Solange at East Side

8.7506.f.6 Each Alternative Care Facility Provider Agency will divide the 24-hour day into two 12hour blocks which will be considered daytime and nighttime. The designation of daytime and nighttime hours shall be permanently documented in the Alternative Care Facilities policy and disclosed in the written Member agreements. In determining appropriate staffing levels, the Alternative Care Facility Provider Agency shall adjust staffing ratios based on the individual acuity and needs of the Members in the Alternative Care Facility. At a minimum, staffing must be sufficient in number to provide the services described in the Provider Care Plan, considering the Member' s needs, level of assistance, and risks of accidents. A staff person may have multiple functions, as long as they meet the definition of Direct Care Worker at Section 8.7402.F Staff counted in the staff-to-Member ratio are those who are trained and able to provide direct services to Members. Staffing at an Alternative Care Facility shall meet the following standards i. A .. A recertification survey with complaint #CO39382 and #CO37688 was completed on 3/10/25. Deficiencies were cited. Based on observation, interview, and record review, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription and non-prescription medications, affecting four (#2, #3 ,#4, and #8) of eight sample residents.Specifically, Resident #3 had diagnoses including schizoaffective disorder. On 2/15/25, Resident #3 was transported to the emergency department (ED) due to extreme pain in the lower abdomen. Resident #3 was discharged with a diagnosis of "severe fecal retention in the colon". A written practitioner' s order, dated 2/15/25, directed the residence to administer, one time, a milk of magnesia and a sodium phosphates enema to Resident #3. However, the residence did not administer this medication on 2/15/25. As a result, on 2/15/25-2/18/25, the resident reported that she experienced pain and discomfort in her abdomen and lower back. Resident #3' s external service provider (ESP) stated that not being administered milk of magnesia and the fleet enema had caused Resident .. Based on record review and interview the facility (residence) failed to comply with all policies and procedures for the monitoring of incident reports and verbal and written reports regarding Mistreatment, Abuse, Neglect, or Exploitation (MANE) affecting one of six sample members (residents) (Former Resident #8).Former Resident #8 was admitted to the residence on 8/1/24 with a diagnosis of human immunodeficiency virus, heart failure, and chronic pulmonary disease. A progress note dated 1/28/25 read that Former Resident #8 slapped another resident in the face and witnesses were present. A progress note dated 2/8/25 read that Former Resident #8 contacted law enforcement to inform them that he was assaulted in the dining room of the residence and that the staff member was aware of this incident.On 3/10/25 at approximately 12:30 p.m. the investigation and occurrence report for the incidents that occurred on 1/28/25 and 2/8/25 were requested. On 3/10/25 at approximately 2:40 p.m., the administrator stated that she was aware of the ..

A relicensure survey with complaint #CO39383, #CO39089, and #CO37690 was completed on 3/10/25. Deficiencies were cited. Based on observation and interview the residence did not dispose of rubbage properly, affecting 27 current residents.On 3/10/25 at approximately 2:00 p.m. glass was observed scattered and broken around the dumpster. Additionally, a full garbage bag sat outside of the front entrance of the residence from 2:00 p.m. until the survey was completed at approximately 5:00 p.m. Lastly, large boards, a wooden ladder and garbage was scattered throughout t.. Based on observations and interviews the residence failed to have a maintained ground to protect residents from slopes and other hazards, affecting 27 current residents.On 3/10/25 at approximately 2:00 p.m. two two-inch raised edges of the sidewalk in the back courtyard were observed. The raised edges were discovered when the surveyor tripped over them.On 3/10/25 at approximately 5:00 p.m. the director of operations acknowledged that the residenc.. Based on observations and interviews the residence failed to select direct care staff that demonstrated competency to effectively provide care and services, affecting 27 current residents. On 3/10/25 at approximately 7:30 a.m., Staff #1 stated that she did not understand English and prompted the use of a translation program on her phone for the rest of the interview.On 3/10/25 at approximately 8:00 a.m., Staff #1 was observed checking on Resident #6. Resident #6 as.. Based on observations and interviews, the residence failed to ensure that each resident received proper monitoring of medications, affecting one (#8) out of six sample residents. 1. Residence PolicyThe residence' s medication management policy, dated 12/21/23, read in part: "The residence shall ensure that each resident receives proper administration and/or monitoring of medications."2. ObservationOn 3/10/25 from 7:15 a.m. to 8:15 a.m., Staff #2 w.. Based on record review and interview the residence failed to comply with all occurrence reporting requirements by state law affecting one former resident (#8).Former Resident #8 was admitted to the residence on 8/1/24 with a diagnosis of human immunodeficiency virus, heart failure, and chronic pulmonary disease. A progress note dated 1/28/25 read that Former Resident #8 slapped another resident in the face and witnesses were present. A progress n.. Based on record review and interview the residence failed to ensure the comprehensive assessment included behaviors, physical health and mental health, affecting three (#2, #3, #5) of eight sample residents.Findings include: 1. Resident #2 was admitted to the residence on 7/19/24 with diagnoses including type 2 diabetes, chronic pain, coronary artery disease, deep vein thrombosis, methamphetamine dependence, schizophrenia and bipolar disorders... Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one (#3) of six sample residents. (Cross Reference S1600)Specifically, Resident #3 had diagnoses including schizoaffective disorder. On 2/15/25, Resident #3 was transported to the emergency department.. Based on record review and interview, the residence failed to ensure all prescribed and PRN (as needed) medications shall be listed and recorded on a medication administration record (MAR), affecting two (#3, #4) of six sample residents. (Cross-reference S1568)Findings include: 1. Residence PolicyThe residence' s medication management policy, dated 12/21/23, read in part: "The residence shall ensure that each resident receives proper administration and/or ..