Wellspring Parker Assisted Living LLC

A licensure revisit was completed on 7/29/24 for all previous deficiencies cited on 11/13/23. A deficiency was cited. Based on observation, record review, and interview, the residence failed to notify the department of a change in administrator, at least 30 calendar days in advance, affecting 10 current residents.This deficiency was cited previously during a state licensure survey completed on 11/13/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.On 7/29/24 the department' s database read the administrator of record was the current administrator of the residence. On 7/29/24 at 8:38 a.m., the acting administrator' s name was posted on the wall of the residence. However, a binder attached to the wall containing an announcement read in pertinent parts: the owner/administrator of the residence, being the administrator of record, designated the position and responsibilities to the acting administrator, indefinitely, as of 5/19/2023. On 7/29/24 at approximately 10:15 a.m., the acting administrator said the administrator of record was the owner and she was brought on to manage the residence and was given the title of officer manager. She said she handled the day to day tasks of receiving communication on resident care from care staff and communicating with the families about resident care. She said she handled a majority of the owner/administrator of record' s responsibilities. She said the administrator of record' s presence was not consistent and his responsibilities at the residence was minimal. She confirmed the administrator of record was not familiar enough with resident care to be of assistance if an emergency were to arise.

A licensure complaint, prompted by #CO34146, was completed on 11/13/23. Deficiencies were cited. A change of ownership occurred on 6/6/23. Based on interview and record review, the residence failed to develop policies and procedures to establish a fall management program, affecting nine current residents and one former resident (#4).Specifically, on 9/8/23, Former Resident #4 fell out of a chair and had a skin tear on his wrist. The care plan for Former Resident #4 did not detail individualized approaches necessary to address fall risks related to deficits in strength, balance and eyesight. Subsequently, Former Resident #4 fell on 9/30/23 and was sent to the emergency department where he was diagnosed with a fractured right hip which required surgery. Findings include:1. References Regulations governing assisted livin.. Based on observation, interview and record review, the residence failed to ensure the residents had the right to be free from restraint, affecting three of three sample residents (#1, #2, #3).Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.42, defines restraint as any method or device used to involuntarily limit freedom of movement including, but not limited to, bodily physical force, mechanical devices, chemicals, or confinement. b. The residence' s undated Resident Right policy, read in part, "The right to live free from ... involuntary confinement, unless for their safety and welfare, except as allowed by the.. Based on observation, record review and interview, the residence failed to notify the department of a change in administrator, at least 30 calendar days in advance, affecting nine current residents.Findings include:On 11/13/23 at approximately 4:30 p.m., the acting administrator' s name and telephone number was posted on the wall of the residence.On 11/13/23, the department' s database read the administrator of record was the current administrator of the residence. On 11/13/23 at approximately 7:30 a.m., Staff #1 said the administrator of record was the owner and he hired the acting administrator to be the administrator. On 11/13/23 at approximately 11:00 a.m., the acting admi.. Based on record review and interview, the residence failed to evaluate a resident transferred to another health care entity prior to readmission, affecting one former resident (#4). (Cross-reference Q1180) Findings include:Former Resident #4 was admitted to the residence on 8/2/23 with diagnoses including dementia. Former Resident #4 passed away on 10/15/23 from a witnessed mechanical fall.An incident report in the record of Former Resident #4, dated 9/30/23, read Former Resident #4 fell on the ground and complained of pain in his right hip. Former Resident #4 was sent to the emergency department for evaluation.A practitioner' s progress note, dated 10/6/23, read the practitione.. 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 7.18.8 Resident records shall contain, but not be limited to, the following items:(D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs;(1) The assisted living residence shall requir..

A revisit survey was completed on 3/17/23 for all previous deficiencies cited on 12/27/22. 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