HARVARD SQUARE RETIREMENT COMMUNITY

A licensure complaint, prompted by #CO39318 and #CO40086, was completed on 12/9/2025. No deficiencies were cited.

A revisit survey was completed on 4/2/25 for all previous deficiencies cited on 12/4/24. 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 complaint revisit was completed on 12/4/24 for the previous deficiencies cited on 3/28/24. The residence is in compliance with all regulations surveyed.

A relicensure survey with complaints #CO33481 and #CO38339 was completed on 12/4/24. Deficiencies were cited.

12.2.1 (A) "All facilities licensed under this chapter shall establish maintain, and implement an infectious disease mitigation, vaccine and treatment plan. The plan must demonstrate prevention of and responsiveness to communicable diseases that are or may become present in the individual facility setting. The plan may include testing, vaccination, and treatment. This plan shall address, at a minimum, the following:(1) Identification of designated staff who shall coordinate vaccine information, administration, and tracking and reporting of the vaccination status of staff and, if applicable, residents on an ongoing basis;(2) The name and location of the infectious disease vaccine and treatment provider(s) that will be used by the facility to facilitate administration of vaccines and treatment;(3) How the facility will assess and address the vaccination of new staff and, if applicable, residents."Based on record review and interview, the residence failed to establish, maintain, and implement an infectious disease mitigation, vaccine and treatment plan. (Cross-reference S0002)Findings include:On 12/3/2024 at 7:40 a.m., the residence's infectious disease mitigation, vaccination, and treatment plan was requested; however, the acting administrator was unable to provide it. On 12/3/24 at approximately 4:00 p.m., the administrator acknowledged that the residence did not have a mitigation, vaccination, and treatment plan.

12.2.2 (B) "Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following:(1) Completing an infection prevention and control training from a nationallyrecognized provider or the Department's training program within two (2) weeks of appointment/designation that meets the following requirements based on facility type;(a) Infection Control Officers at nursing care facilities and intermediate care facilities for persons with intellectual and developmental disabilities shall complete at least nineteen (19) hours of initial training.(b) Infection Control Officers at assisted living residences and all group homes for persons with intellectual and developmental disabilities shall complete at least 1.5 hours of initial training.(2) Completing a minimum of 1.5 hours of continuing education in infection prevention and control on an annual basis from a nationally-recognized provider or the Department's training program sufficient to stay current on changing guidance and requirements in the field;(3) Providing on-site management of infectious disease prevention and response activities and general infection prevention duties;(4) Ensuring the facility complies with Department reporting requirements related to infectious diseases;(5) Providing facility access to, and ensuring proper supply, use, handling, and implementation of Personal Protective Equipment (PPE) and disinfectants, used per manufacturer's guidelines;(6) Maintaining a facility respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard (29 CFR 1910.134);(7) Advising and educating residents, staff, and visitors on current precautions being taken in the facility for infectious diseases and the prevention of their spread; and(8) Notifying residents, designated representatives, and staff of updated Centers for Disease Control (CDC) vaccination recommendations, and ensuring recommended vaccines for infectious diseases are available to staff and residents inside their facility on an annual basis."Based on record review and interview, the residence failed to assign at least one staff member to complete an infection prevention and control training from a nationally-recognized provider and be responsible for the on-site management of the residence's infection prevention and control program and training. (Cross-reference S0001)Findings include:On 12/3/24 at 7:40 a.m., the residence infection control (IC) officer's completed training was requested; however, the administrator was unable to provide one. On 12/3/24 at approximately 4:00 p.m., the administrator acknowledged that he did not assign an IC officer. He added that he did not have the required IC training, the continuing education training, nor a certificate from a nationally-recognized provider.

