LAKE VIEW COMMONS LLC

A certification complaint, prompted by CO42411, was completed on 6/16/26. A deficiency was cited.

Based on record review and interviews, the facility (residence) failed to provide care in a safe setting by ensuring services were provided to support the health and safety of members (facility) affecting one of six sample members (Former #5) Based on record review and interviews, the residence failed to provide care in a safe setting by ensuring services were provided in accordance with staff training to support the health and safety of residents affecting one (former Resident #5) of six sample residents. Specifically, Former Resident #5 had diagnoses including malignant neoplasm of the bladder and received hospice services. On 5/24/26, while eating dinner in the dining room of the residence, Former Resident #5 started coughing and spitting up food. Staff of the residence moved Former Resident #5 to an activities room in a wheelchair. Staff #1 contacted the residence's registered nurse (RN) and did not contact emergency medical services. No attempt was made to dislodge any food by performing the Heimlich maneuver or other first aid on Resident #5. Subsequently, Former Resident #5 passed away on 5/24/26 at the residence from asphyxia due to an airway obstruction. Findings include:1. ReferenceAccording to the National Library of Medicine; Do Not Resuscitate Order, dated 1/14/26 and retrieved on 6/22/26 from https://medlineplus.gov/ency/patientinstructions/000473.htm.,"A Do Not Resuscitate (DNR) order does not prevent a bystander or medical provider from performing the Heimlich maneuver (abdominal thrusts). A DNR only applies if a person's heart or breathing stops completely, whereas the Heimlich maneuver is an immediate intervention to remove a choking obstruction. "Choking & Responsive: If someone is actively choking but still has a pulse and breathing (even with difficulty), you should immediately perform the Heimlich maneuver and first-aid back blows. The goal is to clear the airway before cardiac or respiratory arrest occurs."2. Record reviewFormer Resident #5 was admitted to the residence on 12/30/25, with diagnoses including aortic atherosclerosis and chronic kidney disease. Former Resident #5 was admitted to hospice services on 5/11/26 after being hospitalized for a fall. A mass was discovered on her bladder during the hospitalization, and Former Resident #5 opted to be discharged back to the residence with hospice services. The death certificate for Former Resident #5, issued 5/28/26, listed the cause of death as asphyxia and airway obstruction, and not related to her hospice diagnosis. The residence's staff list indicated the current first aid training for Staff #1, #2, and #3, to include how to respond to choking per the American Red Cross First Aid Training curriculum. 2. InterviewsOn 6/16/26 at 9:29 a.m., Staff #2 stated Former Resident #5 was in the dining room for dinner on 5/24/26 and seated in a wheelchair at a table. Staff #2 observed Former Resident #5 coughing while drinking hot chocolate. Staff #2 approached Resident #5 with Staff #1 already at the side of the wheelchair. Staff #2 stated Resident #5's lips were purple. Staff #2 stated Staff #1 was on the phone with the residence's registered nurse (RN), and with guidance from the RN, Former Resident #5 was wheeled out of the dining room to an activities room down the hall. Staff #2 stated they retrieved a pulse oximeter and were unable to get a reading from Resident #5's finger. Staff #2 stated Former Resident #5 was taken to her apartment on the second floor and placed in her bed. Staff #2 said it appeared that Former Resident #5 was not breathing, their lips were purple, and they were losing color throughout their body by the time they were placed in bed. Staff #2 stated they were aware of Former Resident #5's Do Not Resuscitate (DNR) order and their hospice status. On 6/16/26 at 9:40 a.m., Staff #3 stated they took Resident #5 to the dining room for dinner and then went back to the second floor for other duties. Staff #3 said they saw Staff #1 and #2 bring Former Resident #5 back to her apartment, so they went to help with Former Resident #5. Staff #3 stated they helped move Former Resident #5 into bed and observed Former Resident #5 as very pale with purple lips and not responsive. Staff #3 stated they waited outside the apartment until a hospice nurse arrived approximately 20 minutes later. On 6/16/26 at 4:15 p.m., RN stated they received a phone call from Staff #1 to report that Former Resident #5 was having trouble eating and her skin was changing color. RN said Former Resident #5 started to vomit so she advised Staff #1 to move Former Resident #5 out of the dining room and into an activity room for privacy. RN told Staff #1 and #2 to get a pulse oximeter, and they reported no pulse could be measured, though a pulse could be seen on a vein on Resident #5's neck. RN stated the staff reported that Former Resident #5 had been slumped over in the wheelchair and her lips had been turning blue. During this time, RN called the hospice triage line to request that the on-call nurse go to the residence. RN advised Staff #1 to move Former Resident #5 to their apartment on the second floor, and this was done. RN said that while they were talking to the hospice staff on the phone, Staff #1 said that Former Resident #5 had passed away. In regards to if anything should have been done differently during the event, RN stated Resident #5 stopped breathing and had no pulse, so to honor Former Resident #5's DNR order, nothing more should have been done. -However, interviews revealed Former Resident #5 had not ceased to breathe or have a pulse until staff had moved her to her apartment. Former Resident #5 was never provided the Heimlich maneuver to resolve the choking while in the dining room, activities room, or in her apartment before staff determined she had died. On 6/16/26 at 3:30 p.m., a triage hospice nurse stated they responded to an earlier call from the residence about a fall without injury that Former Resident #5 had experienced earlier in the day of 5/24/26. The hospice nurse said they called the residence to check on Former Resident #5 and was told Resident #5 was not doing well. The hospice nurse arrived at the residence approximately an hour later and was informed that Resident #5 had passed away. The hospice nurse contacted the coroner because the death was not related to the terminal diagnosis of Former Resident #5, and hospice had not considered Former Resident #5 to be actively dying. The hospice nurse stated the event was reported as happening quickly but noted the Heimlich maneuver could have been done if choking was suspected, including methods that could be done without being harmful to patients. The hospice nurse reported receiving a call from the coroner about one week after Former Resident #5's death to report that food was found in the esophagus during the autopsy. On 6/16/26 at 12:30 p.m., the administrator stated they were not in the residence during this event. The administrator stated the RN called to report the passing of Former Resident #5 and the events leading up to the death. The administrator went to the residence after the phone call. The administrator stated Staff #1 and #2 described the event and their response. The administrator stated Staff #1 expressed not being sure if Former Resident #5 was choking due to vomiting during the event.

