Robert Russell Eastern Star-Masonic Center of Colorado INC

A certification complaint revisit was completed on 1/22/25 the previous deficiency cited on 5/30/24. A deficiency was cited. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 12/30/24. Based on record review and interview, the facility (residence) failed to review the Person-Centered Support Plan (PCSP) at least two times per year to determine if results were achieved, if needs were accurately reflected, if the services and support were appropriate to meet member (resident) needs, and what actions are necessary to successfully implement the interventions, affecting one of 11 sample residents (#27).Findings include:Resident #27 was admitted to the residence on 9/17/18 with a diagnosis of Alzheimer' s Disease. A PCSP for Resident #27, dated 4/24/22, read in part the member was to maintain the ability to ambulate and transfer independently without an assistive device. The date of review was also missing on the support plan. A progress note, dated 11/26/24, read in part that Resident #27 was transported to the emergency department after an unwitnessed fall and was experiencing hip pain. X-rays confirmed she had a hip fracture and arthritis to her left leg and would be transferred to a rehabilitation center. A progress note, dated 1/7/25, read in part that Resident #27 was readmitted to the residence after her fracture had healed and she was able to ambulate on her own. It also read that the PCSP would continue to be one person assistance with standby and cue reminders.On 1/22/25 at approximately 2:35 p.m., the resident services director stated the residence did not have an updated PCSP for Resident #27. On 1/22/25 at approximately 2:35 p.m., the administrator stated he was unaware the residence was required to update the PCSP two times per year.

A licensure complaint, prompted by #CO38973, was completed on 1/22/25. Deficiencies were cited. Based on observation and interview, the residence failed to prohibit the use of portable heaters in resident rooms, affecting three of 11 sample residents (#19, #30, and #31). Findings include:1. ObservationsOn 1/21/25 at 9:26 a.m., a portable space heater on in Resident #19' s room. On 1/21/25 at 10:00 a.m., a portable space heater was in Resident #30' s room.On 1/21/25 at 11:08 a.m., a portable space heater was on in Resident #31' s room2. Interviews On 1/21/25 at 9:26 a.m., Resident #19 stated that the heat stopped working the week prior to the on-site investigation. She stated that she was cold and the residence had provided her with the space heater. On 1/21/25 at 10:00 a.m., Resid.. Based on observations, interviews, and record review, the residence failed to provide to the Department upon request access to individual client records, reports, and other records as determined by the Department, affecting 73 current residents.Findings include:1. Record ReviewOn 1/21/25 at 9:00 a.m., resident records for Residents #5, #11, #12, #19, and #25-#29 were requested.On 1/21/25 at 10:00 a.m., records were requested from the administrator and resident services director by email.On 1/21/25 at 11:30 a.m., resident records for Residents #5, #11, #12, #19, and #25-#29 were requested again.On 1/21/25 at 12:17 p.m., resident records for Residents #5, #11, #12, #19, and #25-#29 were .. Based on record review and interview, the residence failed to develop and follow written policies and procedures to endure the continuation of necessary care to all residents for at least 72 hours immediately following an emergency including, but not limited to, a long-term power failure, affecting 73 current residents.Findings include:The residence' s Disaster Manual, revised on 8/25/20, failed to include a plan to ensure the continuation of care to all residents for 72 hours following any emergency.On 1/22/25 at 2:00 p.m., the administrator stated that the residence had a backup generator and was fully equipped to provide residents safety and care for extended periods of time. He.. Based on record review and interview, the residence' s emergency policies failed to address a plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids. The policies also failed to address the assignment of specific tasks and responsibilities to staff members on each shift including the use of a triage system to assess the needs of the most vulnerable residents first, affecting 73 current residents.Findings include:The residence' s Disaster Manual, revised on 8/25/20, failed to include policies that address a plan that ensures the availability of, or access to, emergency power for essential functions and all resi.. 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 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident' s condition changes from baseline status. 12.10 Each resident care plan shall: (B) Reflect the most current assessment information.18.9 The face sheet shall be updated at least annually and contain the following information: (K) Resident' s current diagnoses.25.9 Each resident shall be re-assessed to determine his or her continue..

A certification complaint, prompted by #CO38972, was completed on 1/22/25. A deficiency was cited. Based on record review and interview, the facility failed to develop and follow written policies and procedures to ensure the continuation of necessary care for all members for at least 72 hours immediately following any emergency.Findings include:The facility' s Disaster Manual, revised on 8/25/20, failed to include a plan to ensure the continuation of care to all members for 72 hours following any emergency, including but not limited to, a long-term power failure.On 1/22/25 at 2:00 p.m., the administrator stated that he needed to have the emergency preparedness policies updated to reflect the missing required elements.

A complaint revisit was completed on 1/22/25 for all previous deficiencies cited on 5/30/24. Deficiencies were cited. Based on observations, interviews, and record review, the residence failed to provide to the Department upon request access to individual client records, reports, and other records as determined by the Department, affecting 73 current residents.This deficiency was cited previously during a state licensure survey on 5/30/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewOn 1/21/25 at 9:00 a.m., resident records for Residents #5, #11, #12, #19, and #25-#29 were requested.On 1/21/25 at 10:00 a.m., records were requested from the administrator and resident services director by email.On 1/21/25 at 11:30 a.m., resident records for Residents #5, #11, #12, #19, and #25-#29 were requested again.On 1/21/25 at 12:17 p.m., resident records for Residents #5, #11, #12, #19, and #25-#29 were requested again.On 1/21/25 at 12:36 p.m., partial records were provided for Resident #5.On 1/21/25 .. Based on record review and interview, the residence failed to comply with authorized practitioner orders affecting one of 11 sample residents (#26).This deficiency was cited previously during a state licensure survey on 5/30/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #26 was admitted to the residence on 5/2/16 with diagnoses of bradycardia, muscle weakness, chronic obstructive pulmonary disease (COPD), and bipolar disorder.A written practitioner order, dated 3/3/23, directed the residence to administer vitamin C 500 mg daily.A written practitioner order, dated 3/31/23, directed the residence to administer vitamin D3 5,000 units once daily.The December 2024 MAR indicated the residence failed to administer the medications from 12/1/24 to 12/6/24, 12/8/24 to 12/13/24, 12/15/24 to 12/20/24, and 12/22/24 to 12/31/24 because the medication was not available.On 12/21/.. 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 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident' s condition changes from baseline status. 12.10 Each resident care plan shall: (B) Reflect the most current assessment information18.9 The face sheet shall be updated at least annually and contain the following information: (K) Resident' s current diagnoses25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident' s condition changes from baseline status.

A certification complaint revisit was completed on 1/22/25 all previous deficiencies cited on 5/30/24. A deficiency was cited.The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 12/30/24. Based on record review and interview, the facility (residence) failed to review the Person-Centered Support Plan (PCSP) at least two times per year to determine if results were achieved, if needs were accurately reflected, if the services and support were appropriate to meet member (resident) needs, and what actions are necessary to successfully implement the interventions, affecting one of 11 sample residents (#27).Findings include:Resident #27 was admitted to the residence on 9/17/18 with a diagnosis of Alzheimer' s Disease. A PCSP for Resident #27, dated 4/24/22, read in part the member was to maintain the ability to ambulate and transfer independently without an assistive device. The date of review was also missing on the support plan. A progress note, dated 11/26/24, read in part that Resident #27 was transported to the emergency department after an unwitnessed fall and was experiencing hip pain. X-rays confirmed she had a hip fracture and arthritis to her left leg and would be transferred to a rehabilitation center. A progress note, dated 1/7/25, read in part that Resident #27 was readmitted to the residence after her fracture had healed and she was able to ambulate on her own. It also read that the PCSP would continue to be one person assistance with standby and cue reminders.On 1/22/25 at approximately 2:35 p.m., the resident services director stated the residence did not have an updated PCSP for Resident #27. On 1/22/25 at approximately 2:35 p.m., the administrator stated he was unaware the residence was required to update the PCSP two times per year.

A complaint revisit was completed on 1/22/25 for all previous deficiencies cited on 5/30/24. Deficiencies were cited. Based on observations, interviews, and record review, the residence failed to provide to the Department upon request access to individual client records, reports, and other records as determined by the Department, affecting 73 current residents.This deficiency was cited previously during a state licensure survey on 5/30/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewOn 1/21/25 at 9:00 a.m., resident records for Residents #5, #11, #12, #19, and #25-#29 were requested.On 1/21/25 at 10:00 a.m., records were requested from the administrator and resident services director by email.On 1/21/25 at 11:30 a.m., resident records for Residents #5, #11, #12, #19, and #25-#29 were requested again.On 1/21/25 at 12:17 p.m., resident records for Residents #5, #11, #12, #19, and #25-#29 were requested again.On 1/21/25 at 12:36 p.m., partial records were provided for Resident #5.On 1/21/25 at 1:30 p.m., partial records were provided for Residents #11, #12, #19, and #25-#29On 1/21/25 at 2:01 p.m., Medication administration records (MARs) for Residents #5, #12, #19, and #25-#29 were requested again. On 1/21/25 at 2:07 p.m., progress notes for Resident #29 were requested, and medication orders for #27-#29 were requested.On 1/21/25 at 2:.. Based on record review and interview, the residence failed to provide each staff member with a minimum of six hours of general training and education on providing care and services for residents with dementia or cognitive impairments for one of 10 sample staff, affecting 13 current memory care residents.This deficiency was cited previously during a state licensure survey on 5/30/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 1/21/25 at 10:27 a.m., all training and orientation records were requested for the staff sample.A personnel file for Staff #13, hired on 2/1/24, revealed no evidence of training related to dementia, disease processes, information on non-pharmacological techniques and approaches, communication techniques, positive therapeutic approaches, and information on recognizing physical symptoms. The January 2025 secure environment staff schedule revealed Staff #13 worked from 6:00 a.m. to 2:00 p.m. from 1/1/25 to 1/3/25, 1/5/25 to 1/10/25, 1/12/25, 1/13/25, 1/15/25 to 1/17,/25 1/19/25, and 1/20/25.On 1/22/25 at 2:00 p.m., the administrator stated that Staff #13 along with all other staff were retrained in dementia and fall prevention. She stated, "We pulled everyone off the floor and retrained to make sure ..