BROOKDALE NORTH LOVELAND

An administrative relicensure survey was completed on 3/5/26. No deficiencies were cited.

A licensure complaint, prompted by #CO39134, was conducted on 8/5/25. No deficiencies were cited.

A revisit survey was completed on 4/17/25 for all previous deficiencies cited on 1/22/25. The facility is in compliance with all deficiencies that were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey with complaint #CO34600 was completed on 1/22/25. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure that at least one staff member was onsite at all times with a current certification in first aid, affecting 44 current residents. Findings include:On 1/21/25, the residence provided first aid certifications for all certified staff. The residence failed to provide first aid certifications for Staff #4 and #5. The December 2024 and January 2025 staff schedules read in part that Staff #4 and #5 worked at the residence without other first aid-certified staff present from 10:00 p.m. until 6:00 a.m. on the following dates: 12/26-12/28/24, 1/2-1/4, 1/9-1/10, and 1/16-1/18/25. On 1/21/25 at 12:34 p.m., the administrator stated that Staff #4's first aid certification had lapsed on 12/24/24, and the residence had no evidence of a first aid certification for Staff #5. In a later interview, on 1/22/25 at 10:39 a.m., the administrator stated that the residence was required to have one staff member onsite at all times who was certified in first aid and had not after Staff #4's certification lapsed. She added that the business office manager (BOM) tracked the certifications; however, the residence missed the lapsed certification for Staff #4 as it was during a period that the BOM was on leave and the residence was transitioning to a new administrator

Based on interview and record review, the residence failed to ensure that at least one staff member onsite at all times was certified in cardiopulmonary resuscitation (CPR) and obstructed airway technique, affecting 44 current residents. On 1/21/25, the residence provided CPR certifications for all certified staff. The residence failed to provide CPR certifications for Staff #4 and #5. The December 2024 and January 2025 staff schedules read in part that Staff #4 and #5 worked at the residence without other CPR-certified staff present from 10:00 p.m. until 6:00 a.m. on the following dates: 12/26-12/28/24, 1/2-1/4, 1/9-1/10, and 1/16-1/18/25. On 1/21/25 at 12:34 p.m., the administrator stated that Staff #4's CPR certification had lapsed on 12/24/24, and the residence had no evidence of CPR certification for Staff #5. In a later interview, on 1/22/25 at 10:39 a.m., the administrator stated that the residence was required to have one staff member onsite at all times who was certified in CPR. She added that the residence had someone CPR-certified scheduled for all overnight shifts after Staff #4's certification lapsed. She added that the business office manager (BOM) tracked the certifications; however, the residence missed the lapsed certification for Staff #4 as it was during a period that the BOM was on leave and that the residence was transitioning to the new administrator.

Based on record review and interview, the residence failed to ensure each resident care plan detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting three of four sample residents (#1-#3) and one former resident (#5). Findings include:Resident #1 was admitted to the residence on 3/21/24 with a diagnosis of history of alcohol abuse. A written practitioner's order, dated 12/4/24, directed the residence to administer disulfiram 250 mg daily to prevent drinking alcohol. Additionally, it directed the residence to administer two alcoholic drinks pro re nata (PRN) daily, and the staff was to keep alcohol on the medication cart. A written practitioner's order, dated 12/12/24, directed the residence not to administer Resident #1 alcohol as she was prescribed disulfiram, which was a medication used in the treatment of alcohol use disorders that resulted in unpleasant side effects when administered prior to the ingestion of alcohol. A care plan, dated 8/30/24, contained no information regarding her alcohol use or what approaches the staff were to take when she ingested alcohol after disulfiram administration. On 1/21/25, during the onsite survey, Staff #1 and #2 stated that the care plan for Resident #1 did not include information regarding the resident's history of alcohol use nor what to do in the event she ingested alcohol after the residence administered disulfiram. On 1/22/25 at approximately 10:38 a.m., the health and wellness director and administrator stated care plans identified special needs and served as an outline for the care the staff provides. They affirmed that the residence should have included the resident's history of alcohol abuse and staff approaches when they ingested alcohol after staff administered a medication such as disulfiram in the care plan. Additionally, evidence revealed deficient practice for Residents #2, #3, and Former Resident #5.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one of five sample residents (#1). Findings include:Resident #1 was admitted to the residence on 3/21/24 with diagnoses of history of anxiety and major depressive disorder. A written practitioner's order, dated 12/4/24, directed the residence to administer bupropion 100 mg daily. However, the December 2024 medication administration record read that the residence failed to administer the medication on 12/19 to 12/26/24 because the medication was unavailable. On 1/22/25 at approximately 10:38 a.m., the health and wellness director and administrator stated the residence was responsible for complying with orders. They affirmed that when the residence failed to administer medication, the residence was not complying with the practitioner's orders.

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 2.2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities:(A) Individual client records(B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department.

A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 2/15/23. The facility is in compliance with all deficiencies that were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 2/15/23. The facility is in compliance with all deficiencies that were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A licensure revisit was completed on 2/15/23 for all previous deficiencies cited on 8/4/21. Deficiencies were cited.

Based on record review and interview, the residence failed to include all required documentation in each personnel file, affecting three of three sample staff (#3-#5). This deficiency was cited previously during a relicensure survey with complaint on 8/4/21. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record ReviewOn 2/15/23 at approximately 1:30 p.m., the business office coordinator (BOC) provided staff files for Staff #3-#5. The staff file for Staff #3 did not include documentation of orientation, results of background checks, nor tuberculin test results. The staff files for Staff #4 and #5 did not include documentation of orientation nor results of background checks. On 2/15/23 at approximately 2:30 p.m., the BOC provided plastic sleeves she had taken from a binder that was kept separate from the staff files, which included additional documentation. However, the documentation still did not include Staff #3's tuberculin test results nor documentation of orientation for Staff #3-#5.2. InterviewsOn 2/15/23 at approximately 2:30 p.m., the BOC stated she was not trained to include all required documentation in the staff files and therefore kept some items in a separate area. She acknowledged there was no documentation of orientation for Staff #3-#5 as well as no tuberculin test result available for Staff #3. On 2/15/23 at 4:00 p.m., the administrator stated background checks, tuberculin test results, and orientation were required to be in each staff's file. She stated the residence had kept all required documents in staff files in the past; however, the BOC was trained to keep background checks and tuberculin test results in a separate location outside of the staff files.

Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with mediation administration, affecting three of four current sample residents (#15, #16, #17) and one of three former residents (#19). This deficiency was cited previously during a relicensure survey with complaint on 8/4/21. 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 Policiesa. The residence's Medication and Treatments Absence from Community policy, dated October 2019, read, in part: "When a resident is going to be absent from the community for any period of time, the resident's current medications scheduled during the temporary absence time will be released to the resident/responsible party per state regulation...The nurse will be responsible for reviewing the medication administration orders with the resident and/or responsible party, prior to a scheduled departure from the community...The nurse or designee will document the resident's absence from the community on the residents' medication administration record (MAR or electronic MAR) if the resident is absent during one or more medication passes." b. The residence's Medications and Treatments Availability policy, dated October 2019, read, in part: "It is (The Residence's) policy that all currently ordered medications will be available to the resident. The community is responsible for obtaining newly ordered medication or refills for medication and treatment orders..."c. The residence's Medication and Treatment General Guidelines for Medication Administration/Assistance policy, dated October 2019, read, in part: "Trained and/or licensed associates may administer or assist the resident with medication management or medication administration and treatments per physician/health care provide (HCP) order and as per state regulation."d. The residence's Medication and Treatments Physician's Orders policy, dated October 2019, read, in part: "The community is responsible for complying with physician orders associated with the administration of medication or treatment..."2. Resident #16 was admitted to the residence on 12/5/22 with diagnoses including type I diabetes and renal dialysis.a. HumalogA written practitioner's order, dated 12/6/22, directed the residence to administer Humalog six units once daily before lunch. However, the January and February 2023 electronic medication administration records (eMAR's) for Resident #16 read the resident was absent from home and the medication was not administered on 1/2, 1/4, 1/6, 1/9, 1/11, 1/13, 1/16, 1/18, 1/20, 1/23, 1/25, 1/27, 1/30 and 2/13/23, for a total of 14 missed doses. On 2/15/23 at 3:30 p.m., the area health and wellness director (AHWD) stated when the eMAR's for residents read the resident was absent from home that meant the medication was not administered, as required. b. CalcitriolA written practitioner's order, dated 1/18/23, directed the residence to administer Calcitriol 0.25 milligram (mg) once daily on Monday, Wednesday, and Fridays. However, the January and February 2023 eMAR's for Resident #16 read the medication was not available (16) and not administered on 1/23, 1/25, 1/27, 1/30, and 2/20/23, for a total of five missed doses. 3. Resident #17 Resident #17 was admitted to the residence on 5/20/22 with diagnoses including hyperlipidemia and Parkinson's disease.a. AspirinA written practitioner's order dated 5/20/22, directed the residence to administer Aspirin 81 mg once daily. However, the January 2023 eMAR for Resident #17 read the medication was not available and not administered on 1/19/23 and 1/20/23, for a total of two missed doses. b. Latanoprost A written practitioner's order, dated 5/20/22, directed the residence to administer Latanoprost solution one drop in both eyes once daily. However, the January and February 2023 eMAR's for Resident #17 read the medication was not available. The medication was not administered on 1/16, 1/19-26, 2/1-2/3, and 2/7 and 2/8/23, for a total of 14 missed doses.c. Magnesium Oxide A written practitioner's order dated 5/20/22, directed the residence to administer Magnesium Oxide 400 mg once daily. However, the January 2023 eMAR for Resident #17 read the medication was not available and not administered on 1/16/23, for a total of one missed dose.d. Pantoprazole SodiumA written practitioner's order dated 5/20/22, directed the residence to administer Pantoprazole Sodium once daily. However, the January and February 2023 eMAR's for Resident #17 read the medication was not available and not administered on 1/31 and 2/1-2/3/23, for a total of four missed doses. On 2/15/23 at 3:30 p.m., the AHWD stated when the January and February eMAR's for Resident #17 read the medication was not available that meant the medication was not administered, as required. 4. Former Resident #19 was admitted to the residence on 10/25/18 with diagnoses including atherosclerotic heart disease, hypertension, osteoarthritis, macular degeneration, and gastroesophageal reflux disease. A written practitioner's order, dated 2/25/22, directed the residence to administer medications as follows:Amlodipine 10 mg every morningAspirin 81 mg dailyFamotidine 10 mg dailyHydrocholorathiazide 25 mg every morningIrbesartan 300 mg dailyMiralax 17 gm dailyPreservision 226 mg - 200 unit two capsules dailySpironolactone 25 mg every morningAcetaminophen 500 mg twice dailyPropanolol HCl 60 mg twice dailyHowever, the April 2022 eMAR read the morning doses for the above medications were administered on 4/15/22. However, directly underneath the documentation that the medications were administered, staff documented that Former Resident #19 was absent from the residence. On 2/15/23 at 1:51 p.m., the AHWD stated that the staff documented they administered Former Resident #19's medications on 4/15/22, realized she was not in the residence, and then went back to document that she was out of the residence. She stated this documentation meant that staff failed to administer the above medications that morning. 5. Resident #15 was admitted to the residence on 3/23/21.a. MethocarbamolA written practitioner's order, dated 2/6/23, directed the residence to administer Methocarbamol 750 mg once daily. However, the February 2023 eMAR for Resident #15 read the medication was not available and not administered on 2/7/23. On 2/15/23 at 3:15 p.m., the AHWD stated it was not uncommon for the external service provider to take 24-72 hours to obtain medications for residents. She acknowledged the medication was not administered on 2/7/23, as required. 6. InterviewsOn 2/15/23 at 3:30 p.m. the AHWD stated the number 16 on the eMAR's for residents meant the medication was not available and not administered, as required. On 2/15/23 at approximately 4:00 p.m., the administrator said she expected medications for residents to be in stock and administered, as ordered.