Based on record review and interview, the residence failed to provide, upon request, residence documents and other records requested by the department, affecting 124 current residents. Findings include:1. Record Review Resident records were requested as follows:On 12/3/24 at 7:40 a.m., the residence policy binder was requested and was provided at 9:07 a.m.; however, at 3:02 p.m., an updated and new policy binder was provided. On 12/3/24 at 8:33 a.m., a request for access to online resident records was made, but it was denied due to corporate policy. On 12/3/24 at 1:07 p.m., the national health systems director (NHSD) emailed resident records. This was approximately five hours after the original request. On 12/3/24, at approximately 2:30 p.m., the administrator provided printed files, but she did not provide resident records for Resident #6 until approximately 3:00 p.m., approximately six hours after they were requested. On 12/4/24, at approximately 12:00 p.m., a second request for a visitor policy and involuntary discharge policy was made. They were provided at approximately 2:00 p.m., approximately 32 hours after they were originally requested. On 12/4/24 at approximately 4:00 p.m., a review of Residents #2, #9, and #12's records failed to contain October and November 2024 electronic medication administration records (eMARs), and the resident records for Residents #7, #8, and #13 did not contain October 2024 eMARs. Resident #8 was missing assessments and progress notes. These documents were provided the next day at approximately 7:45 a.m., approximately 24 hours after they were originally requested. 2. Interviews On 12/3/24 at 8:33 a.m., the administrator stated the corporate policy was that the residence provided the resident files without allowing access to the electronic health information management system. On 12/3/24 at 12:44 p.m., the corporate NHSD stated that he was unaware the residence did not provide the requested resident records and planned to email them. .On 12/4/24 at approximately 11:45 a.m., the administrator said resident documents had been emailed to him, but he had to separate and organize the documents into resident files. On 12/4/24 at approximately 2:15 p.m., the administrator acknowledged the residence's failure to provide records as requested.

Based on record review and interview, the residence failed to ensure the administrator completed 40 hours of administrator training as required, affecting 125 current residents. Findings include:On 12/3/24 at 7:45 a.m., the acting administrator's 40-hour training was requested; however, the acting administrator was unable to provide the documentation. On 12/4/24 at 2:30 p.m., the acting administrator acknowledged he did not complete a 40-hour course to be an assisted living administrator, as required.

Based on record review and interview, the residence failed to have a resident roster, including the residents' emergency contact information, readily available, affecting 125 current residents. Findings include:On 12/3/24 at 8:00 a.m., a resident roster was provided but failed to have emergency contacts for residents. On 12/3/24 at 8:00 a.m., the administrator stated he was unaware of what was required to be included in the resident roster. He said he knew the importance of having a resident roster in case of an emergency but was unable to state why one was not available.

Based on observation, record review, and interview, the residence failed to maintain the residence's water temperature, which was accessible to residents, at or below 120 degrees Fahrenheit (F), affecting 125 residents. Findings Include:1. ObservationsOn 12/3/24 at 12:00 p.m., water temperatures were taken in the residence as follows:The common area bathroom sink #1 water measured 145.6 degrees F.The common area resident bathroom sink #2 water measured 145.2 degrees F.The common area main foyer sink water measured 145.4 degrees F.The common area bathroom (on the first floor near the gym) water measured 145.6 degrees F.On 12/4/24 at 8:59 a.m., the water temperature in the common area resident bathroom sink #1 measured 150.9 degrees F.2. Record ReviewA documented proposal from an external contractor, dated 7/24/24, read "replace mixing valve" had an estimated cost of $33,099.00. A second documented proposal from an external contractor, dated 11/4/24, read "replace mixing valve" had an estimated cost of $54,358.00.3. InterviewsOn 12/3/24 at approximately 4:00 p.m., the administrator stated he was aware the hot water was above 120 degrees F but was unable to have it fixed because the cost to fix the hot water was $27,000 and the residence recently finished remodelling the secure environment, and they were capped on the budget. On 12/4/24 at 7:20 a.m., the administrator stated he had known about the boiler issue since August 2024 and had sent two bids to the corporate office for approval to fix the problem. He said he was awaiting corporate approval. He stated that they turned down the boiler from 165 degrees to 150 degrees, and the 15-degree temperature decrease brought the water temperature down, but if they lowered the temperature any more, the boiler would fail. On 12/4/24 at approximately 2:00 p.m., the administrator acknowledged that the water temperature would remain above 120 degrees F until the residence paid to have the valve or the boiler replaced. The administrator acknowledged that the resilience's high water temperatures did not meet the regulatory requirement.

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 2.2.3.6 Applicants must show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements as set forth in section 26-3.1-111, C.R.S. 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 7.7.1 Prior to hire a CBI ran if applicant lived in Colorado more than three years; if less than three years' criminal history checked for each state. 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population. 12.10 Each resident care plan shall:(B) Reflect the most current assessment information. 14.27 No stock medications shall be stored or administered by qualified medication administration persons. (A) All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident's full name. 16.3 An assisted living residence that is licensed for 20 beds or more shall comply with the Department's regulations concerning Colorado Retail Food Establishments at 6 CCR 1010-2.21.1 All interior areas including attics, basements, and garages shall be free from accumulations of extraneous material such as refuse, unused or discarded furniture, and potential combustible materials. 22.5 Each room shall have heat, lighting, and ventilation sufficient to meet the use of the room and the needs of the residents.

A complaint revisit was completed on 12/4/24 for the previous deficiencies cited on 3/28/24. The residence is in compliance with all regulations surveyed.

A complaint revisit was completed on 12/4/24 for the previous deficiencies cited on 3/28/24. The residence is in compliance with all regulations surveyed.

A complaint revisit was completed on 12/4/24 for the previous deficiencies cited on 3/28/24. The residence is in compliance with all regulations surveyed.

A complaint revisit was completed on 12/4/24 for the previous deficiencies cited on 3/28/24. The residence is in compliance with all regulations surveyed.

A licensure revisit was completed on 3/28/23 for all previous deficiencies cited on 8/9/22. 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 105 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a consultant for six months. Following the completion of Event I39413 on 6/2/22, a complaint investigation, the department imposed a consultant for six months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the 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 I39413 and dated June 2, 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 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 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 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 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 consultant was required to complete the following, during the third, fourth and fifth month of the contract period: - Conduct onsite visits at least twice a month, 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 consultant will provide adequate training, mentoring, and monitoring, and prepare the Administrator to independently manage the Residence. The consultant was required to complete the following, during the sixth and final month of the contract period: - Prepare the Administrator to independently manage the Facility to ensure compliance with all applicable regulations governing assisted living residences. The Consultant shall make certain that the Administrator has tools and resources in place to maintain compliance. Additionally, the consultant was required to ensure, during the entire six month contract period, for each of the deficiencies identified in the Deficiency List, for Event I39413 and dated June 2, 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 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 consultant was required to submit a final report to the department, following the end of the contract period, that contained the prior information as well as the actions taken to ensure the administrator has tools and resources in place to maintain compliance. Department records read the following deadlines wererequired for this intermediate condition:- Letter to department to identify possible consultant, due by 9/2/22.- Submit executed consultant contract to the department, due by 9/10/22.- Submit final consultant report, due by 4/15/23. Department records read the residence had chosen the consultant on 12/12/22, approximately three months after the required deadline. Additionally, the contract for the consultant was received on 1/3/23, approximately four months after the required deadline. Therefore, on the dates of the completion of the licensure revisit, (3/28/23), the consultant would have been in her second month as consultant for the residence. 2. Current deficient practiceDuring the 3/28/23 licensure revisit, the revisit established there was current deficient practice. Four deficiencies were recited, including tags 1160, 1468, 1510, and 2130. (Cross-reference Q1160, Q1468, Q1510, Q2130.) 3. InterviewsOn 3/28/23 at 8:44 a.m. the resident care director (RCD) stated the residence was currently under an intermediate condition to maintain a consultant. She stated the consultant came to the residence weekly to assist the residence. The RCD stated the consultant helped with staff education, staff training and updating policies. She stated the consultant had had trained qualified medication administration persons (QMAPs) on processes that included electronic medication administration record (eMAR) documentation. The RCD stated the consultant reviewed the missed medication reports and discussed them with her. She stated the consultant did not assist with resident assessments, but did review fall reports. The RCD stated the consultant reviewed weekly reports that included residents that had been newly admitted, had fallen, had any incident reports and had recent hospitalizations. On 3/28/23 at 9:12 a.m., the administrator stated the residence had contracted with an independent consultant. He stated the consultant had assisted in policy development, review of the residence's current systems and staff accountability. On 3/28/23 at 12:52 p.m., the consultant stated she was aware of the residence's requirement to obtain a consultant for a six-month period. She stated she was aware during the consultant period the residence was required to maintain compliance with all regulations. In regards to tag 1468, the consultant stated the availability of medications for administration had still been a concern. She stated the residence had tried to implement a system that the QMAPs notified the nurse working the shift if a medication was unavailable. The consultant stated the RCD was ultimately responsible for ensuring all medications were available to be administered. The consultant stated she had completed training with the staff in regards to ordering medications at least seven days prior to running out of medications. In regards to tag 1510, the consultant stated she believed the residence had gotten better with documentation at the time of administration and accuracy of the eMAR. She stated the residence still had areas for improvement with the eMAR accuracy. In regards to tag 1160, the consultant stated the residence was aware that coordination of care should have be done with the residence staff and external service providers. In regards to tag 2130, the consultant stated the residence nurses were responsible for ensuring progress notes were completed. She stated the residence staff were aware that any out of the ordinary event should have been documented. The consultant stated she had done a training recently with the residence staff in regards to progress notes. She stated she expected progress notes to have contained documentation of falls, hospitalizations and if a resident returned for the hospital. She added if medications were unavailable then progress notes should have contained documentation on what had been done to obtain the medication. On 3/28/23 at 3:29 p.m., the administrator stated he was aware the residence was under an intermediate condition and required to obtain a consultant. The administrator stated he always tried to be in compliance with regulations; however, he was not aware that while under the intermediate condition he was required to maintain compliance with all regulations. On 3/28/23 at 4:11 p.m., the administrator stated based on the cited deficiencies discussed the residence had not followed the intermediate condition requirement to maintain compliance with all regulations.

Based on record review, and interview, the residence failed to be responsible for the coordination of care services with known external service providers, affecting one of eight sample residents (#34). This deficiency was cited previously during a licensure complaint survey 8/9/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 2.21, defines "External services" as personal services and protective oversight services provided to a resident by family members or healthcare professionals who are not employees, contractors, or volunteers of the facility. External service providers include, but are not limited to, home health, hospice, private pay caregivers and family members. 2. Resident #34 was admitted to the residence on 12/31/21. Progress notes for January and February 2023 for Resident #34 revealed the following:On 1/12/23 Resident #34 was discharged from the hospital. "(Family member) requested to nurse (sic) does a dressing change on the left hand infected every other day before his next appointment. (An unidentified staff member) recommended that (sic) (family member) called (sic) home health to do the dressing changes, because of the infection. (Family member) notified."On 1/13/23 "(Family member) requested a nurse to (sic) apartment. (Family member) concerned arm is more swollen and red than yesterday. This nurse did not see it yesterday but observed area today to be tight, swollen, red and hot. Resident #34 (complained) moderate pain to area also. (Family member) is taking resident back to (Hospital)."1/27/23 Family member of Resident #34 stated Resident #34 was released from the hospital to a rehabilitation facility. On 3/28/23 at 12:16 p.m., a family member of Resident #34 stated when Resident #34 was at the hospital on 1/13/23 the cut on his hand worsened and required wound care twice daily. She added the residence was unable to provide wound care and an external service provider was not covered under Resident #34's insurance to come twice daily to assist. The family member was frustrated because she had to sort all of the details out with the hospital on what external services Resident #34 required for his cut. On 3/28/23 at 2:30 p.m., the resident care director (RCD) stated when Resident #34 was in rehab she had multiple conversations with the hospital and was told Resident #34 required his wound to be packed and bandaged but the residence was unable to provide wound care. The RCD said the family members told her they were able to provide wound care on some of the days and wanted home health to provide wound care on the other days; however, the insurance for Resident #34 would not cover an external service provider seven days a week. The RCD stated the family member coordinated care with the hospital about external service provider options. On 3/28/23 at approximately 3:30 p.m., the administrator stated he expected coordination of care with external service providers and the residence. He added, "(The residence) should be partnering with family." The administrator stated this deficiency was recited because of a breakdown in systems, expectations and accountability.

Based on the record review, and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting seven of eight sample residents (#5, #6, #11, #34, #39, #43, #44). This deficiency was cited previously during a licensure complaint survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #5 was admitted to the residence on 12/1/21 with diagnoses including anxiety and unspecified dementia. a. Lorazepam A written practitioner's order, dated 8/2/22, directed the residence to administer lorazepam 1 mg four times a day. However, the March 2023 eMAR (electronic medication administration record) for Resident #5 read the medication was not available and not administered on 3/17-3/19 and 3/24/23, for a total of 16 doses.b. FamotidineA written practitioner's order, dated 5/27/22, directed the residence to administer famotidine 150 mg. However, the March 2023 eMAR for Resident #5 read the medication was not available and not administered on 3/13/23, for a total of one dose.c. OndansetronA written practitioner's order, dated 8/2/22, directed the residence to administer ondansetron hcl 4 mg. However, the March 2023 eMAR for Resident #5 read the medication was not available and not administered on 3/13/23, for a total of one dose. On 3/28/23 at 3:00 p.m., the Resident Care Director (RCD) stated she was not aware the medication was out of stock and not administered to Resident #5.2. Resident #6 was admitted to the residence on 7/1/21 with diagnoses including unspecified dementia. a. CitalopramA written practitioner's order, dated 8/30/22, directed the residence to administer citalopram 20 mg once daily. However, the March 2023 eMAR for Resident #6 read the medication was not available and not administered on 3/1-3/7, 3/17-3/24 and 3/28/23, for a total of 16 doses.b. Losartan A written practitioner's order, dated 8/30/22, directed the residence to administer losartan 100mg once daily. However, the March 2023 eMAR for Resident #6 read the medication was not available and not administered on 3/1-3/6, 3/17-3/24 and 3/28/23, for a total of 15 doses. On 3/28/23 at 3:00 p.m., the RCD stated she was not aware the medication was out of stock and not administered to Resident #6.3. Resident #11 was admitted to the residence on 2/18/22. a. Oyster ShellA written practitioner's order, dated 2/17/23, directed the residence to administer oyster shell 500 mg once daily. However, the March 2023 eMAR for Resident #11 read the medication was not available and not administered on 3/1/23, for a total of one dose.b. FinasterideA written practitioner's order, dated 2/18/22, directed the residence to administer finasteride 5 mg once daily. However, the March 2023 eMAR for Resident #11 read the medication was not available and not administered on 3/2, 3/6, 3/14, and 3/18/23, for a total of four doses.c. NiacinA written practitioner's order, dated 2/18/22, directed the residence to administer niacin 500 mg once daily. However, the March 2023 eMAR for Resident #11 read the medication was not available and not administered on 3/3/23, for a total of one dose.d. Metoprolol SuccinateA written practitioner's order, dated 6/4/22, directed the residence to administer metoprolol succinate 25 mg once daily. However, the March 2023 eMAR for Resident #11 read the medication was not available and not administered on 3/14/23, for a total of one dose. On 3/28/23 at 3:00 p.m., the RCD stated she was not aware the medication was out of stock and not administered to Resident #11.4. Resident #39 was admitted to the residence on 4/9/21 with diagnoses including unspecified dementia and schizoaffective disorder.a. Citalopram A written practitioner's order, dated 7/28/21, directed the residence to administer citalopram 20 mg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/4-3/7 and 3/12/23, for a total of five doses.b. FluticasoneA written practitioner's order, dated 2/17/21, directed the residence to administer fluticasone 50 mcg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/4-3/7 and 3/12/23, for a total of five doses.c. Metoprolol A written practitioner's order, dated 12/8/21, directed the residence to administer metoprolol 50 mg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/4-3/5 and 3/7/23, for a total of three doses.d. Stomach ReliefA written practitioner's order, dated 8/14/22, directed the residence to administer stomach relief 262 mg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/7, 3/20-3/24 and 3/26/23, for a total of seven doses.e. Trazodone A written practitioner's order, dated 8/14/22, directed the residence to administer trazadone 50 mg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/7/23, for a total of one dose.f. Calcium A written practitioner's order, dated 3/19/23, directed the residence to administer calcium 600 mg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/20-3/24/23, for a total of five doses. 