Winslow Court Retirement Community

A licensure complaint, prompted by #CO40697 and #CO40662, was completed on 8/12/25. Deficiencies were cited. Based on record review and interview the residence failed to detail specific personal service needs andpreferences along with staff tasks necessary to meet those needs affecting four of nine sample residents (#12, #14,Former Resident #16, and Former Resident #17). (Cross-reference U1010, U1110, and U2232)Specifically, Resident #12 entered the residence as a high-risk fall resident on 4/25/25. Resident #12 then continued to have frequent falls with injuries, such as bruising and a broken rib, between 6/23/25 and 7/30/25. During that time the residence performed multiple updates to care plans and assessments but did not include specific personal interventions for falls or directions to sta.. Based on record review and interview the residence failed to discharge Former Resident #17 who required moreservices that could be routinely provided by the assisted living residence, affecting one of nine sample residents.(Cross-reference U0430, U1110, and U1150)Specifically, Former Resident #17 entered the residence on 2/16/25 and on 3/19/25 a signed practitioner' sstatement read that Former Resident #17 required a secure environment; the residence did not have a securedenvironment. A physician notification dated 4/7/25 read that Former Resident #17 eloped from the residence andhad a fall which resulted in pain to his right shoulder joint. On 4/.. Based on record review and interview the residence failed to evaluate a resident after transfer and discharge toanother health care entity for additional care prior to re-admission to the residence affecting one of nine sampleresidents. (#12) (Cross-reference U1110)Findings Include1. Record ReviewResident #12 was admitted to the residence on 4/25/25 with a diagnosis of Parkinson' s disease, chronic pain, andrespiratory arrest. An assessment dated 7/1/25, did not include details of Resident #12' s mental health. On 7/30/25 an observation note read that Resident #12 was found in his room with self inflicted laceration to hisleft arm and to his abdomen and that Resident #12 was .. Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one of nine sample residents (#17). (Cross-reference U1010 and U1110)Findings include:1. Referencea. According to the Occurrence Reporting Manual, dated May 2018, "Any time that a resident or patient of the facility cannot be located following a search of the facility, the facility grounds, and the area surrounding the facility and there are circumstances that place the resident' s health, safety or welfare at risk or, regardless of whether such circumstances exist, the patient." Section 25-1-124 (2)(c), C.R.S. One element needed: At risk and missing after sear.. Based on record review, interview, and observations the residence failed to provide a physically safe environment,to include reducing the risk of potential hazards in the physical environment affecting two of nine sample residents(#12 and Former Resident #17). (Cross-reference U0430, U1010, U1150, U1068 and U2232)Specifically, Resident #12 was transferred to the emergency department via ambulance on 7/30/25 due to anattempted suicide by self-inflicted lacerations to his left arm and abdomen. Resident #12 returned to theresidence on 8/7/25. On 8/12/25, the resident care coordinator stated that the interventions for Resident #12 inplace to prevent further suicide attempts included ..