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 licensure complaint, prompted by #CO29135 and #CO29583, was completed on 2/15/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure the residents received the cooperation of the residence to achieve the maximum degree of benefit, assistance from staff when residents summoned staff for assistance, affecting two of eight residents in assisted living, who utilized their call lights to summon staff assistance (#17, #18). Findings include:1. Residence Policy A residence policy, dated April 2021, titled Resident Rights, read in part: "Residents have the right to receive care and services in accordance with their care plans. The right to expect the cooperation of the facility in achieving the maximum degree of benefit from those services the residence provides."2. Record Reviewa. The call light response logs for January 2023 and February 2023 revealed two residents in assisted living, who utilized their call lights to summon staff assistance, waited longer than 10 minutes for staff assistance on:Resident #17:2/1/23 13 minutes2/1/23 10 minutes2/1/23 16 minutes 2/1/23 53 minutes 2/2/23 27 minutes 2/2/23 30 minutes 2/2/23 15 minutes2/2/23 20 minutes2/3/23 21 minutes 2/3/23 18 minutes2/4/23 10 minutes2/4/23 29 minutes 2/4/23 50 minutes 2/5/23 21 minutes2/5/23 46 minutes2/5/23 10 minutes2/6/23 22 minutes 2/6/23 11 minutes2/6/23 12 minutes2/7/23 12 minutes2/7/23 22 minutes2/8/23 10 minutes2/8/23 42 minutes 2/9/23 37 minutes2/9/23 15 minutes2/11/23 10 minutes2/11/23 44 minutes2/12/23 60 minutes2/12/23 45 minutes2/13/23 66 minutes2/13/23 17 minutes2/13/23 29 minutes2/14/23 14 minutes 2/14/23 15 minutes2/14/23 13 minutes Resident #18: 2/8/23 10 minutes 2/9/23 9 minutes2/9/23 20 minutes 2/9/23 14 minutes2/9/23 23 minutes2/9/23 16 minutes2/10/23 38 minutes2/10/23 14 minutes2/10/23 21 minutes2/10/23 45 minutes2/10/23 47 minutes2/12/23 20 minutes 2/12/23 14 minutes2/12/23 13 minutes 2/12/23 13 minutes2/12/23 22 minutes2/12/23 12 minutes2/13/23 37 minutes2/13/23 16 minutes 2/13/23 50 minutes 3. Interviews On 2/15/23 at 8:06 a.m., Staff #2 stated she worked the morning shift and often Resident #17 had to wait over 30 minutes on the toilet before staff could assist her. Staff #2 stated residents would often be left soiled and had to wait 30 to 45 minutes for staff assistance. On 2/15/23 at 10:15 a.m., Resident #17 stated there were times where she would ask for assistance or pull the call light, and no one would respond up to 60 minutes. On 2/15/23 at 3:14 p.m., the administrator stated staff were expected to respond to call lights within eight minutes during meal time. If staff were serving residents in the dining room they were slower. The administrator was aware of the long response times.

Based on observation, interview and record review, the residence shall ensure that each resident received proper administration and monitoring of medication, affecting one of six sample residents (#15). Findings include:1. Residences and Residence Policiesa. Chapter XXIV regulation governing assisted living residences, section 2.13, defines "monitoring" as (C) Visual observation of the resident to ensure compliance.b. Chapter VII regulations governing assisted living residences, part 2.27 defines "medication monitoring" as (C) Visual observation of the resident to ensure compliance.c. The residence's Medication and Treatment General Guidelines for Medication Administration Assistance, dated October 2019, read in part: "Trained or licensed associates administering or assisting with medications should follow...the observation of the resident taking the medication to verify administration or assist per state regulation...Residents should be observed taking the medication followed by the offering (sic) water or other fluids. Medications should not be left for the resident to consume at a later time." d. The residence's Medication and Treatment Administration Assistance policy, dated October 2019, read, in part: "The individual assisting with the medication shall observe the resident ingesting the medication prior to documenting the administration/assistance on the resident's medication record or eMAR (electronic medication administration record) and record it immediately after medication assistance."2. ObservationsOn 2/15/23 at approximately 7:45 a.m., Resident #15 was seated at the dining room table and had a plastic medication container filled with medication. On 2/15/23 at approximately 8:00 a.m., the cup of medications was still on the dining room table in front of Resident #15.3. InterviewsOn 2/15/23 at approximately 7:45 a.m., Resident #15 stated staff administered medications whenever they wanted. On 2/15/23 at 8:10 a.m., Resident #15 stated when the qualified medication administration person (QMAP) administered her medications in the morning they did not watch ingestion. She added, "(They) don't watch me take it. (They) always leave the medications with me...my meds were on the kitchen sink every morning. (I) will take with me. Bring (medications) down to breakfast."On 2/15/23 at 9:15 a.m., Staff #2 stated she always left Resident #15's medications at bedside in her room to take them later. On 2/15/23 at approximately 3:00 p.m., the area health and wellness director stated she was not aware the QMAPs left Resident #15's medications aside. She added she expected there to be an order, if medications were able to left at bedside. On 2/15/23 at 4:00 p.m., the administrator said she expected QMAPs to watch residents ingest their medications. She added she was not aware staff did not monitor Resident #15 ingest her medications, as required.

Based on record review and interview, the residence failed to prepare or administer only medication that has been ordered by an authorized practitioner, affecting one sample resident (#18). Findings include:The residence's medication policy, dated 10/1/19, read in part: The medications or treatments brought to the residence by the resident, legally responsible party, or family member must be accompanied by a current practitioner order issued by a licensed physician or authorized practitioner. The resident record for Resident #18 contained an illegible practitioner order, with an unknown date, which included a medication list. However, the medications appeared blurred and the medication list could not be deciphered. A written practitioner's order, dated 12/8/22, directed the residence to administer fiber tablets twice daily for 10 days. A written practitioner's order, dated 2/9/23, directed the residence to administer one fiber tablet twice daily. The January and February 2023 electronic medication administration record (eMAR) revealed the residence administered one fiber tablet twice daily from 1/1/23 to 2/1/23, except on 1/9/23, 1/20/23, and 1/29/23 when the residence administered one fiber tablet once daily. The residence did not provide a written practitioner's order that directed them to do so. On 2/15/23 at 4:00 p.m., the administrator stated the residence was required to signed and legible practitioner's orders for all medications administered by the residence. She acknowledged the order in the resident record for Resident #18 was illegible to the point that one would not be able to decipher what the order read.

Based on record review and interview, the residence failed to clarify with the authorized practitioner an incomplete or unclear order and obtain a new order in writing, affecting one of four sample residents (#16). Findings include:1. Resident #16 was admitted to the residence on 12/5/22 with diagnoses including type I diabetes and renal dialysis.a. Bumetanide (Bumex)A written practitioner's order, dated 1/6/23, directed the residence to administer Bumex 2 milligram (mg) twice daily on Tuesday, Thursday, Saturday, and Sunday; and administer Bumex 2 mg once daily on Monday, Wednesday and Fridays. A written practitioner's order, dated 1/18/23, directed the residence to discontinue Bumex 2 mg once daily. Another written practitioner's order, dated 1/19/23, directed the residence to discontinue previous Bumetanide orders, and administer Bumetanide 2 mg once daily and Bumetanide 2 mg every Tuesday, Thursday, Saturday, and Sunday. A written practitioner's order, dated 1/24/23, directed the residence to discontinue Bumex 2 mg once daily and to discontinue Bumex 2 mg twice daily on Monday, Wednesday, and Friday; and to administer Bumex 2 mg once every Monday, Wednesday, and Friday and to administer Bumex 2 mg twice daily every Tuesday, Thursday, Saturday, and Sunday. The January 2023 electronic medication administration record (eMAR) for Resident #16 read Bumex 2 mg once daily was administered from 1/6/23 until 1/20/23, for a total of 14 additional doses of Bumex administered. 2. InterviewsOn 2/15/23 at 11:15 a.m., the area health and wellness director (AHWD) said the qualified medication administration person (QMAP) should not have administered the additional Bumex 2 mg once daily dose to Resident #16 from 1/6/23 to 1/20/23. She added the medication should have been discontinued, and the previous health and wellness coordinator (HWC) was responsible for transcribing the orders during that time and should have clarified the Bumex orders for Resident #16 before she added the medication to the January 2023 eMAR.On 2/15/23 at 1:30 p.m., the AHWD stated the Bumex 2 mg once daily order came from the dialysis clinic Resident #16 attended. She added it was noted by the previous HWC and entered but the previous orders for Bumex were not removed, as required. The AHWD said the HWC entered the Bumex as an additional order and had not clarified all the Bumex orders. On 2/15/23 at 4:00 p.m., the administrator stated she expected medications that were unclear to be clarified with the practitioner.

Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with mediation administration, affecting three of four current sample residents (#15, #16, #17) and one of three former residents (#19). This deficiency was cited previously during a relicensure survey with complaint on 8/4/21. 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 Policiesa. The residence's Medication and Treatments Absence from Community policy, dated October 2019, read, in part: "When a resident is going to be absent from the community for any period of time, the resident's current medications scheduled during the temporary absence time will be released to the resident/responsible party per state regulation...The nurse will be responsible for reviewing the medication administration orders with the resident and/or responsible party, prior to a scheduled departure from the community...The nurse or designee will document the resident's absence from the community on the residents' medication administration record (MAR or electronic MAR) if the resident is absent during one or more medication passes." b. The residence's Medications and Treatments Availability policy, dated October 2019, read, in part: "It is (The Residence's) policy that all currently ordered medications will be available to the resident. The community is responsible for obtaining newly ordered medication or refills for medication and treatment orders..."c. The residence's Medication and Treatment General Guidelines for Medication Administration/Assistance policy, dated October 2019, read, in part: "Trained and/or licensed associates may administer or assist the resident with medication management or medication administration and treatments per physician/health care provide (HCP) order and as per state regulation."d. The residence's Medication and Treatments Physician's Orders policy, dated October 2019, read, in part: "The community is responsible for complying with physician orders associated with the administration of medication or treatment..."2. Resident #16 was admitted to the residence on 12/5/22 with diagnoses including type I diabetes and renal dialysis.a. HumalogA written practitioner's order, dated 12/6/22, directed the residence to administer Humalog six units once daily before lunch. However, the January and February 2023 electronic medication administration records (eMAR's) for Resident #16 read the resident was absent from home and the medication was not administered on 1/2, 1/4, 1/6, 1/9, 1/11, 1/13, 1/16, 1/18, 1/20, 1/23, 1/25, 1/27, 1/30 and 2/13/23, for a total of 14 missed doses. On 2/15/23 at 3:30 p.m., the area health and wellness director (AHWD) stated when the eMAR's for residents read the resident was absent from home that meant the medication was not administered, as required. b. CalcitriolA written practitioner's order, dated 1/18/23, directed the residence to administer Calcitriol 0.25 milligram (mg) once daily on Monday, Wednesday, and Fridays. However, the January and February 2023 eMAR's for Resident #16 read the medication was not available (16) and not administered on 1/23, 1/25, 1/27, 1/30, and 2/20/23, for a total of five missed doses. 3. Resident #17 Resident #17 was admitted to the residence on 5/20/22 with diagnoses including hyperlipidemia and Parkinson's disease.a. AspirinA written practitioner's order dated 5/20/22, directed the residence to administer Aspirin 81 mg once daily. However, the January 2023 eMAR for Resident #17 read the medication was not available and not administered on 1/19/23 and 1/20/23, for a total of two missed doses. b. Latanoprost A written practitioner's order, dated 5/20/22, directed the residence to administer Latanoprost solution one drop in both eyes once daily. However, the January and February 2023 eMAR's for Resident #17 read the medication was not available. The medication was not administered on 1/16, 1/19-26, 2/1-2/3, and 2/7 and 2/8/23, for a total of 14 missed doses.c. Magnesium Oxide A written practitioner's order dated 5/20/22, directed the residence to administer Magnesium Oxide 400 mg once daily. However, the January 2023 eMAR for Resident #17 read the medication was not available and not administered on 1/16/23, for a total of one missed dose.d. Pantoprazole SodiumA written practitioner's order dated 5/20/22, directed the residence to administer Pantoprazole Sodium once daily. However, the January and February 2023 eMAR's for Resident #17 read the medication was not available and not administered on 1/31 and 2/1-2/3/23, for a total of four missed doses. On 2/15/23 at 3:30 p.m., the AHWD stated when the January and February eMAR's for Resident #17 read the medication was not available that meant the medication was not administered, as required. 4. Former Resident #19 was admitted to the residence on 10/25/18 with diagnoses including atherosclerotic heart disease, hypertension, osteoarthritis, macular degeneration, and gastroesophageal reflux disease. A written practitioner's order, dated 2/25/22, directed the residence to administer medications as follows:Amlodipine 10 mg every morningAspirin 81 mg dailyFamotidine 10 mg dailyHydrocholorathiazide 25 mg every morningIrbesartan 300 mg dailyMiralax 17 gm dailyPreservision 226 mg - 200 unit two capsules dailySpironolactone 25 mg every morningAcetaminophen 500 mg twice dailyPropanolol HCl 60 mg twice dailyHowever, the April 2022 eMAR read the morning doses for the above medications were administered on 4/15/22. However, directly underneath the documentation that the medications were administered, staff documented that Former Resident #19 was absent from the residence. On 2/15/23 at 1:51 p.m., the AHWD stated that the staff documented they administered Former Resident #19's medications on 4/15/22, realized she was not in the residence, and then went back to document that she was out of the residence. She stated this documentation meant that staff failed to administer the above medications that morning. 5. Resident #15 was admitted to the residence on 3/23/21.a. MethocarbamolA written practitioner's order, dated 2/6/23, directed the residence to administer Methocarbamol 750 mg once daily. However, the February 2023 eMAR for Resident #15 read the medication was not available and not administered on 2/7/23. On 2/15/23 at 3:15 p.m., the AHWD stated it was not uncommon for the external service provider to take 24-72 hours to obtain medications for residents. She acknowledged the medication was not administered on 2/7/23, as required. 6. InterviewsOn 2/15/23 at 3:30 p.m. the AHWD stated the number 16 on the eMAR's for residents meant the medication was not available and not administered, as required. On 2/15/23 at approximately 4:00 p.m., the administrator said she expected medications for residents to be in stock and administered, as ordered.

