FORUM PUEBLO NORTE ASSISTED LIVING

INSP-0069261

Complete

Date: 7/20/2023

Type: Compliance (Annual)

Worksheet: Assisted Living Center

SOD Sent: 2023-08-02

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on July 20, 2023:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
3. Includes the following:
f. For a resident who will be storing medication in the resident's bedroom or residential unit, how the medication will be stored and controlled;

Evidence/Findings:

Based on observation, record review, documentation review, and interview, for one resident who stored medications in their residential unit, the manager failed to ensure the service plan included how the medication was stored and controlled. The deficient practice posed a health and safety risk if medications were not stored in a safe manner.

Findings include:

1. During an environmental inspection with E1, the compliance officer observed R4's residential unit was unlocked, and had medications stored in the unit. The resident was not in the unit. Medications were observed in a medication organizer on a cabinet close to the unit entrance. The bedroom had a bottle of Acetaminophen in a basket, and an unlabeled bottle of unknown pills.

2. In record review, R4's service plan (received personal care services), dated March 13, 2023, documented, "... I am able to self-administer my medications... My daughter fills my medi set ... and I self admin meds..." R4's service plan did not include documentation of how the medication was stored and controlled.

3. In documentation review, a facility policy, titled "Resident Self-Administration of Medications,.. Revision date 11/14/05...," documented, ... "Storage of self-administered medications/treatments will comply with state/federal and Community requirements for medication storage..."

4. During an interview, E1 reported R4 self administered medications. E1 acknowledged R4's medications were stored were stored in R4's residential unit in an unlocked manner, and R4's service plan did not include how the medication was stored and controlled.

Deficiency #2

Rule/Regulation Violated:

F. When medication is stored by an assisted living facility, a manager shall ensure that:
1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

Evidence/Findings:

Based on observation, record review, and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked area used only for medication storage. The deficient practice posed a health and safety risk if medications were accessible to residents.

Findings include:

1. During an environmental inspection with E1, the compliance officer observed R3's unlocked residential unit contained two bottles of Miralax, a bottle of Acetaminophen, and Calmol 4 Suppositories. R3 was not in the unit during the inspection.

2. In record review, R3's service plan (received personal care services) documented "... need staff assistance for medication administration... will receive medications safely..."

3. During an interview, E1 acknowledged R3's residential unit was unlocked and contained medications, and R3 received medication administration services. E1 acknowledged the medications were not stored in a locked manner.

Deficiency #3

Rule/Regulation Violated:

A. A manager shall ensure that:
6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'ba F and 120\'ba F.

Findings include:

1. During an environmental inspection with E1, hot water temperatures were measured in the residential units of R3, R6, and R7. The hot water temperatures were above 120\'ba F:

R3's unit 221 - water temperature at 125.5 in the kitchen and 125.8 in the bathroom
R6's unit 215 - water temperature at 124.8
R7's unit 225 - water temperature at 124.8

3. During an interview, E1 observed and acknowledged the hot water temperatures in the residential units were above 120\'ba F.

Deficiency #4

Rule/Regulation Violated:

R9-10-120. Opioid Prescribing and Treatment
F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, including a health care institution in which an opioid may be prescribed or ordered as part of treatment, a medical director, a manager as defined in R9-10-801, or a provider, as applicable to the health care institution, shall:
1. Establish, document, and implement policies and procedures for administering an opioid as part of treatment or providing assistance in the self-administration of medication for a prescribed opioid, to protect the health and safety of a patient, that:
a. Cover which personnel members may administer an opioid in treating a patient and the required knowledge and qualifications of these personnel members;
b. Cover which personnel members may provide assistance in the self administration of medication for a prescribed opioid and the required knowledge and qualifications of these personnel members;
c. Include how, when, and by whom a patient ' s need for opioid administration is assessed;
d. Include how, when, and by whom a patient receiving an opioid is monitored; and
e. Cover how, when, and by whom the actions taken according to subsections (F)(1)(c) and (d) are documented;
2. Include in the plan for the health care institution ' s quality management program a process for:
a. Review of incidents of opioid-related adverse reactions or other negative outcomes a patient experiences or opioid-related deaths, and
b. Surveillance and monitoring of adherence to the policies and procedures in subsection (F)(1);
3. Except as prohibited by Title 42 Code of Federal Regulations, Chapter I, Subchapter A, Part 2, or as provided in subsection (H)(1), ensure that, if a patient's death may be related to an opioid administered as part of treatment, written notification, in a Department-prov

Evidence/Findings:

Based on documentation review and interview, the manager failed to establish and document policies and procedures for administering an opioid to protect the health and safety of a patient in compliance with R9-10-120.F. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. The Department was unable to determine substantial compliance as the documentation was not in the policies and procedures during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. In documentation review, a review of the facility's policy and procedures revealed the facility did not have a policy and procedures covering opioid administration per R9-10-120.F.

2. During an interview, E1 reported the facility had implemented procedures for administering opioid medications to residents; however acknowledged the facility did not have documented policies and procedures for administering opioid medication.

FORUM PUEBLO NORTE ASSISTED LIVING

Facility Information

Inspection History

INSP-0069263

Summary:

INSP-0069261

Summary:

Deficiencies Found: 4

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings: