INGLENOOK AT BRIGHTON

A licensure complaint, prompted by #CO33502, was completed on 9/6/23. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure the resident agreement included a list of specific assisted living residence services included for the agreed upon rates and charges, affecting 59 residents. Findings include: 1. Resident Agreement The residence's Resident Agreement, undated, read in part: "We will evaluate your service needs by assessing your functional capabilities, physical status,mental condition, and social factors. By using an assessment tool that assigns point values to specific services, we will analyze the results of completed assessment and calculate your level of care. For details regarding this assessment, please refer to the attached Levels of Care Assessment Worksheet." 2. Record Review On 9/6/23 at approximately 9:00 a.m., review of sample Resident #38, #43, #44 and former Resident #42 and #45's signed resident agreement revealed no completed levels of care assessment worksheets were attached, as required. 3. InterviewsOn 9/6/23 at 9:32 a.m., the marketing director stated he was not aware that the completed level of care assessment conducted by the residence's wellness director needed to be attached to the resident agreement, as required. On 9/6/23 at 10:22 a.m., the administrator stated the resident agreements did not individually list the separate care levels and what care was provided. She added, "It's not specifically written down in the agreement. It's not broken down and itemized. It's a question I get a lot from families. They ask what that includes. I'd like to see it more broken down."

Based on record review and interview, the residence failed to notify the responsible party regarding a resident's change of condition, affecting one former resident (#45). Findings include:The residence's undated Unanticipated Illness, Serious Injury, Significant Change of Status from Baseline Status, or Death of the Participant policy, read in part, "This community notifies a participant's emergency contact person, the primary care provider and the appropriate case managers when an unanticipated illness, serious injury or death occurs."Former Resident #45 was admitted to the residence on 3/2/23 with diagnoses including congestive heart failure. A progress note for Former Resident #45, dated 6/14/23, read the residence reported to Former Resident #45's practitioner that she lost 10 pounds in one month. A practitioner's progress note for Former Resident #45, dated 6/15/23, read Former Resident #45 had lost 28 pounds in three months. On 9/6/23 at 8:00 a.m., a family member of Former Resident #45 said he was never notified by the residence in June 2023 about Former Resident #45's weight loss. He added Former Resident #45's practitioner notified him in June and not the residence. On 9/6/23 at 11:31 a.m., the administrator stated she considered weight loss a change in baseline for residents. The administrator said the residence had not contacted the family member of Former Resident #45 when she experienced weight loss in June 2023. She added, "They (Residence) did not contact family because the PCP (primary care physician) said she was going to contact them." The administrator said residence staff should have contacted the family member instead of the practitioner.

Based on interview and record review, the residence failed to observe resident food consumption on a regular basis in order to detect unplanned changes such as weight gain or weight loss and changes in consumption that may indicate the need for assistance with eating shall be reported to the resident's practitioner, affecting 59 residents. (Cross-reference Q1162)Findings include: 1. Former Resident #45 was admitted to the residence on 3/2/23. A progress note for Former Resident #45, dated 6/14/23 read the residence reported to Former Resident #45's practitioner that she lost 10 pounds in one month. A practitioner's progress note for Former Resident #45, dated 6/15/23 read Former Resident #45 had lost 28 pounds in three months. 2. InterviewsOn 9/5/23 at 1:58 p.m., Staff #20 stated the residence required a practitioner's order for the kitchen staff to monitor changes in resident food consumption. On 9/5/23 at 1:02 p.m., the health services director said the residence had nothing in place to detect unplanned changes in resident food consumption. She added a practitioner's order was required for staff to track resident food consumption. On 9/5/23 at 1:08 p.m., Staff #21 and #22 said if a resident was not eating consistently they reported the concern to the front desk. On 9/6/23 at 9:49 p.m., the resident care coordinator stated the residence never tracked resident food consumption. On 9/6/23 at 9:53 p.m., Staff #23 said the residence did not track resident food consumption. 9/6/23 at 10:22 a.m., the administrator said the resident food consumption was monitored more closely in the secure environment part of the residence. She added, in assisted living the dining room servers noticed resident food consumption and notified the care staff. The administrator stated the residence could have done a better job at monitoring resident food consumption.

Based on record review and interview, the residence failed to ensure a family member of a former resident (#45) was allowed to inspect that former resident's own record. (Cross-reference Q2016)Findings include:Chapter VII regulations governing assisted living residences, part 18.8, requires that resident records must contain, but not be limited to, the following items:(A) Face Sheet,(B) Practitioner order,(C) Individualized resident care plan,(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 require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them.(E) Medication Administration Record,(F) Documentation of on-going services provided by external service providers including, but not limited to, family members, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants and caregivers;(G) Advance directives, if applicable, with extra copies.(H) Final disposition of resident including, if applicable, date, time, and circumstances of a resident ' s death, along with the name of the person to whom the body is released. Former Resident #45 was admitted to the residence on 3/2/23. An email correspondence from a family member of Former Resident #45 to the administrator, dated 8/1/23, read the family member requested Former Resident #45's records. On 9/5/23 at 12:20 p.m., a family member of Former Resident #45 said on 8/10/23 she requested via email to the administrator, a copy of Former Resident #45's records. She added she had not received any of Former Resident #45's records as of the day of the onsite visit on 9/5/23. On 9/6/23 at 11:33 a.m., the administrator said she considered resident records to include progress notes, care plan and practitioner contact information. She added, if a family member requested their loved ones records she expected the family member to receive the records within five to seven days of the initial request. She added she received an email from the family member of Former Resident #45 in August 2023 that requested records, however, she said the email was misinterpreted and no follow up was made to clarify the misinterpretation. The administrator said she expected the family member of Former Resident #45 to receive the records within five to seven days.

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:(F) Documentation of on-going services provided by external service providers including, but not limited to, family members, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants, and caregivers;

A certification complaint, prompted by #CO33503, was completed on 9/6/23. A deficiency was cited.

Based on interviews and record reviews the facility (residence) failed to specify the services to be provided, the charges associated with the services and written disclosures of that information, affecting 59 participants (residents). Findings include: 1. Reference and Resident Agreement a. Chapter VII regulations governing assisted living residences, part 11.6, requires the written resident agreement shall specify the understanding between the parties concerning, at a minimum, the following items: (C) A list of specific assisted living residence services included for the agreed upon rates and charges, along with a list of all available optional services and the specified charge for each;b. The residence's Resident Agreement, undated, read in part: "We will evaluate your service needs by assessing your functional capabilities, physical status,mental condition, and social factors. By using an assessment tool that assigns point values to specific services, we will analyze the results of completed assessment and calculate your level of care. For details regarding this assessment, please refer to the attached Levels of Care Assessment Worksheet." 2. Record ReviewOn 9/6/23 at approximately 9:00 a.m., review of sample Resident #38, #43 and #44's signed resident agreement revealed no completed levels of care assessment worksheets were attached, as required. 3. Interviews On 9/6/23 at 9:32 a.m., the marketing director stated he was not aware that the completed level of care assessment conducted by the residence's wellness director needed to be attached to the resident agreement, as required. On 9/6/23 at 10:22 a.m., the administrator stated the resident agreements did not individually list the separate care levels and what care was provided. She added, "It's not specifically written down in the agreement. It's not broken down and itemized. It's a question I get a lot from families. They ask what that includes. I'd like to see it more broken down."

A certification revisit was completed on 4/12/23 for the previous deficiency cited on 9/28/22. The facility is in compliance with all regulations surveyed.

A licensure revisit was completed on 4/12/23 for all previous deficiencies cited on 9/28/22. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 59 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for six months. Following the completion of Event 9LK611 on 9/28/22, a licensure survey and complaint investigation, the department imposed a RN consultant for six months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the RN consultant was required to complete the following, during the first month of the contract period:- Review each of the cited deficiencies identified in the Deficiency List, for Event 9LK611 and dated September 28, 2022, with the Administrator, and evaluate the Residence's current compliance with corresponding regulations as outlined in 6 CCR 1011-1 Chapters 2, 7, and 24, where applicable. The RN consultant was required to complete the following, during the first two months of the contract period:- Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Administrator on any additional areas of noncompliance. The RN Consultant would also implement a monitoring program, to be completed at least monthly, to ensure the Residence remains in compliance with previously cited deficiencies. The monitoring program will be incorporated into the Residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, Section 4. The RN Consultant will make certain that the QMP was designed to improve resident safety and well-being, and promoted continued quality improvement to enhance service delivery. The RN consultant was required to complete the following, during the first two months of the contract period:- Conduct onsite visits at least weekly, increasing the frequency as necessary to assist the Residence in maintaining compliance with 6 CCR 1011-1 Chapter 2, Chapter 7, and Chapter 24 and, to prepare the Administrator to independently manage the residence. The RN consultant was required to complete the following, during the third through sixth month of the contract period: - Conduct onsite visits at least twice monthly, increasing the frequency as necessary to assist the Residence in maintaining compliance with 6 CCR 1011-1 Chapter 2, Chapter 7, and Chapter 24. During these visits, the RN consultant will provide adequate training, mentoring, and monitoring, and prepare the Administrator to independently manage the Residence. The RN consultant was required to complete the following, during the final two months of the contract period: - Prepare the Administrator to independently manage the Facility to ensure compliance with all applicable regulations governing assisted living residences. The RN Consultant shall make certain that the Administrator has tools and resources in place to maintain compliance. Additionally, the RN consultant was required to ensure, during the entire six month contract period, for each of the deficiencies identified in the Deficiency List, for Event 9LK611 and dated September 28, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. The RN Consultant will make certain that the monitoring identified the scope of review, how a sample was identified for monitoring purposes, the total length of time the monitoring would continue, and how the monitoring would be documented. The RN consultant was required to submit a report to the department on a monthly basis during the contract period, to detail progress, identified areas of deficient practice and the actions taken by the administrator to correct the deficient practice. The RN consultant was required to submit a final report to the department, following the end of the contract period, that contains the prior information as well as the actions taken to ensure the administrator has tools and resources in place to maintain compliance. Consultant Contract Attachments read: The consultant contract and any successor consultant contract shall reference and have as attachments the following documents:- A copy of the notice letter, and all notice letter attachments, dated November 8, 2022 and- Statement of deficiencies dated September 28, 2022. Contract Cancellation read in part: (I) Licensee/Facility shall not cancel or amend this contract without the prior written Department approval.(II) In the event that either party determines it is necessary to cancel this contract, the party canceling shall provide written notification to the other party and to the Department no less than fourteen calendar days prior to the date of cancellation. In the event of such cancellation, Licensee/Facility shall, within seven calendar days of such cancellation date, provide the Department with the name of the intended successor consultant for Department approval. The Department will either approve or not approve the intended successor consultant, and notify the Licensee of such decision within ten days of receipt of letter. The Licensee/Facility shall not employ an intended successor consultant until Department approves the intended successor consultant. The Department reserves the right to contact the intended successor consultant, if necessary, to determine whether the intended successor consultant is appropriate to complete the above duties and requirements. Once the Department approves the intended successor consultant, the Licensee/Facility shall submit a copy of the fully signed successor consultant contract to the Department within three calendar days. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible RN consultant, due by 12/1/22.- Submit executed RN consultant contract to the department, due by 12/9/22.- Submit final RN consultant report, due by 6/15/23. Department records read the residence had identified multiple RN consultants on 11/16/22, 11/28/22 and 12/1/22 that were unable to be approved. The residence chose an RN consultant on 12/7/22 and was approved. Additionally, the contract for the RN consultant was received on 12/30/22. Therefore, on the date of the completion of the licensure revisit, (4/11/23), the RN consultant would have been in his fifth month as consultant for the residence. 2. Current deficient practiceDuring the 4/11-4/12/23 licensure revisit, the revisit established there was current deficient practice. Six deficiencies were recited and one additional tag was cited, including tags 540, 910, 1350, 1468, 1510, 1514 and 290. (Cross-reference Q540, Q910, Q1350, Q1468, Q1510, Q1514, and B290). On 4/11/23 at 2:16 p.m., the administrator stated she was aware the residence had been under a department-issued intermediate condition. The administrator confirmed she was aware the residence had to obtain an RN consultant. The administrator stated that she had heard the terms of the intermediate condition included compliance with all regulations during the term. She stated she believed the residence had complied with the requirements. At 2:45 p.m., the administrator stated that the RN consultant had been working on medication audits with the health services director (HSD). She stated the RN consultant worked on training the HSD for her position. The administrator stated the RN consultant worked on ensuring the residence was in compliance with regulations. The administrator was unable to provide additional areas of work that were completed with the RN consultant. She stated she believed the residence had done their part to meet the requirements outlined in the department-issued intermediate condition letter. On 4/12/23 at 10:32 a.m., the RN consultant stated she had supported the residence's clinical team. She stated she completed monthly audits in some areas. However, she did not disclose what areas she had completed monthly audits on. In regards to tag 1468, the RN consultant stated every time she had been at the residence she asked how many medications had been unavailable that day. She stated it was at least one or two medications that had been unavailable at each visit. The RN consultant stated she was unsure if the residence had documented what they were doing to resolve the medication issues. She stated she thought the residence staff had followed up with the pharmacy when medication was unavailable. In regards to tag 1510, the RN consultant stated the residence electronic records system had a software issue. She stated she had discussed with the HSD that she needed to print out the exception report daily and go to each qualified medication administration person to find out why medications were not documented when they were administered. The RN consultant stated she was not made aware of the software issues with the electronic records system until the date of the interview (4/12/23). In regards to tag 1514, the RN consultant stated she could not speak in regards to audits because she was not sure if the administrator had been completing them. Contrary to her previous statement, the RN consultant stated she had made sure medication cart audits had been completed. She added the external pharmacy was currently completing a medication cart audit during the interview. In regards to tag 540, the RN consultant stated she had no difficulties with the administrator. She stated she asked the administrator questions and the administrator was able to answer the questions. The RN consultant stated, based on the regulation, the administrator was required to have oversight on all areas of the day to day operation. She stated she could not speak in regards to what the administrator had direct oversight over, and added the administrator would have needed to disclose that to the surveyor. In regards to the intermediate condition letter, the RN consultant stated she did not recall seeing the letter. She stated she was unsure of what the required terms of the consultant were according to the department-issued intermediate condition letter. 3. Failure to submit monthly reportsOn 4/11/23, the department database revealed the RN consultant had failed to submit a monthly report to the department in March 2023. The departments database revealed RN consultant reports had been submitted on 1/6/23 and 2/6/23. On 4/11/23 at 10:48 a.m., a representative from the external consulting agency stated she believed she had submitted the monthly report for March 2023 on 3/6/23 as she had all other reports. The representative confirmed she had not submitted the report as required and was unsure why she had not submitted the report. 4. Failure to obtain approval for a consultant changeThe department's database revealed the following emails were sent between the external consulting agency and department regarding RN consultant approval:On 12/1/22, email correspondence from the owner of the external consulting agency to the department to submit an RN consultant resume for an RN consultant based in Utah for temporary use while the company hired and trained an RN consultant based in Colorado. The submitted resume for the RN consultant revealed the requested consultant had no Colorado experience listed on her resume. Additionally, the owner of the external consulting agency was unable to provide a resume for a Colorado RN because they had not hired a Colorado RN consultant. On 12/5/22, email corresponded from a department representative to the owner of the external consulting agency "we are unable to approve this RN consultant due to the lack of regulatory knowledge in Colorado, the consultant's resume does not reflect experience in Colorado. Additionally, we are unable to approve temporary consultants without being able to also approve the intended Colorado RN consultant at the same time as we cannot approve a contract without verification the consultant has a CO (Colorado) license in good standing." The owner of the external consulting agency's response read; "(the RN consultant) does have extensive experience supporting Colorado communities. Would it help if I updated her resume? We can keep her on for the duration of the contract as well if that helps." The department representative's response read; "Yes, it would definitely help if the resume reflected that information for consideration. It would also be helpful if the (RN) consultant was able to remain in place the entire time period."On 12/6/22, the owner of the external consulting agency submitted an additional resume for the requested RN consultant. A meeting was set with the owner of the external consulting agency to discuss RN consultant requirements. On 12/7/22, the owner of the external consultant agency submitted an additional resume for a second intended consultant that met the requirements outlined in the department-issued intermediate condition letter. The intended consultant was approved by the department and a signed contract was requested. On 12/30/22, the department received the signed consultant contract dated 12/4/22. The signed contract read in part; "The lead consultant will be (approved RN consultant). He will be supervised by (the owner of the external consulting agency) and supported by other nurses from (the external consulting agency) as needed ..."During the 4/11-4/12/23 licensure revisit, it was identified the residence had not had consulting services completed by the approved RN consultant since 2/3/23. Additionally, the residence had utilized an unapproved RN consultant and had not notified the department of the change of RN consultant. On 4/11/23 at approximately 10:00 a.m., the administrator stated the name of the residence's RN consultant. The name was different from the department approved RN consultant listed in the departments database. The administrator confirmed the residence had utilized the named RN consultant since approximately February 2023. On 4/11/23 at 10:38 a.m., a representative from the external consultant agency stated the approved RN consultant had been in the residence consulting prior to the (un-approved) RN consultant. However, the current (un-approved) RN consultant was the Colorado RN consultant for the consulting agency. She stated the approved RN consultant had not visited the residence since 2/3/23. On 4/11/23 at 2:45 p.m., the administrator stated she was not aware the residence should have requested approval from the department for the current RN consultant. She stated she believed the external consulting agency was approved and not the individual RN consultant. The administrator stated she was aware that the department had denied another RN consultant from the same external consulting agency initially, as she was included on the email communication. The administrator confirmed the residence had not notified the department of a change in the RN consultant. On 4/12/23 at 10:32 a.m., the (un-approved) RN consultant stated she was not aware the department was required to be notified of a change in the RN consultant. She stated she believed the external consulting agency was approved and not the individual RN consultant. The RN consultant stated she had not seen the consulting contract nor was she aware the contract named the approved RN consultant.

Based on interview and record review, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting eight of eight sample residents #4, #13, #34, #38-#42). This deficiency was cited previously during a state licensure survey 9/28/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(I) Completing, maintaining, and submitting all reports and records required by the Department.b. Chapter VII regulations governing assisted living residences, part 18.8, requires that the resident record shall contain but not be limited to the following items: (B) Practitioner order; (D) Progress notes 2. Record reviewOn 4/11/23 at 8:18 a.m., the resident records for Residents #4, #13, #34, and #38-#42 were requested. On 4/11/23 at 11:47 a.m., progress notes and practitioner orders were requested for Residents #4, #13, #34, and #38-#42. On 4/11/23 at approximately 12:30 p.m., progress notes were provided for the aforementioned residents, approximately four hours after resident records were requested. On 4/11/23 at approximately 12:45 p.m., practitioner orders were provided for Resident #4, approximately four and a half hours after resident records were requested. On 4/11/23 at approximately 1:35 p.m., practitioner orders were provided for Resident #34, approximately five hours after resident records were requested. On 4/11/23 at approximately 2:16 p.m., the administrator stated she was confused about the records that were requested. She stated she was not sure exactly what belonged in a resident record. Additionally, she stated they had purged the resident records of recent practitioner's orders so they had to look for several orders. She stated the previous deficient practice was not corrected because she misunderstood what belonged in a resident record.

Based on interview and record review, the administrator failed to be responsible for managing the day-to-day operation of the assisted living residence, affecting 59 current residents. (Cross-reference Q1510, Q1514)Findings include:On 4/11/23 at approximately 10:00 a.m., electronic medication administration records (MAR) were provided for Residents #4, #39, and #40. However, the MARs read the health services director documented medications were administered even though she was not the staff member who administered the medications. On 4/11/23 at 10:19 a.m., Staff #18 stated the MAR system the residence used locked staff members out and the health services director had to go back at a later time to document that the medications were administered. On 4/11/23 at approximately 2:16 p.m., the health services director stated the MAR system the residence used would lock staff members out and she had to go back at a later time to document that the medications were administered. She stated she had been doing this for all 59 current residents since January 2023. On 4/11/23 at approximately 2:16 p.m., the administrator stated she was not aware there were medication documentation problems. She stated no one had reported to her that the electronic MAR system did not function properly; however, she confirmed she did not ask about it. She confirmed that she reviewed MARs with the nurse consultant; however, she did not find it concerning that the health services director documented medications as administered almost every day even though the health services director did not administer all the medications. Additionally, the administrator stated she should have had more oversight of the medications and performed medication audits as required to ensure there were no issues. The administrator confirmed she did not oversee the day-to-day management of medication services as required.

Based on interview and record review, the residence failed to have a roster of current residents that included their emergency contact information, along with a facility diagram showing room locations, affecting 59 current residents. Findings include:On 4/11/23 at approximately 7:00 a.m. the resident roster was requested and provided. However, the resident roster did not include the residents' emergency contact information, along with a facility diagram showing room locations. On 4/11/23 at approximately 2:16 p.m., the administrator stated she was not aware that residents' emergency contact information or a facility diagram showing room locations was required to be included with the resident roster. She stated that when emergency services entered the residence, she provided them with each resident's face sheet.

Based on observation, record review and interview, the residence failed to ensure the process for raising and addressing grievances and complaints was placed in a visible on-site location along with the full contact information for the Colorado Department of Health Care Policy and the advocacy services of the area's agency on aging, affecting 59 current residents. This deficiency was cited previously during a state licensure survey 9/28/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's undated Resident Grievance Policy did not include the full contact information for the Colorado Department of Health Care Policy and the advocacy services of the area's agency on aging. 2. ObservationOn 4/11/23 from 7:30 to 3:30 p.m., the residence had the grievance process placed in a visible on-site location. However, the posting did not include the full contact information for the Colorado Department of Health Care Policy and the advocacy services of the area's agency on aging. 3. InterviewOn 4/11/23 at 2:45 p.m., the administrator stated the previous deficient practice was not corrected because she was not aware the full contact information for the Colorado Department of Health Care Policy and the advocacy services of the area's agency on aging was required to be included in the grievance posting.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting four of seven sample residents (#4, #38, #39, #42). (Cross-reference Q1514)This deficiency was cited previously during a state licensure survey 9/28/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Medication Administration and Management policy, dated 2/1/23, read in part, the residence shall administer medications as ordered. 2. Resident #39 was admitted to the residence on 9/1/22 with diagnoses including anxiety.a. Sertraline A written practitioner order, dated 9/1/22, directed the residence to administer sertraline HCI 25 mg once daily. However, the March 2023 medication administration record (MAR) read the medication was not administered on 3/21, 3/22, 3/23, 3/25, 3/27, and 3/28/23, for a total of six missed doses due to the medication being out of stock.b. LevothyroxineA written practitioner order, dated 9/1/22, directed the residence to administer levothyroxine 100 mg once daily. However, the March 2023 MAR read the medication was not administered on 3/2 and 3/3/23 due to medication being out of stock, for a total of two missed doses.c. LeflunomideA written practitioner order, dated 9/1/22, directed the residence to administer leflunomide 10 mg once daily. However, the March 2023 MAR read the medication was not administered on 3/2/23 because it was not in stock, for a total of one missed dose. 3. Resident #42 was admitted to the residence on 5/5/22 with diagnosis including recurrent deep vein thrombosis.a. ChlorthalidoneA written practitioner's order, dated 3/6/23, directed the residence to administer chlorthalidone 25 mg once every two days. However, the March and April 2023 MAR read the medication was not administered on 3/7, 3/9, 3/13, 3/31, and 4/4, and 4/8/23, for a total of six missed doses due to the medication being out of stockb. Diclofenac sodiumA written practitioner's order, dated 1/30/23, directed the residence to administer diclofenac sodium gel 1% three times daily. However, the March 2023 MAR read the medication was not administered in the morning on 3/8, 3/14 and in the afternoon on 3/2, 3/9, and 3/14/23, for a total of five missed doses due to the medication being out of stock. 4. Resident #38 was admitted to the residence on 5/1/21. A written practitioner's order, dated 9/28/21, directed the residence to administer acetaminophen 500 mg every six hours for pain. However, the March and April 2023 MARs read the medication had been administered three times daily instead of four times daily from 3/1-4/10/23, for a total of 41 missed doses. 5. Resident #4 was admitted to the residence on 8/28/17 with diagnoses including eye disorder. A written practitioner's order, dated 11/29/22, directed the residence to administer artificial tears ophthalmic solution 1.4% one drop in each eye three to four times daily. However, the April 2023 MAR read artificial tears were administered five times daily on 4/1-4/7 and 4/9/23, for a total of at least eight additional doses. On 4/11/23 at 7:30 a.m., Staff #19 stated it was the health service director's responsibility to order medications if they were out of stock. On 4/11/23 at 7:45 a.m., the health services director stated medications were to be ordered by qualified medication administration persons and herself when there was a seven day supply left. She stated they often had to wait on the pharmacy to deliver medications which caused residents to not be administered medications as ordered. She confirmed she was responsible for transcribing medications onto the MAR.On 4/11/23 at 2:16 p.m., the administrator confirmed that Residents #4, #38, #39, and #42 were not administered medications as ordered. She stated the expectation was that medications were always in stock and transcribed onto the MAR as ordered. Additionally, she stated the deficient practice was not corrected because she had not provided the day to day oversight of medication management as required.

Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) shall accurately document each medication administration at the time the event was completed, affecting four of seven sample residents (#4, #13, #39, #40). (Cross-reference Q540, Q1514)This deficiency was cited previously during a state licensure survey 9/28/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. InterviewsOn 4/11/23 at 10:19 a.m., Staff #18 stated the electronic medication administration record (MAR) system the residence used locked staff members out and the health services director had to go back at a later time to document that the medications were administered. On 4/11/23 at approximately 2:16 p.m., the health services director (HSD) stated the MAR system the residence used locked staff members out and she had to go back at a later time to document that the medications were administered. She stated she had been doing this since January 2023. Further, the HSD confirmed she had documented the medications that QMAPs had administered to Residents #4, #13, #39 and #40, although she was not the QMAP who administered the medications. On 4/11/23 at approximately 2:16 p.m., the administrator stated she was not aware there were medication documentation problems. She stated no one had reported to her that the electronic MAR system did not function properly; however, she confirmed she did not ask about it. She confirmed that she reviewed MARs with the nurse consultant; however, she did not find it concerning that the HSD documented medications as administered almost every day even though the HSD did not administer all the medications. Additionally, the administrator stated she should have had more oversight of the medications and performed medication audits as required to ensure there were no issues. The administrator confirmed she did not oversee the day-to-day management of medications as required. 2. Resident #4 was admitted to the residence on 8/28/17 with diagnoses including arthritis and eye disorder.a. AcetaminophenA written practitioner's order, dated 6/20/22, directed the residence to administer acetaminophen 325 mg three times daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/1, 3/6, 3/7, 3/14, 3/26 at 12:30 a.m., 3/13 and 3/15/23 at 7:30 a.m., for a total of seven instances.b. RopiniroleA written practitioner's order, dated 6/20/22, directed the residence to administer ropinirole HCI 1 mg three times daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication for all three doses on 3/1/3 and the morning dose on 3/15/23, for a total of four instances. c. SennaA written practitioner's order, dated 6/20/22, directed the residence to administer senna 8.6 mg twice daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication for both doses on 3/13 and the morning dose on 3/15/23, for a total of three instances.d. SertralineA written practitioner's order, dated 6/20/22, directed the residence to administer sertraline HCI 100 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/15/23, for a total of two missed doses.e. OmeprazoleA written practitioner's order, dated 5/17/22, directed the residence to administer omeprazole 40 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/1 and 3/3/23, for a total of two instances.f. Potassium chlorideA written practitioner's order, dated 6/20/22, directed the residence to administer potassium chloride 20 MEQ once every morning. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/15/23, for a total of two instances.g. Acidophilus probioticA written practitioner's order, dated 1/17/23, directed the residence to administer acidophilus probiotic once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/15/23, for a total of two instances.h. MorphineA written practitioner's order, dated 3/20/23, directed the residence to administer morphine sulfate extended release 15 mg three times daily. However, the March 2023 MAR read the medication administration was documented as administered by the health services director and not the QMAP who administered the medication at 12:30 a.m. on 3/26/23, for a total of one instance. i. FurosemideA written practitioner's order, dated 1/18/22, directed the residence to administer furosemide 40 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/15/23, for a total of two instances. j. LevothyroxineA written practitioner's order, dated 6/20/22, directed the residence to administer levothyroxine 125 mcg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/1 and 3/3/23, for a total of two instances.k. MiralaxA written practitioner's order, dated 1/18/22, directed the residence to administer Miralax powder 17 grams per scoop once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/15/23, for a total of two instances. 3. Resident #39 was admitted to the residence on 9/1/22 with diagnoses including anxiety.a. BuspironeA written practitioner's order, dated 9/1/22, directed the residence to administer buspirone HCI 20 mg twice daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication for both doses on 3/13 and the morning dose on 3/24/23, for a total of three instances.b. Calcium carbonateA written practitioner's order, dated 9/1/22, directed the residence to administer calcium carbonate 1250 mg twice daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication for both doses on 3/13 and the morning dose on 3/24/23, for a total of three instances.c. SertralineA written practitioner's order, dated 9/1/22, directed the residence to administer sertraline HCI 175 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/14 and 3/24/23, for a total of two instances.d. LeflunomideA written practitioner's order, dated 9/1/22, directed the residence to administer leflunomide 10 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/24/23, for a total of two instances.e. ProtonixA written practitioner's order, dated 9/1/22, directed the residence to administer Protonix 20 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/24/23, for a total of two instances.f. SulfasalazineA written practitioner's order, dated 9/1/22, directed the residence to administer sulfasalazine 500 mg twice daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication for both doses on 3/13 and the morning dose on 3/24/23, for a total of three instances.g. AtorvastatinA written practitioner's order, dated 9/1/22 directed the residence to administer atorvastatin calcium 40 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance.h. LevothyroxineA written practitioner's order, dated 9/1/22, directed the residence to administer levothyroxine sodium 100 mcg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/1/23, for a total of one instance. 4. Resident #38 was admitted to the residence on 4/26/21 with diagnoses including dementia.a. LevetiracetamA written practitioner's order, dated 4/26/21, directed the residence to administer levetiracetam 500 mg twice daily. However, the March and April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 4/6 at 8:00 a.m. and 3/8/23 at 6:00 p.m., for a total of three instances.b. DonepezilA written practitioner's order, dated 4/26/21, directed the residence to administer donepezil 10 mg once daily. However, the March and April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 4/6/23, for a total of two instances.c. FurosemideA written practitioner's order, dated 8/1/22, directed the residence to administer furosemide 20 mg once daily. However, the March and April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 4/6/23, for a total of two instances.d. LevothyroxineA written practitioner's order, dated 4/26/21, directed the residence to administer levothyroxine 50 mcg once daily. However, the March and April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 4/6/23, for a total of two instances.e. SimvastatinA written practitioner's order, dated 4/26/21, directed the residence to administer simvastatin 20 mg once daily. However, the March and April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 4/6/23, for a total of two instances.f. FosamaxA written practitioner's order, dated 3/10/22, directed the residence to administer Fosamax 70 mg every Thursday. However, the April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 4/6/23, for a total of one instance. 5. Resident #13 was admitted to the residence on 2/14/14 with diagnoses including diabetes.a. JardianceA written practitioner's order, dated 6/21/22, directed the residence to administer Jardiance 25 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance.b. Losartan potassiumA written practitioner's order, dated 6/21/22, directed the residence to administer losartan potassium 100 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance.c. Polyethylene glycolA written practitioner's order, dated 6/21/22, directed the residence to administer polyethylene glycol 17 grams per scoop once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance.d. SertralineA written practitioner's order, dated 6/21/22, directed the residence to administer sertraline HCI 50 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance.e. SennaA written practitioner's order, dated 6/21/23, directed the residence to administer senna 8.8-50 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance.f. SpironolactoneA written practitioner's order, dated 6/21/22, directed the residence to administer spironolactone 25 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance.

Based on interview and record review, the residence failed to ensure the administrator and the qualified medication administration personnel (QMAP) supervisor audited on a quarterly basis, the accuracy and completeness of the medication administration records and document the results of the audits, affecting 59 current residents. (Cross-reference Q540, Q1468, Q1510)This deficiency was cited previously during a state licensure survey 9/28/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Finding include:On 4/11/23 at 8:18 a.m., the last three medication audits were requested. On 4/11/23 at approximately 10:15 a.m., medication cart audits were provided. The medication audits read that Staff #18 completed the medication audits. However, no evidence was provided to prove the administrator and QMAP supervisor completed audits quarterly. On 4/11/23 at approximately 7:45 a.m., the health services director stated she had not completed a medication audit and was not sure when the last medication audit had been completed. She confirmed she had never completed a medication audit with the administrator. She also stated the resident care coordinator was the QMAP supervisor. On 4/11/23 at approximately 2:16 p.m., the administrator confirmed she had no documented evidence to prove she and the QMAP supervisor had completed medication audits quarterly for all 59 current residents. She stated the QMAP supervisor was the resident care coordinator. She stated she was not aware of the requirement that medication audits were required to be completed quarterly with the QMAP supervisor and documented. Additionally, she stated the deficient practice was not corrected because she had not provided the day to day oversight of medication management as required.

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 certification revisit was completed on 4/12/23 for all previous deficiencies cited on 9/28/22. A deficiency was cited.

Based on record review and interview, the facility (residence) failed to comply with written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting 59 current participants (residents). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.29, requires that all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.a. InterviewsOn 4/11/23 at 10:19 a.m., Staff #18 stated the electronic medication administration record (MAR) system the residence used locked staff members out and the health services director had to go back at a later time to document that the medications were administered. On 4/11/23 at approximately 2:16 p.m., the health services director (HSD) stated the MAR system the residence used locked staff members out and she had to go back at a later time to document that the medications were administered. She stated she had been doing this since January 2023. Further, the HSD confirmed she had documented the medications that QMAPs had administered to Residents #4, #13, #39 and #40, although she was not the QMAP who administered the medications. On 4/11/23 at approximately 2:16 p.m., the administrator stated she was not aware there were medication documentation problems. She stated no one had reported to her that the electronic MAR system did not function properly; however, she confirmed she did not ask about it. She confirmed that she reviewed MARs with the nurse consultant; however, she did not find it concerning that the HSD documented medications as administered almost every day even though the HSD did not administer all the medications. Additionally, the administrator stated she should have had more oversight of the medications and performed medication audits as required to ensure there were no issues. The administrator confirmed she did not oversee the day-to-day management of medications as required.b. Resident #4 was admitted to the residence on 8/28/17 with diagnoses including arthritis and eye disorder. AcetaminophenA written practitioner's order, dated 6/20/22, directed the residence to administer acetaminophen 325 mg three times daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/1, 3/6, 3/7, 3/14, 3/26 at 12:30 a.m., 3/13 and 3/15/23 at 7:30 a.m., for a total of seven instances. RopiniroleA written practitioner's order, dated 6/20/22, directed the residence to administer ropinirole HCI 1 mg three times daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication for all three doses on 3/1/3 and the morning dose on 3/15/23, for a total of four instances. SennaA written practitioner's order, dated 6/20/22, directed the residence to administer senna 8.6 mg twice daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication for both doses on 3/13 and the morning dose on 3/15/23, for a total of three instances. SertralineA written practitioner's order, dated 6/20/22, directed the residence to administer sertraline HCI 100 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAPwho administered the medication on 3/13 and 3/15/23, for a total of two missed doses. OmeprazoleA written practitioner's order, dated 5/17/22, directed the residence to administer omeprazole 40 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/1 and 3/3/23, for a total of two instances. Potassium chlorideA written practitioner's order, dated 6/20/22, directed the residence to administer potassium chloride 20 MEQ once every morning. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/15/23, for a total of two instances. Acidophilus probioticA written practitioner's order, dated 1/17/23, directed the residence to administer acidophilus probiotic once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/15/23, for a total of two instances. MorphineA written practitioner's order, dated 3/20/23, directed the residence to administer morphine sulfate extended release 15 mg three times daily. However, the March 2023 MAR read the medication administration was documented as administered by the health services director and not the QMAP who administered the medication at 12:30 a.m. on 3/26/23, for a total of one instance. FurosemideA written practitioner's order, dated 1/18/22, directed the residence to administer furosemide 40 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/15/23, for a total of two instances. LevothyroxineA written practitioner's order, dated 6/20/22, directed the residence to administer levothyroxine 125 mcg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/1 and 3/3/23, for a total of two instances. MiralaxA written practitioner's order, dated 1/18/22, directed the residence to administer Miralax powder 17 grams per scoop once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/15/23, for a total of two instances.c. Resident #39 was admitted to the residence on 9/1/22 with diagnoses including anxiety. BuspironeA written practitioner's order, dated 9/1/22, directed the residence to administer buspirone HCI 20 mg twice daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication for both doses on 3/13 and the morning dose on 3/24/23, for a total of three instances. Calcium carbonateA written practitioner's order, dated 9/1/22, directed the residence to administer calcium carbonate 1250 mg twice daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication for both doses on 3/13 and the morning dose on 3/24/23, for a total of three instances. SertralineA written practitioner's order, dated 9/1/22, directed the residence to administer sertraline HCI 175 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/14 and 3/24/23, for a total of two instances. LeflunomideA written practitioner's order, dated 9/1/22, directed the residence to administer leflunomide 10 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/24/23, for a total of two instances. ProtonixA writtenpractitioner's order, dated 9/1/22, directed the residence to administer Protonix 20 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 3/24/23, for a total of two instances. SulfasalazineA written practitioner's order, dated 9/1/22, directed the residence to administer sulfasalazine 500 mg twice daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication for both doses on 3/13 and the morning dose on 3/24/23, for a total of three instances. AtorvastatinA written practitioner's order, dated 9/1/22 directed the residence to administer atorvastatin calcium 40 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance. LevothyroxineA written practitioner's order, dated 9/1/22, directed the residence to administer levothyroxine sodium 100 mcg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/1/23, for a total of one instance.d. Resident #38 was admitted to the residence on 4/26/21 with diagnoses including dementia. LevetiracetamA written practitioner's order, dated 4/26/21, directed the residence to administer levetiracetam 500 mg twice daily. However, the March and April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 4/6 at 8:00 a.m. and 3/8/23 at 6:00 p.m., for a total of three instances. DonepezilA written practitioner's order, dated 4/26/21, directed the residence to administer donepezil 10 mg once daily. However, the March and April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 4/6/23, for a total of two instances. FurosemideA written practitioner's order, dated 8/1/22, directed the residence to administer furosemide 20 mg once daily. However, the March and April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 4/6/23, for a total of two instances. LevothyroxineA written practitioner's order, dated 4/26/21, directed the residence to administer levothyroxine 50 mcg once daily. However, the March and April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 4/6/23, for a total of two instances. SimvastatinA written practitioner's order, dated 4/26/21, directed the residence to administer simvastatin 20 mg once daily. However, the March and April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13 and 4/6/23, for a total of two instances. FosamaxA written practitioner's order, dated 3/10/22, directed the residence to administer Fosamax 70 mg every Thursday. However, the April 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 4/6/23, for a total of one instance.e. Resident #13 was admitted to the residence on 2/14/14 with diagnoses including diabetes. JardianceA written practitioner's order, dated 6/21/22, directed the residence to administer Jardiance 25 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance. Losartan potassiumA written practitioner's order, dated 6/21/22, directed the residence to administer losartan potassium 100 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance. Polyethylene glycolA written practitioner's order, dated 6/21/22, directed the residence to administer polyethylene glycol 17 grams per scoop once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance. SertralineA written practitioner's order, dated 6/21/22, directed the residence to administer sertraline HCI 50 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance. SennaA written practitioner's order, dated 6/21/23, directed the residence to administer senna 8.8-50 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance. SpironolactoneA written practitioner's order, dated 6/21/22, directed the residence to administer spironolactone 25 mg once daily. However, the March 2023 MAR read the medication administration was documented as administered by the HSD and not the QMAP who administered the medication on 3/13/23, for a total of one instance. 2. Chapter VII regulations governing assisted living residences, part 14.21, requires that the assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Residence policyThe residence's Medication Administration and Management policy, dated 2/1/23, read in part, the residence shall administer medications as ordered.b. Resident #39 was admitted to the residence on 9/1/22 with diagnoses including anxiety. Sertraline A written practitioner order, dated 9/1/22, directed the residence to administer sertraline HCI 25 mg once daily. However, the March 2023 medication administration record (MAR) read the medication was not administered on 3/21, 3/22, 3/23, 3/25, 3/27, and 3/28/23, for a total of six missed doses due to the medication being out of stock. LevothyroxineA written practitioner order, dated 9/1/22, directed the residence to administer levothyroxine 100 mg once daily. However, the March 2023 MAR read the medication was not administered on 3/2 and 3/3/23 due to medication being out of stock, for a total of two missed doses. LeflunomideA written practitioner order, dated 9/1/22, directed the residence to administer leflunomide 10 mg once daily. However, the March 2023 MAR read the medication was not administered on 3/2/23 because it was not in stock, for a total of one missed dose.c. Resident #42 was admitted to the residence on 5/5/22 with diagnosis including recurrent deep vein thrombosis. ChlorthalidoneA written practitioner's order, dated 3/6/23, directed the residence to administer chlorthalidone 25 mg once every two days. However, the March and April 2023 MAR read the medication was not administered on 3/7, 3/9, 3/13, 3/31, and 4/4, and 4/8/23, for a total of six missed doses due to the medication being out of stockDiclofenac sodiumA written practitioner's order, dated 1/30/23, directed the residence to administer diclofenac sodium gel 1% three times daily. However, the March 2023 MAR read the medication was not administered in the morning on 3/8, 3/14 and in the afternoon on 3/2, 3/9, and 3/14/23, for a total of five missed doses due to the medication being out of stock.d. Resident #38 was admitted to the residence on 5/1/21. A written practitioner's order, dated 9/28/21, directed the residence to administer acetaminophen 500 mg every six hours for pain. However, the March and April 2023 MARs read the medication had been administered three times daily instead of four times daily from 3/1-4/10/23, for a total of 41 missed doses. e. Resident #4 was admitted to the residence on 8/28/17 with diagnoses including eye disorder. A written practitioner's order, dated 11/29/22, directed the residence to administer artificial tears ophthalmic solution 1.4% one drop in each eye three to four times daily. However, the April 2023 MAR read artificial tears were administered five times daily on 4/1-4/7 and 4/9/23, for a total of at least eight additional doses. On 4/11/23 at 7:30 a.m., Staff #19 stated it was the health service director's responsibility to order medications if they were out of stock. On 4/11/23 at 7:45 a.m., the health services director stated medications were to be ordered by qualified medication administration persons and herself when there was a seven day supply left. She stated they often had to wait on the pharmacy to deliver medications which caused residents to not be administered medications as ordered. She confirmed she was responsible for transcribing medications onto the MAR.On 4/11/23 at 2:16 p.m., the administrator confirmed that Residents #4, #38, #39, and #42 were not administered medications as ordered. She stated the expectation was that medications were always in stock and transcribed onto the MAR as ordered. Additionally, she stated the deficient practice was not corrected because she had not provided the day to day oversight of medication management as required. 3. Chapter VII regulations governing assisted living residences, part 14.31, requires the administrator and the QMAP supervisor shall, 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 results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review. On 4/11/23 at 8:18 a.m., the last three medication audits were requested. On 4/11/23 at approximately 10:15 a.m., medication cart audits were provided. The medication audits read that Staff #18 completed the medication audits. However, no evidence was provided to prove the administrator and QMAP supervisor completed audits quarterly. On 4/11/23 at approximately 7:45 a.m., the health services director stated she had not completed a medication audit and was not sure when the last medication audit had been completed. She confirmed she had never completed a medication audit with the administrator. She also stated the resident care coordinator was the QMAP supervisor. On 4/11/23 at approximately 2:16 p.m., the administrator confirmed she had no documented evidence to prove she and the QMAP supervisor had completed medication audits quarterly. She stated the QMAP supervisor was the resident care coordinator. She stated she was not aware of the requirement that medication audits were required to be completed quarterly with the QMAP supervisor and documented. Additionally, she stated the deficient practice was not corrected because she had not provided the day to day oversight of medication management as required. 4. Chapter VII regulations governing assisted living residences, part 14.11, requires that only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.a. Residence policyThe residence's Medication Administration and Management policy, dated 2/1/23, read in part, only medications that had been ordered by an authorized practitioner be administered to residents.b. Resident #4 was admitted to the residence on 8/28/17 with diagnoses including eye disorder. MyrbetriqThe March and April 2023 medication administration record (MAR) read the resident was administered Myrbetriq 50 mg once daily from 3/1-4/10/23, for a total of 41 doses. However, the residence was unable to provide a written practitioner's order for the medication. Ophthalmic ointmentThe March and April 2023 MAR read the resident was administered ophthalmic ointment every night at bedtime from 3/1-4/10/23, for a total of 41 doses. However, the residence was unable to provide a written practitioner's order for the medication. On 4/11/23 at 2:16 p.m., the administrator confirmed she was unable to locate the practitioner's order for Resident #42 and had to contact the pharmacy for the practitioner order. She stated the expectation was that only medications ordered by a practitioner were administered to a resident. Additionally, she stated the deficient practice was not corrected because she had not provided the day to day oversight of medication management as required.c. Resident #42 was admitted to the residence on 5/5/22 with diagnosis including recurrent deep vein thrombosis. The March and April 2023 MAR read the resident was administered Eliquis 2.5 mg twice daily from 3/1-4/10/23, for a total of 82 doses. However, the residence was unable to provide a written practitioner's order for the medication. On 4/11/23 at 12:45 p.m., the health services director stated she was unable to locate the written practitioner's order for the Eliquis and ointment. She confirmed the resident was administered the medications; however, she had to contact the pharmacy to get the order.

A licensure revisit was completed on 4/12/23 for all previous deficiencies cited on 9/28/22. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 59 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for six months. Following the completion of Event 9LK611 on 9/28/22, a licensure survey and complaint investigation, the department imposed a RN consultant for six months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the RN consultant was required to complete the following, during the first month of the contract period:- Review each of the cited deficiencies identified in the Deficiency List, for Event 9LK611 and dated September 28, 2022, with the Administrator, and evaluate the Residence's current compliance with corresponding regulations as outlined in 6 CCR 1011-1 Chapters 2, 7, and 24, where applicable. The RN consultant was required to complete the following, during the first two months of the contract period:- Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Administrator on any additional areas of noncompliance. The RN Consultant would also implement a monitoring program, to be completed at least monthly, to ensure the Residence remains in compliance with previously cited deficiencies. The monitoring program will be incorporated into the Residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, Section 4. The RN Consultant will make certain that the QMP was designed to improve resident safety and well-being, and promoted continued quality improvement to enhance service delivery. The RN consultant was required to complete the following, during the first two months of the contract period:- Conduct onsite visits at least weekly, increasing the frequency as necessary to assist the Residence in maintaining compliance with 6 CCR 1011-1 Chapter 2, Chapter 7, and Chapter 24 and, to prepare the Administrator to independently manage the residence. The RN consultant was required to complete the following, during the third through sixth month of the contract period: - Conduct onsite visits at least twice monthly, increasing the frequency as necessary to assist the Residence in maintaining compliance with 6 CCR 1011-1 Chapter 2, Chapter 7, and Chapter 24. During these visits, the RN consultant will provide adequate training, mentoring, and monitoring, and prepare the Administrator to independently manage the Residence. The RN consultant was required to complete the following, during the final two months of the contract period: - Prepare the Administrator to independently manage the Facility to ensure compliance with all applicable regulations governing assisted living residences. The RN Consultant shall make certain that the Administrator has tools and resources in place to maintain compliance. Additionally, the RN consultant was required to ensure, during the entire six month contract period, for each of the deficiencies identified in the Deficiency List, for Event 9LK611 and dated September 28, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. The RN Consultant will make certain that the monitoring identified the scope of review, how a sample was identified for monitoring purposes, the total length of time the monitoring would continue, and how the monitoring would be documented. The RN consultant was required to submit a report to the department on a monthly basis during the contract period, to detail progress, identified areas of deficient practice and the actions taken by the administrator to correct the deficient practice. The RN consultant was required to submit a final report to the department, following the end of the contract period, that contains the prior information as well as the actions taken to ensure the administrator has tools and resources in place to maintain compliance. Consultant Contract Attachments read: The consultant contract and any successor consultant contract shall reference and have as attachments the following documents:- A copy of the notice letter, and all notice letter attachments, dated November 8, 2022 and- Statement of deficiencies dated September 28, 2022. Contract Cancellation read in part: (I) Licensee/Facility shall not cancel or amend this contract without the prior written Department approval.(II) In the event that either party determines it is necessary to cancel this contract, the party cancelling shall provide written notification to the other party and to the Department no less than fourteen calendar days prior to the date of cancellation. In the event of such cancellation, Licensee/Facility shall, within seven calendar days of such cancellation date, provide the Department with the name of the intended successor consultant for Department approval. The Department will either approve or not approve the intended successor consultant, and notify the Licensee of such decision within ten days of receipt of letter. The Licensee/Facility shall not employ an intended successor consultant until Department approves the intended successor consultant. The Department reserves the right to contact the intended successor consultant, if necessary, to determine whether the intended successor consultant is appropriate to complete the above duties and requirements. Once the Department approves the intended successor consultant, the Licensee/Facility shall submit a copy of the fully signed successor consultant contract to the Department within three calendar days. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible RN consultant, due by 12/1/22.- Submit executed RN consultant contract to the department, due by 12/9/22.- Submit final RN consultant report, due by 6/15/23. Department records read the residence had identified multiple RN consultants on 11/16/22, 11/28/22 and 12/1/22 that were unable to be approved. The residence chose an RN consultant on 12/7/22 and was approved. Additionally, the contract for the RN consultant was received on 12/30/22. Therefore, on the date of the completion of the licensure revisit, (4/11/23), the RN consultant would have been in his fifth month as consultant for the residence. 2. Current deficient practiceDuring the 4/11-4/12/23 licensure revisit, the revisit established there was current deficient practice. Three deficiencies were recited and one additional tag was cited: tags 910, 1430, 1468 and 2606. (Cross-reference Q910, Q1430, Q1468 and Q2606). On 4/11/23 at 2:16 p.m., the administrator stated she was aware the residence had been under a department-issued intermediate condition. The administrator confirmed she was aware the residence had to obtain an RN consultant. The administrator stated that she had heard the terms of the intermediate condition included compliance with all regulations during the term. She stated she believed the residence had complied with the requirements. At 2:45 p.m., the administrator stated that the RN consultant had been working on medication audits with the health services director (HSD). She stated the RN consultant worked on training the HSD for her position. The administrator stated the RN consultant worked on ensuring the residence was in compliance with regulations. The administrator was unable to provide additional areas of work that were completed with the RN consultant. She stated she believed the residence had done their part to meet the requirements outlined in the department-issued intermediate condition letter. On 4/12/23 at 10:32 a.m., the RN consultant stated she had supported the residence's clinical team. She stated she completed monthly audits in some areas. However, she did not disclose what areas she had completed monthly audits on. In regards to tag 2606, the RN consultant stated she had completed weekly audits on oxygen to ensure the oxygen was stored appropriately. She stated she had identified one concern with a new admission that they had not appropriately secured the resident's oxygen. The RN consultant stated she discussed the concern with the administrator and addressed it. In regards to tags 1430 and 1468, the RN consultant stated every time she had been at the residence she asked how many medications had been unavailable that day. She stated it was at least one or two medications that had been unavailable at each visit. The RN consultant stated she was unsure if the residence had documented what they were doing to resolve the medication issues. She stated she thought the residence staff had followed up with the pharmacy when medication was unavailable. The RN consultant stated she believed the residence had organized the resident records and ensured all records contained medication order for all medications. In regards to the intermediate condition letter, the RN consultant stated she did not recall seeing the letter. She stated she was unsure of what the required terms of the consultant were according to the department-issued intermediate condition letter. 3. Failure to submit monthly reportsOn 4/11/23, the department database revealed the RN consultant had failed to submit a monthly report to the department in March 2023. The departments database revealed RN consultant reports had been submitted on 1/6/23 and 2/6/23. On 4/11/23 at 10:48 a.m., a representative from the external consulting agency stated she believed she had submitted the monthly report for March 2023 on 3/6/23 as she had all other reports. The representative confirmed she had not submitted the report as required and was unsure why she had not submitted the report. 4. Failure to obtain approval for a consultant changeThe departments database revealed the following emails had been from and to the external consulting agency regarding RN consultant approval:On 12/1/22, email correspondence from the owner of the external consulting agency to the department to submit an RN consultant resume for an RN consultant based in Utah for temporary use while the company hired and trained an RN consultant based in Colorado RN.The submitted resume for the RN consultant revealed the requested consultant had no Colorado experience listed on her resume. Additionally, the owner of the external consulting agency was unable unable to provide a resume for a Colorado RN because they had not hired a Colorado RN consultant. On 12/5/22, email corresponded from a department representative to the owner of the external consulting agency "we are unable to approve this RN consultant due to the lack of regulatory knowledge in Colorado, the consultant's resume does not reflect experience in Colorado. Additionally, we are unable to approve temporary consultants without being able to also approve the intended Colorado RN consultant at the same time as we cannot approve a contract without verification the consultant has a CO (Colorado) license in good standing." The owner of the external consulting agency's response read; "(the RN consultant) does have extensive experience supporting Colorado communities. Would it help if I updated her resume? We can keep her on for the duration of the contract as well if that helps." The department representative's response read; "Yes, it would definitely help if the resume reflected that information for consideration. It would also be helpful if the (RN) consultant was able to remain in place the entire time period."On 12/6/22, the owner of the external consulting agency submitted an additional resume for the requested RN consultant. A meeting was set with the owner of the external consulting agency to discuss RN consultant requirements. On 12/7/22, the owner of the external consultant agency submitted an additional resume for a second intended consultant that met the requirements outlined in the department-issued intermediate condition letter. The intended consultant was approved by the department and a signed contract was requested. On 12/30/22 the department received the signed consultant contract dated 12/4/22. The signed contract read in part; "The lead consultant will be (approved RN consultant). He will be supervised by (the owner of the external consulting agency) and supported by other nurses from (the external consulting agency) as needed ..."During the 4/11-4/12/23 licensure revisit, it was identified the residence had not had consulting services completed by the approved RN consultant since 2/3/23. Additionally, the residence had utilized an unapproved RN consultant and had not notified the department of the change of RN consultant. On 4/11/23 at approximately 10:00 a.m., the administrator stated the name of the residence's RN consultant. The name was different from the department approved RN consultant listed in the departments database. The administrator confirmed the residence had utilized the named RN consultant since approximately February 2023. On 4/11/23 at 10:38 a.m., a representative from the external consultant agency stated the approved RN consultant had been in the residence consulting prior to the (un-approved) RN consultant. However, the current (un-approved) RN consultant was the Colorado RN consultant for the consulting agency. She stated the approved RN consultant had not visited the residence since 2/3/23. On 4/11/23 at 2:45 p.m., the administrator stated she was not aware the residence should have requested approval from the department for the current RN consultant. She stated she believed the external consulting agency was approved and not the individual RN consultant. The administrator stated she was aware that the department had denied another RN consultant by from the same external consulting agency initially as she was included on the email communication. The administrator confirmed the residence had not notified the department of a change in the RN consultant. On 4/12/23 at 10:32 a.m., the (un-approved) RN consultant stated she was not aware the department was required to be notified of a change in the RN consultant. She stated she believed the external consulting agency was approved and not the individual RN consultant. The RN consultant stated she had not seen the consulting contract nor was she aware the contract named the approved RN consultant.

Based on interview and record review, the residence failed to have a roster of current residents that included their emergency contact information, along with a facility diagram showing room locations, affecting 59 current residents. Findings include:On 4/11/23 at approximately 7:00 a.m. the resident roster was requested and provided. However, the resident roster did not include the residents' emergency contact information, along with a facility diagram showing room locations. On 4/11/23 at approximately 2:16 p.m., the administrator stated she was not aware that residents' emergency contact information or a facility diagram showing room locations was required to be included with the resident roster. She stated that when emergency services entered the residence, she provided them with each resident's face sheet.

Based on interview and record review, the residence failed to ensure only medication that had been ordered by an authorized practitioner be prepared for or administered to residents, affecting two of seven sample residents (#4, #42). This deficiency was cited previously during a state licensure survey 9/28/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Medication Administration and Management policy, dated 2/1/23, read in part, only medications that had been ordered by an authorized practitioner be administered to residents. 2. Resident #4 was admitted to the residence on 8/28/17 with diagnoses including eye disorder.a. MyrbetriqThe March and April 2023 medication administration record (MAR) read the resident was administered Myrbetriq 50 mg once daily from 3/1-4/10/23, for a total of 41 doses. However, the residence was unable to provide a written practitioner's order for the medication.b. Ophthalmic ointmentThe March and April 2023 MAR read the resident was administered ophthalmic ointment every night at bedtime from 3/1-4/10/23, for a total of 41 doses. However, the residence was unable to provide a written practitioner's order for the medication. On 4/11/23 at 2:16 p.m., the administrator confirmed she was unable to locate the practitioner's order for Resident #42 and had to contact the pharmacy for the practitioner order. She stated the expectation was that only medications ordered by a practitioner were administered to a resident. Additionally, she stated the deficient practice was not corrected because she had not provided the day to day oversight of medication management as required. 3. Resident #42 was admitted to the residence on 5/5/22 with diagnosis including recurrent deep vein thrombosis. The March and April 2023 MAR read the resident was administered Eliquis 2.5 mg twice daily from 3/1-4/10/23, for a total of 82 doses. However, the residence was unable to provide a written practitioner's order for the medication. On 4/11/23 at 12:45 p.m., the health services director stated she was unable to locate the written practitioner's order for the Eliquis and ointment. She confirmed the resident was administered the medications; however, she had to contact the pharmacy to get the order.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting four of seven sample residents (#4, #38, #39, #42). This deficiency was cited previously during a state licensure survey 9/28/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Medication Administration and Management policy, dated 2/1/23, read in part, the residence shall administer medications as ordered. 2. Resident #39 was admitted to the residence on 9/1/22 with diagnoses including anxiety.a. Sertraline A written practitioner order, dated 9/1/22, directed the residence to administer sertraline HCI 25 mg once daily. However, the March 2023 medication administration record (MAR) read the medication was not administered on 3/21, 3/22, 3/23, 3/25, 3/27, and 3/28/23, for a total of six missed doses due to the medication being out of stock.b. LevothyroxineA written practitioner order, dated 9/1/22, directed the residence to administer levothyroxine 100 mg once daily. However, the March 2023 MAR read the medication was not administered on 3/2 and 3/3/23 due to medication being out of stock, for a total of two missed doses.c. LeflunomideA written practitioner order, dated 9/1/22, directed the residence to administer leflunomide 10 mg once daily. However, the March 2023 MAR read the medication was not administered on 3/2/23 because it was not in stock, for a total of one missed dose. 3. Resident #42 was admitted to the residence on 5/5/22 with diagnosis including recurrent deep vein thrombosis.a. ChlorthalidoneA written practitioner's order, dated 3/6/23, directed the residence to administer chlorthalidone 25 mg once every two days. However, the March and April 2023 MAR read the medication was not administered on 3/7, 3/9, 3/13, 3/31, and 4/4, and 4/8/23, for a total of six missed doses due to the medication being out of stockb. Diclofenac sodiumA written practitioner's order, dated 1/30/23, directed the residence to administer diclofenac sodium gel 1% three times daily. However, the March 2023 MAR read the medication was not administered in the morning on 3/8, 3/14 and in the afternoon on 3/2, 3/9, and 3/14/23, for a total of five missed doses due to the medication being out of stock. 4. Resident #38 was admitted to the residence on 5/1/21. A written practitioner's order, dated 9/28/21, directed the residence to administer acetaminophen 500 mg every six hours for pain. However, the March and April 2023 MARs read the medication had been administered three times daily instead of four times daily from 3/1-4/10/23, for a total of 41 missed doses. 5. Resident #4 was admitted to the residence on 8/28/17 with diagnoses including eye disorder. A written practitioner's order, dated 11/29/22, directed the residence to administer artificial tears ophthalmic solution 1.4% one drop in each eye three to four times daily. However, the April 2023 MAR read artificial tears were administered five times daily on 4/1-4/7 and 4/9/23, for a total of at least eight additional doses. On 4/11/23 at 7:30 a.m., Staff #19 stated it was the health service director's responsibility to order medications if they were out of stock. On 4/11/23 at 7:45 a.m., the health services director stated medications were to be ordered by qualified medication administration persons and herself when there was a seven day supply left. She stated they often had to wait on the pharmacy to deliver medications which caused residents to not be administered medications as ordered. She confirmed she was responsible for transcribing medications onto the MAR.On 4/11/23 at 2:16 p.m., the administrator confirmed that Residents #4, #38, #39, and #42 were not administered medications as ordered. She stated the expectation was that medications were always in stock and transcribed onto the MAR as ordered. Additionally, she stated the deficient practice was not corrected because she had not provided the day to day oversight of medication management as required.

Based on interview, observation, and record review, the residence failed to ensure oxygen tanks were store upright at all times in a manner that prevented tanks from falling over, being dropped, or striking each other, affecting one sample resident (#13). This deficiency was cited previously during a state licensure survey 9/28/22. Although the residence the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Oxygen Tank Storage policy, dated 2/1/23, read in part, oxygen tanks were required to be stored in a secure upright position. 2. ObservationOn 4/11/23 from 8:00 to 8:15 a.m., the following was observed in Resident #13's room:An oxygen tank leaning against a wallTwo oxygen tanks laying on their sides on the floorThree oxygen tanks stored in a rack that was not uprightFive oxygen tanks that were on the floor but not secureOn 4/11/23 at 7:30 a.m., Staff #19 stated all oxygen tanks were required to be stored upright and in a secure manner. On 4/11/23 at 7:45 a.m., the health services director stated all oxygen tanks were required to be stored upright and in a secure manner. On 4/11/23 at approximately 2:16 p.m., the administrator stated all oxygen tanks were required to be stored upright and in a secure manner. She stated oxygen tank storage had been difficult to maintain for Resident #13 because he used so much oxygen each day so the tanks were not always stored as required. She stated she was not aware of why the previous deficient practice was not corrected because she had trained staff on how to store oxygen tanks.