A licensure complaint, prompted by CO42410, was completed on 6/16/26. A deficiency was cited.

Based on record review and interviews, the residence failed to provide care in a safe setting by ensuring services were provided in accordance with staff training to support the health and safety of residents affecting one (former Resident #5) of six sample residents. Specifically, Former Resident #5 had diagnoses including malignant neoplasm of the bladder and received hospice services. On 5/24/26, while eating dinner in the dining room of the residence, Former Resident #5 started coughing and spitting up food. Staff of the residence moved Former Resident #5 to an activities room in a wheelchair. Staff #1 contacted the residence's registered nurse (RN) and did not contact emergency medical services. No attempt was made to dislodge any food by performing the Heimlich maneuver or other first aid on Resident #5. Subsequently, Former Resident #5 passed away on 5/24/26 at the residence from asphyxia due to an airway obstruction. Findings include:1. ReferenceAccording to the National Library of Medicine; Do Not Resuscitate Order, dated 1/14/26 and retrieved on 6/22/26 from https://medlineplus.gov/ency/patientinstructions/000473.htm.,"A Do Not Resuscitate (DNR) order does not prevent a bystander or medical provider from performing the Heimlich maneuver (abdominal thrusts). A DNR only applies if a person's heart or breathing stops completely, whereas the Heimlich maneuver is an immediate intervention to remove a choking obstruction. "Choking & Responsive: If someone is actively choking but still has a pulse and breathing (even with difficulty), you should immediately perform the Heimlich maneuver and first-aid back blows. The goal is to clear the airway before cardiac or respiratory arrest occurs."2. Record reviewFormer Resident #5 was admitted to the residence on 12/30/25, with diagnoses including aortic atherosclerosis and chronic kidney disease. Former Resident #5 was admitted to hospice services on 5/11/26 after being hospitalized for a fall. A mass was discovered on her bladder during the hospitalization, and Former Resident #5 opted to be discharged back to the residence with hospice services. The death certificate for Former Resident #5, issued 5/28/26, listed the cause of death as asphyxia and airway obstruction, and not related to her hospice diagnosis. The residence's staff list indicated the current first aid training for Staff #1, #2, and #3, to include how to respond to choking per the American Red Cross First Aid Training curriculum. 2. InterviewsOn 6/16/26 at 9:29 a.m., Staff #2 stated Former Resident #5 was in the dining room for dinner on 5/24/26 and seated in a wheelchair at a table. Staff #2 observed Former Resident #5 coughing while drinking hot chocolate. Staff #2 approached Resident #5 with Staff #1 already at the side of the wheelchair. Staff #2 stated Resident #5's lips were purple. Staff #2 stated Staff #1 was on the phone with the residence's registered nurse (RN), and with guidance from the RN, Former Resident #5 was wheeled out of the dining room to an activities room down the hall. Staff #2 stated they retrieved a pulse oximeter and were unable to get a reading from Resident #5's finger. Staff #2 stated Former Resident #5 was taken to her apartment on the second floor and placed in her bed. Staff #2 said it appeared that Former Resident #5 was not breathing, their lips were purple, and they were losing color throughout their body by the time they were placed in bed. Staff #2 stated they were aware of Former Resident #5's Do Not Resuscitate (DNR) order and their hospice status. On 6/16/26 at 9:40 a.m., Staff #3 stated they took Resident #5 to the dining room for dinner and then went back to the second floor for other duties. Staff #3 said they saw Staff #1 and #2 bring Former Resident #5 back to her apartment, so they went to help