A relicensure with complaints revisit was completed on 8/12/25 for the previous deficiencies cited on 2/4/25. Deficiencies were cited. Tags U1110 and U2232 were not cited in the previous event, however, the deficiencies were included in the previous event' s informational 9999 tag.The deficiencies cited for Event JIC311 were cited prior to the regulation revision that was implemented on 3/17/25. Based on record review and interview the residence failed to detail specific personal service needs andpreferences along with staff tasks necessary to meet those needs affecting four of nine sample residents (#12, #14,Former Resident #16, and Former Resident #17). (Cross-reference U1010, U1110, and U2232)Specifically, Resident #12 entered the residence as a high-risk fall resident on 4/25/25. Resident #12 then continued to have frequent falls with injuries, su.. Based on record review and interview the residence failed to document, investigate, and resolve irregularities of the medication administration record audit affecting 110 current residents. (Cross-reference U1568)This deficiency was cited previously during a state licensure survey 2/4/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory Requirement.Findings include:Th.. Based on record review and interview the residence failed to ensure each resident had an updated face sheet with the required components, affecting two current (#12 and #13) and one former #17 resident(s). (Cross-referenceU1110 and U1150)Resident #13 was admitted to the residence on 5/19/25, no diagnoses were listed on the facesheet. An external provider' s progress note, dated 8/1/25, read Resident #13 had a past medical history of Alzheimer' sdisease, co.. Based on record review and interview, the residence failed to comply with authorized practitioner ordersassociated with medication administration except for those medications which a resident self-administer, affectingthree ( #7, #8 and #15) sample residents. (Cross-reference U1604)This deficiency was cited previously during a state licensure survey 2/4/25. Although the facility corrected thedeficiency, based on the findings below, the facility has not maintained c.. Based on record review, interview, and observations the residence failed to provide a physically safe environment,to include reducing the risk of potential hazards in the physical environment affecting two of nine sample residents(#12 and Former Resident #17). (Cross-reference U0430, U1010, U1150, U1068 and U2232)Specifically, Resident #12 was transferred to the emergency department via ambulance on 7/30/25 due to anattempted suicide by self-inflicted lac.. 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 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 7.22.35 Assisted living residences shall comply with the Colorado Clean Indoor Air Act at Sections 25-14201 through 25-14-209, C.R.S.

A licensure complaint revisit was completed on 2/4/25 for the previous deficiency cited on 1/27/21. The residence is in compliance with all regulations surveyed. 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 complaints #CO38975, #CO37685, #CO37340, #CO37057, and #CO35923 was completed on 2/4/25. Deficiencies were cited. Based on interview and record review the residence failed to comply with practitioner' s orders for three sample residents (#3, #6, #7) and one former resident (#10). (Cross-Reference S1604) Specifically, Former Resident #10 was prescribed fentanyl for severe pain on 1/13/24. The order read to place two 25 mcg patches and remove the old ones. The medication administration record (MAR) read the patches were placed on the resident on 4/18, 4/21, and 4/24/24. Then on 4/23/24, Former Resident #27 experienced a change in condition that included a fall and altered .. Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records, affecting four of nine sample residents (#3, #6, #7) and one former resident (#10). (Cross-reference S1568)Findings include: On 2/3/25 at 2:00 p.m., the quarterly medication cart audits were requested from the administrator. However, the administrator was unable to provide the requested documentation. On 2/4/25 at 2:12 p.m., the administrator stated the health and wellness director (HWD) was respon.. Based on observation and interview, the residence failed to keep the residence ramps in good repair, affecting 87 current residents.Findings include:1. ObservationOn 2/3/25 throughout the onsite visit from approximately 7:00 a.m. to 4:30 p.m., the ramp for the "b lot entrance" to the residence was observed to have broken and crumbling concrete at the front portion of the ramp supporting the metal grate covering the sump pump. On 2/4/25 throughout the onsite visit from approximately 7:00 a.m. to 2:30 p.m, the ramp for the "b lot entrance" to the residence was observed to h.. Based on observation, record review, and interview the residence failed to detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting two of 11 sample residents (#2, #8).Findings include:1. Record ReviewResident #8 was admitted on 5/31/21 with a diagnosis including stage four chronic kidney diseases, and pain in left and right shoulders. An assessment, dated 1/29/25, indicated that Resident #8 was at risk for falls and required high care. However, the assessment failed to mention that Resident #8 had a lim.. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 87 current residents. Findings include: On 2/3/25 at 2:00 p.m., the involuntary discharge grievance policy was requested from the administrator. The administrator provided the residence' s discharge policy; however, it did not comply with the requirements under Section 25-27-104.3, C.R.S.On 2/4/25 at 2:00 p.m., the administrator and the regional registered nurse stated they were aware of the involuntary d.. 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 7.6.5 An administrator training program shall meet all of the following requirements: (B) Completing a 30-hour administrator training program on or before December 31, 2018, and documenting an additional 10 hours of training in topics related to the assisted Living administrator' s responsibilities, regulatory upda..