Seven Lakes Memory Care

A licensure complaint, prompted by #CO38865, was completed on 3/19/25. A deficiency was cited. A change of ownership survey was completed on 10/13/23. Based on observation, interview, and record review, the residence failed to detail personal service needs along with the staff tasks necessary to meet those needs in the care plan, affecting one sample resident (#3).Findings include:Resident #3 was admitted to the residence on 10/30/24 with a diagnosis of chronic obstructive pulmonary disease (COPD).On 3/19/25 at 1:01 p.m., Resident #3 was administered oxygen (O2) from a portable O2 concentrator. The screen of the concentrator read 2 liters per minute (L/Min).A written practitioner' s order, dated 11/13/24, directed the residence to ensure the continuous administration of 4-5 L/Min of O2 to Resident #3.The care plan, dated 2/3/25, read Resident #3 used practitioner-ordered O2 at 2 L/Min via nasal cannula continuously due to a diagnosis of COPD.On 3/19/25 at 1:02 p.m., Staff #1 stated Resident #3 used O2 at 2 L/Min if that was what the portable concentrator screen read. She added that she ensured the portable concentrator was on prior to lunch; however, she did not know that the concentrator was on the incorrect level.On 3/19/25 at 1:03 p.m., Staff #2 stated that Resident #3 had O2 as ordered by the practitioner. She added that she was not sure what the practitioner' s order read and thought the O2 was supposed to be 2 L/Min.On 3/19/25 at 1:11 p.m., the health services director (HSD) stated that she was a nurse and took a verbal order from the practitioner that clarified the O2 order with the practitioner that Resident #3 required 4 L/Min of O2 continuously. She stated the portable concentrator was not set at the correct L/Min as it was on 2 L/Min instead of 4 L/Min. She stated that the care plan directed staff to ensure the required L/Min the O2 for the resident. She added that she was not aware that the care plan read that the resident was to have 2 L/Min, and that level was incorrect. On 3/19/25 at 2:02 p.m., the administrator stated that the residence was required to ensure Resident #3 was administered the correct L/Min of O2. He added that the care plan should have r..

A revisit survey was completed on 9/19/23 for all previous deficiencies cited on 2/15/23. 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 #CO30699 was completed on 2/15/23. Deficiencies were cited. Based on observation and interview, the residence failed to ensure exterior grounds were kept free of rubbish, affecting 22 residents with access to the west courtyard.Findings include:On 2/14/23 at approximately 2:00 p.m., an environmental tour of the residence' s external environment revealed an area between the asphalt and the residence' .. Based on observation, record review and interview, the residence failed to ensure each staff member completed an overview of state regulatory oversight applicable to the assisted living residence, person-centered care, the role and communication with external service providers, recognizing behavioral expressions and management techniques, how.. Based on observation, record review and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation), so that the information was readily available to staff at all times, affecting 46 current residents. Findings include:1. Residence PoliciesThe residence' s C.. Based on record review and interview, the administrator failed to, along with the qualified medication administration personnel (QMAP) supervisor, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Additionally, the residence faile.. Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting two of seven sample residents (#8, #12). (Cross-reference Q1360, Q1362)Findings include:1. References and Residence Policya. According to the Health Facilities and Emergency Medical Services Division Occurrence Reporting .. Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting three of three sample residents with documented injuries of unknown origin (#8-#10). Findings include:1. Residence PolicyThe residence' s Identificati.. Based on record review and interview, the residence failed to ensure each staff member received an initial orientation prior to providing any care or services to a resident, affecting one of three sample staff (#11). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.45, defines "Sta.. Based on record review and interview, the residence failed to investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy, affecting two of two sample residents with allegations of abuse (#8, #12). (Cross-reference Q414)Findings include:1. Residence PolicyThe residence' s abuse polic.. Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of five sample residents (#5).Findings include:1. Residence PolicyThe residence' s Medication policy, dated 12/7/22, read in part that the residence was responsible for complying with aut.. Based on the record review and interview the residence failed to have a quality management program designed to improve resident safety and well-being, affecting 46 current residents.Findings include:The residence' s dated Quality Improvement (QI) Program Report read, in part: "The program evaluates the community' s performance against nation.. 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: 12.1 The assisted living residence shall make available, either directly or indirectly through a re..

A licensure revisit was completed on 2/15/23 for all previous deficiencies cited on 4/13/22. A deficiency cited. Based on record review and interview, the residence failed to ensure each staff member received an initial orientation prior to providing any care or services to a resident, affecting one of three sample staff (#11). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" means employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.b. The residence' s Staff Education and Training policy, dated 8/27/12, read, in part, "Connections for Living staff will receive training and education in the core concepts of dementia care at orientation ... In addition staff will be oriented to Connections for Living policies, procedures and practices. A core curriculum will be provided to each Connection for Living staff member during orientation specific to the care of dementia residents. The following topics will be covered ... Connections for Living policies and procedures."2. Record ReviewOn 2/14/23 at approximately 8:00 a.m., Staff #11 was identified by the administrator as a contracted staff member. His initial start date was 2/6/23.According to the February 2023 staffing schedule, Contracted Staff #11 worked the following days:2/6/23 from 2:00 p.m. to 10:00 p... Based on record review and interview, the residence failed to immediately comply with all conditions issued by the department, affecting 46 current residents.Findings include:The department completed a licensure complaint on 4/13/22. The event resulted in tag Q540 being cited at a B level for the residence' s failure to comply with all applicable state laws and ensure infection control processes were established and maintained to help prevent the possible development and transmission of Covid-19. The department imposed a $500 civil fine payable by June 30, 2022. The residence did not appeal the immediate condition.Review of the department database revealed the administrator had reviewed the intermediate condition letter through the department' s database on 5/31/22. Review of the department database revealed the residence had not yet paid the civil fine as of 2/14/23. A department representative confirmed the residence had not paid the civil fine as of 2/14/23.On 2/14/23 at 4:20 p.m., the administrator stated she was not aware the residence was required to pay a civil fine by 6/30/23. She stated she was not responsible for paying the fines, adding that someone from the residence' s corporate office paid them. The administrator stated that she did not receive a fine notification via the department' s database nor the postal mail.