with Former Resident #5. Staff #3 stated they helped move Former Resident #5 into bed and observed Former Resident #5 as very pale with purple lips and not responsive. Staff #3stated they waited outside the apartment until a hospice nurse arrived approximately 20 minutes later. On 6/16/26 at 4:15 p.m., RN stated they received a phone call from Staff #1 to report that Former Resident #5 was having trouble eating and her skin was changing color. RN said Former Resident #5 started to vomit so she advised Staff #1 to move Former Resident #5 out of the dining room and into an activity room for privacy. RN told Staff #1 and #2 to get a pulse oximeter, and they reported no pulse could be measured, though a pulse could be seen on a vein on Resident #5's neck. RN stated the staff reported that Former Resident #5 had been slumped over in the wheelchair and her lips had been turning blue. During this time, RN called the hospice triage line to request that the on-call nurse go to the residence. RN advised Staff #1 to move Former Resident #5 to their apartment on the second floor, and this was done. RN said that while they were talking to the hospice staff on the phone, Staff #1 said that Former Resident #5 had passed away. In regards to if anything should have been done differently during the event, RN stated Resident #5 stopped breathing and had no pulse, so to honor Former Resident #5's DNR order, nothing more should have been done. -However, interviews revealed Former Resident #5 had not ceased to breathe or have a pulse until staff had moved her to her apartment. Former Resident #5 was never provided the Heimlich maneuver to resolve the choking while in the dining room, activities room, or in her apartment before staff determined she had died. On 6/16/26 at 3:30 p.m., a triage hospice nurse stated they responded to an earlier call from the residence about a fall without injury that Former Resident #5 had experienced earlier in the day of 5/24/26. The hospice nurse said they called the residence to check on Former Resident #5 and was told Resident #5 was not doing well. The hospice nurse arrived at the residence approximately an hour later and was informed that Resident #5 had passed away. The hospice nurse contacted the coroner because the death was not related to the terminal diagnosis of Former Resident #5, and hospice had not considered Former Resident #5 to be actively dying. The hospice nurse stated the event was reported as happening quickly but noted the Heimlich maneuver could have been done if choking was suspected, including methods that could be done without being harmful to patients. The hospice nurse reported receiving a call from the coroner about one week after Former Resident #5's death to report that food was found in the esophagus during the autopsy. On 6/16/26 at 12:30 p.m., the administrator stated they were not in the residence during this event. The administrator stated the RN called to report the passing of Former Resident #5 and the events leading up to the death. The administrator went to the residence after the phone call. The administrator stated Staff #1 and #2 described the event and their response. The administrator stated Staff #1 expressed not being sure if Former Resident #5 was choking due to vomiting during the event.

A relicensure survey was completed on 4/23/26. No deficiencies were cited.

A recertification survey was completed on 4/23/26. No deficiencies were cited.

A certification complaint, prompted by #CO33725, was completed on 9/17/24. No deficiencies were cited.

A licensure complaint, prompted by #CO33724, was completed on 9/17/24. No deficiencies were cited.

A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 4/6/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 4/6/23. 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 recertification survey was completed on 4/6/23. A deficiency was cited.