Based on record review and interview, the residence failed to accurately document each medication administration or monitoring event at the time the event was completed for each resident, affecting three of four current sample residents (#15, #16, #17) and two of three former resident (#19, #21). Findings include:1. Residence PolicyThe residence's medication policy dated 10/1/19, read in part: The qualified medication administration persons (QMAP) were required to document administered medications promptly after the resident ingested the medication or the treatment was applied. They should initial each medication administered or follow the electronic medication administration record (eMAR) procedure as required. 2. Resident #16 was admitted to the residence on 12/5/22.a. AtorvastatinA written practitioner's order, dated 12/6/22, directed the residence to administer Atorvastatin 40 milligram (mg) once daily. However, the January 2023 eMAR for Resident #16 had a blank space on 1/11/23.b. HumalogA written practitioner's order, dated 12/6/22, directed the residence to administer Humalog 4 units before dinner. However, the 2023 eMAR for Resident #16 had a blank space on 1/11/23. 3. Resident #15 was admitted to the residence on 3/23/21.a. LevothyroxineA written practitioner's order, dated 11/11/22, directed the residence to administer Levothyroxine 88 microgram (mcg) once daily. However, the January 2023 eMAR for Resident #15 had a blank space on 1/11/23.b. Rosuvastatin CalciumA written practitioner's order, dated 11/11/22, directed the residence to administer Rosuvastatin Calcium 10 mg once daily. However, the January 2023 eMAR for Resident #15 had a blank space on 1/11/23.c. XareltoA written practitioner's order, dated 11/11/22, directed the residence to administer Xarelto 15 mg once daily. However, the January 2023 eMAR for Resident #15 had a blank space on 1/11/23. d. Pregablin A written practitioner's order, dated 11/11/22, directed the residence to administer Pregablin 50 twice daily. However, the January 2023 eMAR for Resident #15 had a blank space on the 1/11/23 evening dose. 4. Resident #17 was admitted to the residence on 5/20/22.a. Brimonidine Tartrate and TimololA written practitioner's order, dated 5/24/22, directed the residence to administer Brimonidine Tartrate and Timolol solution one drop in the left eye once daily. However, the January 2023 eMAR for Resident #17 had a blank space on 1/11/23.b. LatanoprostA written practitioner's order, dated 5/20/22, directed the residence to administer Latanoprost one drop in both eyes once daily. However, the January 2023 eMAR for Resident #17 had a blank space on 1/11/23.c. Magnesium Oxide A written practitioner's order, dated 5/20/22, directed the residence to administer Magnesium Oxide 400 mg once daily. However, the January eMAR for Resident #17 had a blank space on 1/11/23.d. TylenolA written practitioner's order, dated 7/12/22, directed the residence to administer Tylenol 500 mg once daily. However, the January eMAR for Resident #17 had a blank space on 1/11/23.e. Advair DiskusA written practitioner's order, dated 5/20/22, directed the residence to administer Advair Diskus 250 twice daily. However, the January eMAR for Resident #17 had a blank space on 1/11/23.5. Former Resident #21 was admitted to the residence on 3/29/22.a. Tramadol A written practitioner's order, dated 3/29/22, directed the resident to administer Tramadol 50 mg four times a day. However, the April 2022 eMAR had a blank space on 4/13/22.6. Former Resident #19 was admitted to the residence on 10/25/18 with diagnoses including hypothyroidism and type II diabetes. A practitioner's order, dated 2/25/22, directed the residence to administer Levothyroxine 137 mcg orally and Victroza 0.6/0.1 mL (18 mg/3mL) 1.8 mg subcutaneously every morning. However, the April 2022 eMAR revealed blank spaces on the morning of 4/10/22 for both of these medications. 7. InterviewsOn 2/15/23 at 3:30 p.m., the area health and wellness director stated blank spaces on the eMAR's for residents meant the medication was administered but not signed off. On 2/15/23 at 4:30 p.m., the administrator stated the eMAR's for residents should be complete and accurate, and medications that were administered should be signed off on.

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) at least quarterly audited the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting three of four sample residents (#15, #16, #17). Findings include:On 2/25/23 at approximately 12:00 p.m., the residence's audits of the medication administration records, controlled substance lists, medication error reports, and medication disposal records were requested. However, no such audits were provided other than an internal audit completed by an external service representative in September 2022. On 2/15/23 at 4:30 p.m., the administrator stated she was unable to find the medication audit documentation and acknowledged the audits should be completed, as required.

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 7.7.13 If the employee or volunteer is a qualified medication administration person, the following shall also be retained in the employee's or volunteer's personnel file:(B) A signed disclosure that the individual has not had a professional medical, nursing, or pharmacy license revoked in this or any other state for reasons directly related to the administration of medications. 18.8 Resident records shall contain, but not be limited to, the following items:(D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs;(1) The assisted living residence shall 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.