and the right to private, consensual sexual activity. 2. Resident #25 was admitted to the residence on 8/14/.. 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 7.5.1 Assisted living residence personnel engaged in the admission, care or treatment of at-risk persons shall report suspected physical or sexual abuse, exploitation and/or caretaker neglect to law enforcement wi..