Nightingale Lane

A licensure complaint, prompted by #CO40146, was completed on 6/4/25. Deficiencies were cited. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting two of three sample residents (#1, #3).Findings include:1. Former Resident #3 was admitted to the residence on 11/23/24, with diagnoses including anxiety, auditory hallucinations and aphasia. A signed practitioner' s order, dated 1/16/25, directed the residence to administer clonazepam .25 mg three times daily. Another signed practitioner' s order, dated, 4/9/25, directed the residence to discontinue the clonazepam .25 mg three times daily dose and administer clonazepam 0.5 mg three times daily. However, the controlled substance documents for the clonazepam .25 mg dose for April 2025 for Former Resident #3 revealed that only clonazepam .25 mg was administered three times daily, instead of the clonazepam .5 mg tablet three times daily from 4/9-4/19/25. Additionally, according to the April 2025 medication administration record (MAR) and the controlled substance list for clonazepam .25 mg the residence did not administer any clonazepam on 4/20 and 4/21/25, for a total of five missed doses of clonazepam. On 6/3/25 at 8:46 a.m., a family member of Former Resident #3 said she was informed by Staff #1 on 4/21/25 that the residence had discontinued the clonazepam medication and Former Resident #3 had not recei.. Based on record review and interview, the residence failed to only administer medications ordered by an authorized practitioner, affecting one of three sample residents (#1).Findings include:Resident #1 was admitted to the residence on 5/1/25.The following medications were administered to Resident #1 in May and June 2025 without signed practitioner' s orders:Diclofenac sodium 1% three times daily administered from 5/15 to 6/3/25, for a total of 53 doses administered.Levothyroxine 50 mcg once daily administered from 5/2 to 5/7/25, for a total of six doses administered. Quetiapine 100 mg twice daily administered from 5/1 to 6/3/25, for a total of 45 doses administered.Vitamin B-12 two and a half tabs once daily. Administered 5/17 to 6/3/25, for a total of 18 doses administered.There were no signed practitioner' s orders for the medications listed above found in Resident #1' s record. On 6/4/25 at approximately 9:45 a.m., the memory care manager acknowledged there were no signed authorized practitioner' s orders for the medications listed above.On 6/4/25 at approximately 10:30 a.m., the administrator said she expected there to be signed practitioner' s orders for medications the residence was administering.

A licensure complaint, prompted by #CO39045, #CO39063 and #CO39308 was completed on 2/26/25. Deficiencies were cited Based on observation, record review and interview, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 16 current residents.Findings include:1. Observations On 2/26/25 from approximately 8:30 a.m. to 9:30 a.m., a walk through tour of the secured environment courtyard was conducted at the residence; the six foot fence along with walking paths were identified as follows:The fence had recently been repaired on one side, however the fence had many areas that were wobbly and not secured with nails due to shifting and weather breakdown. The fence pickets had been rotted out on one of the gates. Another observed secured courtyard residents could access, had whole concrete slabs raised up nearly a foot in some areas, due to a tree' s roots. A metal grate observed around the tree had been raised up over a foot in some areas as well. 2. InterviewsOn 2/26/25 at approximately 9:00 a.m., Staff #2 stated the fence was recently repaired due to two separate residents eloping from the residence. She stated that Resident #9 scaled the fence to get out sometime in January 2024. Staff #2 stated the resident was later found and unharmed. She also stated that Resident #9 accessed the courtyard often. On 2/26/25 at approximately 10:00 a.m., the administrator confirmed that two separate residents eloped from the secured environment in January 2024. She stated the residence soon after repaired the one side of the fence they knew the residents eloped from. The administrator also acknowledged the fence needed additional repairs along with the concrete area in the second courtyard.

A complaint revisit was completed on 2/26/25 for the previous deficiency cited on 10/16/24. A deficiency was cited. Based on interview and record review, the residence failed to establish a fall management program which included detailing in each resident' s care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting one sample residents who sustained injuries from falls (#8). This deficiency was cited previously during a complaint investigation on 10/16/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Specifically, Resident #8 had sustained a fall from a sitting position which resulted in a nose bleed on 12/4/24. An undated care plan with no personalized interventions were observed. Ultimately, Resident #8 sustained an additional fall on 12/18/24 falling out of a chair to his face where he had redness. The resident fell on 12/27/24 which resulted in bruising to his right arm. On 1/3/24 staff found Resident #8 on the floor of his room with a bleeding cut to his forehead. On 1/4/25 Resident #8 had fallen forward out of a chair which resulted in bleeding to his head and right hand. On 1/21/25 staff found Resident #8 on the floor of his bathroom where he had reopened a skin tear on his right hand. On 1/31/25 staff had heard Resident #8 fall in the community area which resulted in a cut on his left wrist. Findings include:Chapter VII regulations governing assisted living residences, part 2.10, defines "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual' s need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual' s needs. In order to deliver person-centered care, the care plan shall take into account the resident' s preferences and desired outcomes. "Care plan" may also mean a service plan for those facilities which are licensed to provide services specifically for the mentally ill. Resident #8 was admitted to the residence on 11/7/24 with a diagno..