Based on record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting three of three sample participants (residents) (#1-#3). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, require the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. The residence's Medication and Treatment Administration policy, dated 2/3/22, read, in part: "All medications and treatments will be administered with a provided order in a timely manner. If an order cannot be followed, the provider will be notified and the situation will be documented in the resident record...Timely administration of medications/treatments means the medication/treatment is administered as close to the scheduled time as possible. 1 hour before or after the time scheduled. If unable, reasoning will be documented." a. Resident #1 was admitted to the residence on 9/22/22 with diagnoses that included Parkinson's disease. A written practitioner's order, dated 1/11/23, directed the residence to administer Carbidopa-Levodopa 25-100 milligram (mg) five times daily at 7:00 a.m., 10:00 a.m., 1:00 p.m., 4:00 p.m. and 7:00 p.m. However, the March and April 2023 electronic medication administration records (eMARs) for Resident #1 read the medication was administered late on the following days and times:3/4/23 at 11:53 a.m., 2:10 p.m. and 8:20 p.m. 3/5/23 at 8:55 a.m. and 12:33 p.m. 3/7/23 at 8:31 p.m. 3/17/23 at 8:12 p.m. 3/23/23 at 5:31 p.m. 3/24/23 at 8:08 p.m. 3/28 at 8:04 p.m. 4/1/23 at 8:13 p.m. Progress notes for March 2023 in Resident #1's record revealed that Resident #1 had unwitnessed falls on 3/5/23 at 3:02 a.m., 3/8/23 at 8:45 p.m., 3/24/23 at 2:15 p.m., and 3/25/23 at 6:23 a.m. InterviewsOn 4/6/23 at 4:08 p.m., a registered nurse of Resident #1's stated the efficacy of the Carbidopa-Levodopa weans if not given timely and placed him at high risk for falling. On 4/6/23 at approximately 4:15 p.m., the medication manager (MM) said the reason the medication was scheduled for Resident #1 was because it helped manage his Parkinson's disease symptoms. b. Resident #2 was admitted to the residence on 3/27/23 with diagnoses that included atrial fibrillation. A written practitioner's order, dated 3/22/23, directed the residence to administer Carvedilol 3.125 mg twice daily at 7:00 a.m. and 5:00 p.m. However, the March and April 2023 eMARs for Resident #2 read the medication was administered late on 3/27/23 at 6:41 p.m., 3/29/23 at 7:27 p.m., and 4/1/23 at 8:28 p.m. 2. Chapter VII regulations governing assisted living residence, part 14.33, requires that the assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of a resident's repetitive request for and use of PRN medications. The residence's Medication and Treatment Administration policy, dated 2/3/22, read, in part: "Residents have the right to refuse medications/treatments. If a resident refuses a medication/treatment, the following will occur...If a nurse determines that the medication/treatment being refused has the ability to cause a significant adverse event...the provider will be notified by midnight of the next calendar day...If there is a pattern of refusals (e.g. 3 consecutive refusals), the provider and responsible party shall be taken into consideration and nursing judgment shall be used." a. Resident #3 was admitted to the residence on 5/28/19. A written practitioner's order, dated 3/9/23, directed the residence to administer Oxybutynin Chloride 5 mg twice daily. However, the March and April 2023 eMARs for Resident #3 read the medication was refused every morning from 3/26-4/5/23, for a total of 11 doses refused. The March and April 2023 progress notes for Resident #3 did not include any notification of Resident #3 refusing her medications. On 4/6/23 at 8:15 a.m., Staff #4 stated Resident #3 had been refusing her Oxybutynin medication for the last week because it caused her to have a dry mouth. On 4/6/23 at 9:15 a.m., Resident #3 stated she had been refusing the Oxybutynin medication for the last two weeks in the morning. On 4/6/23 at approximately 4:15 p.m. the MM said the residence was aware Resident #3 had been refusing her Oxybutynin in the morning. She added she was not aware if the practitioner had been notified, as required. On 4/6/23 at approximately 4:45 p.m., the administrator said she expected the practitioner for Resident #3 to have been notified of her pattern of medication refusal. She said she expected a nurse to document in the progress note or the eMAR's for residents. 3. Chapter VII regulations governing assisted living residences, part 14.31, requires the administrator and the QMAP (qualified medication administration person) supervisor to, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The residence's Medication and Treatment Administration policy, dated 2/3/22, read, in part: "A consultant pharmacist will provide random observation of personnel responsible for medication administration. These observations include but are not inclusive to...Review of medication record for accuracy and compliance with MD (doctor of medicine) /NP (nurse practitioner) order and state/federal regulations." On 4/6/23 at 8:45 a.m., the residence's last two medication audits that included accuracy and completeness of the MARs, controlled substance lists, medication error reports and medication disposal records were requested. On 4/6/23 at approximately 1:00 p.m., the residence's medication cart audits and controlled substance lists were provided. The residence's QMP (quality management program) included review of the prior year's medication error report. On 4/6/23 at approximately 4:45 p.m., the administrator said she was not aware she was required to complete a quarterly audit of the accuracy of the MARs, controlled substance list, medication error reports and medication disposal records with the QMAP supervisor.

