Renaissance House

A mental health transitional living program complaint, prompted by #CO41084, was completed on 10/30/25. A deficiency was cited. Based on record review, observation and interview, the residence failed to comply with the practitioner' s orders affecting three of three sample residents (#1, #2, and #3).Specifically, Resident #2 had diagnoses including schizophrenia. A written practitioner' s order, dated 8/25/25, directed the residence to administer psychotropic medication, including desvenlafaxine, daily. The residence did not administer the medication for a total of 15 missed doses. Subsequently, Resident #2 reported hewas unable to sleep, felt restless, and experienced intrusive thoughts caused by pain and discomfort since missinghis medications.Findings include:1. Residence PolicyThe undated residence agreement policy read in part, that the residence will administer medications to a resident if the resident' s physician provides the facility with written medication orders. Only medication administered with a provider' s medication order will be administered.2. Record ReviewResident #2 was admitted to the residence on 8/25/25 with diagnoses including schizoaffective and post-traumatic stress disorder. A written practitioner' s order, dated 8/25/25, directed the residence to administer desvenlafaxine daily. However, the medication administration record (MAR) did not indicate that the prescribed medication was administered since 10/15/25 with a total of 15 missed doses.2. InterviewsOn 10/30/25 at 12:50 p.m., Resident #2 reported that he had not taken desvenlafaxine for two weeks and noticed a change in condition that included pain and discomfort. Resident #2 reported that he was unable to sleep, felt restless, and experienced intrusive thoughts. Resident #2 described pain as a relentless battle between his body and mind, emphasizing the distress it caused him.On 10/30/25 at 10:30 a.m., Staff #1 reported that she noticed perseveration and restlessness, such as pacing with Resident #2. Staff #1 was aware that Resident #2 had not received his prescribed psychotropicme..

A licensure complaint, prompted by #CO41061, was completed on 10/30/25. Deficiencies were cited. Based on observation, record review and interview, the residence failed to have sufficient food on hand to prepare three nutritionally balanced meals per day for three (3) calendar days. (Cross-reference U540)Findings Include:1. Residence PolicyThe residence dining policy dated June 2023, read in pertinent part, that the residence will have sufficient food on hand to prepare three nutritionally balanced meals per day for three (3) calendar days. 2. Observation:On 10/30/25 at 7:16 a.m., the residence fridge, freezer, and pantries did not have nutritionally balanced meals sufficient for three days. The fridge, freezer, and pantry did not contain protein, fruits, vegetables, grains, and dairy. The pantry had several cans of the cream soup with little to no diversity in food groups. At 7:31 a... Based on record review, observation and interview, the residence failed to comply with the practitioner' s orders affecting three of three sample residents (#1, #2, and #3) (Cross-reference U540)Specifically, Resident #2 had diagnoses including schizophrenia. A written practitioner' s order, dated 8/25/25, directed the residence to administer psychotropic medication, including desvenlafaxine, daily. The residence did not administer the medication for a total of 15 missed doses. Subsequently, Resident #2 reported hewas unable to sleep, felt restless, and experienced intrusive thoughts caused by pain and discomfort since missinghis medications.Findings include:1. Residence PolicyThe undated residence agreement policy read in part, that the residence will administer medications to a resident if the resident' s.. Based on record review, observations and interviews, the residence failed to ensure the administrator managed the day-to-day delivery of services, conducted medication audits, maintained a three-day supply of food, and followed practitioners ' orders, including verifying that all medication orders were entered into the Medication Administration Record (MAR), affecting 7 current residents. (Cross-reference U1568, U1604 and U2130)Findings include:1. References and Resident AgreementChapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management, and maintenance of the assisted living residence. The undated resident agreement, read in part that the residence w.. Based upon record review and interview, the residence failed to ensure medication cart audits were completed by the administrator and the qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting 7 current residents. (Cross-reference U540)Findings include:On 10/30/25 at 9:00 a.m., documentation of quarterly medication audits was requested but not provided.On 10/30/25 at approximately 3:30 p.m., the administrator acknowledged that she had not participated in the quarterly medication audits.

An initial mental health transitional living survey was completed on 1/10/24. Deficiencies were cited. Based on observation and interview the facility failed to ensure residents had unrestricted access to all common areas affecting eight current residents. Findings include:1. Reference The House Rules read in part, "The common areas such as the dining room, TV room are free for the residents to enjoy. All residents are expected to act in a manor of respect towards others while enjoying the common areas."The Resident Agreement read in part, "Resident shall have full use of the room assigned and the common areas."The facility' s Resident Rights policy read in part, residents had the right "to full use of the assisted living residence common areas in compliance with written house rules." 2. InterviewsOn 1/10/24 at approximately 8:45 a.m. Resident #1 and #2 stated they both smoked and utilized the common use smoking area throughout the day; however, after 7:30 p.m. they were no longer allowed to go out to use the smoking area. On 1/10/24 at approximately 9:45 a.m. the administrator confirmed that there was a rule at the facility where residents were not allowed to use the common use smoking area after 7:30 p.m. He stated residents typically went to bed early and it would not be used anyway. 3. Record reviewThe records for Resident #1 and #2 did not contain rights modifications in the person centered care plan regarding the restriction of use of the common use .. Based on record review and interview the facility failed to ensure rights modifications were documented in the resident' s person-centered support plan, and failed to maintain a copy of such documentation for two sample residents (#1, #2).Findings include:1. ReferenceThe facility' s Resident' s Rights policy read in part, the residents had the right "to make decisions and choices in the management of personal affairs, funds and property in accordance with resident ability." 2. InterviewOn 1/10/24 at approximately 8:45 a.m. Resident #1 and #2 stated they were not allowed to leave the facility unaccompanied by a staff member. They further stated they believed if they left the facility unaccompanied then the staff would notify the police and report a missing person. On 1/10/24 at approximately 9:45 a.m. the administrator confirmed all residents were restricted to the facility and were not allowed to leave without staff. The administrator further stated personal devices such as cell phones were restricted from residents for the first 30 days of admission. The administrator stated they could not stop a resident from leaving, however if a resident violated these rules they would receive a verbal warning, if the violation continued then a behavior plan would be implemented, and if the violation continued after that then their residency at the facility could possibly be revoked. ..

A change of ownership survey was completed on 1/10/24. No deficiencies were cited. A change of ownership occurred on 11/28/23. 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 Residence program regulations.13.1The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items:(4)The right to live free from financial exploitation, restraint as defined in this chapter, and involuntary confinement except as allowed by the secure environment requirements of this chapter;(C)The right to personal and community engagement, including:(4)The right to participate in activities outside the assisted living residence and request assistance with transportation; and(D)The right to choice and personal involvement regarding care and services, including:(5)The right to make decisions and choices in the management of personal affairs, funds, and property in accordance with resident ability;13.4The house rules shall list all possible actions which may be taken by the assisted living residence if any rule is knowingly violated by a resident. House rules shall not supersede or contradict any regulation herein, or in any way discourage or hinder a resident' s exercise of his or her rights.