Nightingale Suites

A revisit survey was completed on 4/17/25 for all previous deficiencies cited on 8/28/24. 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 #CO32375, #CO32455, #CO35908 was completed on 8/28/24. Deficiencies were cited. Based on interview and record review the residence failed to develop and implement an involuntary discharge grievance policy, affecting 46 current residents.Findings include:The residence' s undated discharge policy read in par.. Based on interview and record review, the residence failed to ensure resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affects a resident' s physical, behaviora.. Based on interview and records review, the residence failed to document routinely completed audits of the accuracy and completeness of medication administration records (MARs), controlled substance lists, medication error reports, .. Based on observation, interview and record review, the residence failed to provide protective oversight, either directly or indirectly, through a resident agreement, affecting one of eight sample residents (#12). (Cross-reference .. Based on observation, interview, and record review, the residence failed to ensure the residence grounds were maintained to protect residents from hazards, affecting 46 current residents.Findings include:On 8/27/24 at 1.. Based on observation, record review, and interview, the residence failed to complete CAPS Check requirements for staff who provided direct care to at-risk residents for four of four sample staff (#8, #9, #10, and qualified medication.. Based on record review and interview the residence failed to define procedures to prevent the spread of influenza from unvaccinated healthcare workers, affecting 46 current residents.Findings include:A policy untitled and undated .. Based on record review and interview the residence failed to ensure at least one staff member was onsite at all times with Cardio-pulmonary Resuscitation (CPR) certification training from a nationally recognized organization or meet t.. Based on record review and interview the residence failed to only administer medications ordered by an authorized practitioner, affecting eight of eight sample residents (#8, #10, #12-#17). (Cross-reference S1110)Findings include:1. .. Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following an emergency including, but not limited to, a long-term power failure, .. Based on record review and interviews the assisted living residence shall have readily available a roster along with a residence diagram showing room location, affecting 46 current residents.Findings include:1. Record ReviewOn 8/27/.. Based on record review and interviews, the residence failed to ensure its emergency policies addressed when to evacuate the premises and the procedure for doing so, as needed to meet the care needs of the residents during em.. 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 a..

A complaint revisit was completed on 8/28/24 for all previous deficiencies cited on 4/27/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on record review and interviews the assisted living residence shall have readily available a roster along with a residence diagram showing room location, affecting 46 current residents.Findings include:1. Record ReviewOn 8/27/24 at approximately 8:30 am., the wellness coordinator provided a resident roster labeled as "rent roll" that failed to include the residence diagram showing room locations.2. InterviewOn 8/28/24 at approximately 2:15 p.m, the administrator agreed that in an emergency, time could cost lives. The administrator stated everything was " in chaos" because informational pieces were all over the place. The administrator also stated the deficiency had not been corrected because of the disorganization.

A licensure complaint, prompted by #CO30470 was completed on 4/27/23. Deficiencies were cited. Based on interviews and record review, the residence failed to ensure personnel files for five of five current employees, (#1-#5) were readily available onsite for Department review. Findings include:1. Reference:Part 7.12 of the Chapter VII regulations governing assisted living residences requires each personnel file to contain written documentation of numerous items, including orientation and training. 2. 4/25/23: At 12:30 pm on 4/25/23, the administrator of record (AOR) was asked to provide the personnel files for five sample staff, (#1-#5), for department .. Based upon interview, the administrator failed to be responsible for the overall day-to-day operations of the residence, affecting 46 current residents. Findings include:Following entrance to the residence at approximately 7:33 a.m, qualified medication administration person (QMAP) #1 stated that the assisted living administrator (ALA) was the administrator of record (AOR) and had been in place for one year. QMAP #1 was asked about the AOR who was designated as the administrator of record in the department' s database, but provided no response. At approximately .. Based upon observation and interview, the residence failed to have a list of staff, in a visible location, who had current certification in first aid or CPR, affecting 46 current residents. Upon entrance to the facility, a list of all staff who had current certification in first aid or CPR was not found. Several other items were in visible locations, including resident rights, grievance procedures and the residence' s license to operate as an assisted living residence. The front desk clerk stated he was not aware of the requirement and had never seen such a list. Qualified medication administ.. Based upon observation, interviews and record review, the residence failed to have staff sufficient in number to help residents needing or potentially needing assistance, affecting seven of seven interviewed residents. Findings include: 1. Upon arrival to the residence at approximately 7:33 a.m., there was no staff found at the front desk, and qualified medication administration person (QMAP) #1 was found in an adjacent hallway, preparing medications for administration. QMAP #1 stated the residence was currently short of staff due to a staff member calling off, therefor.. Based upon record review and interview, the residence failed to have a roster of current residents, their room assignments and emergency contact information, affecting 46 residents. Findings include:Following entrance to the residence at approximately 7:33 a.m. qualified medication administration person (QMAP) #1 stated that 43 residents currently resided in the residence. At approximately 8:05 a.m. the roster was requested from the administrator of record (AOR). The AOR provided a roster that had 46 resident names on it, and it did not contain em.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised they must review and maintain the following processes in accordance with existing Assisted Living Residences program regulations: 1.2 Assisted living residences, as defined herein, shall comply with all applicable federal and statestatutes and regulations including, but not limited to, the following:(B) 6 CCR 1011-1, Chapter 2, General Licensure Standards.Chapter 2, part 2.10.5 requires the licensee to provide, upon request, access to or copies of the ..