A relicensure survey was completed on 4/6/23. Deficiencies were cited.

Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 46 current residents. Findings include:1. References a. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that's useful in many emergencies, such as a heart attack or near drowning, in which someone's breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to both untrained bystanders and first responders." Mayo Clinic (5/1/21) Cardiopulmonary Resuscitation, retrieved from: https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 b. According to the American Red Cross: "Obstructed Airway Care for Adults...If the patient is able to speak to you or is coughing forcefully: Encourage the patient to keep coughing but be prepared to clear the airway if the patient's condition changes...Obtain consent...Perform abdominal thrusts...Perform alternate techniques-back blows, chest thrusts, or airway management...Continue to clear the airway ...If the patient becomes unresponsive, carefully lower them to a firm, flat surface, while protecting their head. Immediately begin CPR, starting with chest compressions. After each set of compressions and before ventilation, open the patient's mouth and look for the object-if seen, remove it using a finger sweep." Skill Sheet: Obstructed Airway Care for Adults and Children (2019). Retrieved from: https://www.redcrosslearning.com/course-bin/bls-healthcare-resuscitation/app/content/a/en-US/resources/SS-Obstructed-Airway-Care-for-Adults-and-Children.pdf c. According to Very Well Health, "For employees required to have CPR training, OSHA (Occupational Safety and Health Association) standards specify that OSHA online-only certifications are not acceptable. Many employers, especially healthcare organizations, only accept certification from the American Red Cross or the American Heart Association. Those cannot be obtained online." Rod Brouhard EMT (4/20/22) Are Online Certifications Valid, retrieved from: https://www.verywellhealth.com/are-online-cpr-certifications-valid-12984232. Record Reviewa. Staff CPR CertificationsThe following staff received CPR certifications from an organization that was not nationally recognized, as follows:Staff #4 on 3/23/22. Staff #5 on 5/9/22. Staff #6 on 3/6/22.b. Staffing ScheduleReview of the March and April 2023 staffing schedule revealed not nationally recognized staff worked, as follows:Staff #4 worked on 3/23-3/26, 3/31-4/2 and 4/6/23. Staff #5 worked on 3/23-3/24, 3/29-4/2 and 4/5/23. Staff #6 worked on 3/27, 4/4-4/6/23. 3. InterviewsOn 4/6/23 at 2:51 p.m., a representative from the certification company where Staff #4 received her CPR certification from said she had completed an online-only certification. On 4/6/23 at approximately 4:15 p.m., the administrator stated Staff #5 confirmed her certification was completed online only. On 4/6/24 at 4:45 p.m., the administrator acknowledged the CPR/obstructed airway training was required to be from a nationally recognized organization and was working on getting the rest of the staff certified, as required.

Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents, their room assignments and emergency contact information, along with a diagram showing room locations, affecting 46 current residents. Findings include:On 4/6/23 at 8:45 a.m., the administrator was asked to provide a resident roster according to the regulations. On 4/6/23 at 9:35 p.m., the administrator provided a list of residents and their room numbers. There was no emergency contact information listed or a diagram that showed room locations. On 4/6/23 at approximately 4:45 p.m., the administrator said she was not aware of the resident roster requirement, which included emergency contact and diagram.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#1-#3). (Cross-reference Q1514)Findings include:1. Residence PolicyThe residence's Medication and Treatment Administration policy, dated 2/3/22, read, in part: "All medications and treatments will be administered with a provided order in a timely manner. If an order cannot be followed, the provider will be notified and the situation will be documented in the resident record...Timely administration of medications/treatments means the medication/treatment is administered as close to the scheduled time as possible. 1 hour before or after the time scheduled. If unable, reasoning will be documented." 2. Resident #1 was admitted to the residence on 9/22/22 with diagnoses that included Parkinson's disease. A written practitioner's order, dated 1/11/23, directed the residence to administer Carbidopa-Levodopa 25-100 milligram (mg) five times daily at 7:00 a.m., 10:00 a.m., 1:00 p.m., 4:00 p.m. and 7:00 p.m. However, the March and April 2023 electronic medication administration records (eMARs) for Resident #1 read the medication was administered late on the following days and times:3/4/23 at 11:53 a.m., 2:10 p.m. and 8:20 p.m. 3/5/23 at 8:55 a.m. and 12:33 p.m. 3/7/23 at 8:31 p.m. 3/17/23 at 8:12 p.m. 3/23/23 at 5:31 p.m. 3/24/23 at 8:08 p.m. 3/28 at 8:04 p.m. 4/1/23 at 8:13 p.m. Progress notes for March 2023 in Resident #1's record revealed that Resident #1 had unwitnessed falls on 3/5/23 at 3:02 a.m., 3/8/23 at 8:45 p.m., 3/24/23 at 2:15 p.m., and 3/25/23 at 6:23 a.m. On 4/6/23 at 4:08 p.m., a registered nurse of Resident #1's stated the efficacy of the Carbidopa-Levodopa weans if not given timely and placed him at high risk for falling. On 4/6/23 at approximately 4:15 p.m., the medication manager (MM) said the reason the medication was scheduled for Resident #1 was because it helped manage his Parkinson's disease symptoms. 3. Resident #2 was admitted to the residence on 3/27/23 with diagnoses that included atrial fibrillation. A written practitioner's order, dated 3/22/23, directed the residence to administer Carvedilol 3.125 mg twice daily at 7:00 a.m. and 5:00 p.m. However, the March and April 2023 eMARs for Resident #2 read the medication was administered late on 3/27/23 at 6:41 p.m., 3/29/23 at 7:27 p.m., and 4/1/23 at 8:28 p.m. 4. Resident #3 was admitted to the residence on 5/28/19. A written practitioner's order, dated 3/9/23, directed the residence to administer Systane Ultra one drop into each eye four times daily. However, the March and April eMARs for Resident #3 read the medication was not administered because the resident was out of the residence on 3/28 and 4/5/23 in the afternoon, for a total of two missed doses. On 4/6/23 at approximately 4:15 p.m., the MM said she expected the qualified medication administration person (QMAP) to administer medications for residents before they left the residence. 5. InterviewOn 4/6/23 at approximately 4:45 p.m., the administrator said she expected medications to be administered to residents, as ordered, and not run out of stock. She added, if a resident was out of the residence for whatever reason, staff were expected to administer their medications, as ordered.

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) at least quarterly audited the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting three of three sample residents (#1-#3). (Cross-reference Q1468)Findings include:The residence's Medication and Treatment Administration policy, dated 2/3/22, read, in part: "A consultant pharmacist will provide random observation of personnel responsible for medication administration. These observations include but are not inclusive to...Review of medication record for accuracy and compliance with MD (doctor of medicine) /NP (nurse practitioner) order and state/federal regulations." On 4/6/23 at 8:45 a.m. the residence's last two medication audits that included accuracy and completeness of the MARs, controlled substance lists, medication error reports and medication disposal records were requested. On 4/6/23 at approximately 1:00 p.m., the residence's medication cart audits and controlled substance lists were provided. The residence's QMP (quality management program) included review of the prior year's medication error report. On 4/6/23 at approximately 4:45 p.m., the administrator said she was not aware she was required to complete a quarterly audit of the accuracy of the MARs, controlled substance list, medication error reports and medication disposal records with the QMAP supervisor.

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 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status. 12.10 Each resident care plan shall:(A) Be developed with input from the resident and the resident's representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers along with care coordination arrangements; and(F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident's personal choices and needs. 12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following:(A) Providing fall management education and materials to residents and family members;(B) Detailing in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment;(C) Providing resident engagement activities to improve strength and balance as specified in Part 12.22(C);(D) Routinely inspecting and maintaining a safe exterior and interior environment as specified in Parts 21 and 22; and(E) Providing staff training related to fall prevention as specified in Part 7.8(B)(6). 14.33 The assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of:(B) A resident's pattern of refusal