5. Resident #44 was admitted to the residence on 2/1/20 with diagnoses including diabetes and Alzheimer's disease. a. Atorvastatin Calcium A written practitioner's order, dated 1/23/23, directed the residence to administer atorvastatin calcium 10 mg once daily. However, the March 2023 eMAR for Resident #44 read the medication was not available and not administered on 3/1-3/7/23, for a total of seven doses.b. Metoprolol Succinate A written practitioner's order, dated 1/23/23, directed the residence to administer metoprolol 50 mg once daily. However, the March 2023 eMAR for Resident #44 read the medication was not available and not administered on 3/2-3/3, 3/5-3/6 and 3/8/23, for a total of five doses.c. Escitalopram Oxalate A written practitioner's order, dated 2/21/23, directed the residence to administer escitalopram oxalate 10 mg once daily. However, the March 2023 eMAR for Resident #44 read the medication was not available and not administered on 3/19/23, for a total of one dose.d. LisinoprilA written practitioner's order, dated 1/23/23, directed the residence to administer lisinopril 20 mg once daily. However, the March 2023 eMAR for Resident #44 read the medication was not available and not administered on 3/19/23, for a total of one dose. On 3/28/23 at 3:00 p.m., the RCD stated she was not aware the medication was out of stock and not administered to Resident #44.6. Resident #43 was admitted to the residence on 9/24/21 with diagnoses including spinal stenosis, osteoarthritis in right hip, benign prostatic hyperplasia and left artificial hip. a. Folic AcidA written practitioner's order, dated 1/23/23, directed the residence to administer folic acid 0.4 mcg once daily. However, the March 2023 eMAR for Resident #43 read the medication was not available and not administered on 3/1, 3/3-3/10, 3/13-3/14, 3/16-3/19 and 3/21-3/27/23, for a total of 22 doses. On 3/28/23 at 3:00 p.m., the RCD stated she was not aware the medication was out of stock and not administered to Resident #43.b. Trospium ChlorideA written practitioner's order, dated 1/23/23, directed the residence to administer trospium chloride 20 mg once daily. However, the March 2023 eMAR for Resident #43 read the medication was not available and not administered on 3/1, 3/3-3/10, 3/13-3/16, 3/18-3/19 and 3/21-3/27/23, for a total of 21 missed doses. 7. Resident #34 was admitted to the residence on 12/31/21.a. Lidocaine PatchA written practitioner's order, dated 2/3/23, directed the residence to administer lidocaine patch 5% once daily. However, the March 2023 eMAR for Resident #34 read the medication was not available and not administered on 3/13, 3/15-3/19, 3/22-3/25 and 3/27/23, for a total of 10 doses.b. Polyethylene GlycolA written practitioner's order, dated 2/3/23, directed the residence to administer polyethylene glycol 3350 oral powder twice daily. However, the March 2023 eMAR for Resident #34 read the medication was not available and not administered on 3/2/23 in the morning. 8. Interviews On 3/28/23 at 3:00 p.m., the RCD stated when the eMAR read a medication was not available that meant the medication was not in stock and not available to administer. She added she expected the wellness nurses to notify her when a medication for a resident was out of stock and not administered, as required. The RCD said she expected the QMAP to order medication for residents when seven days of medications remained and she expected medications to be administered as ordered. On 3/28/23 at approximately 3:30 p.m., the administrator stated he expected medications to be administered as ordered and not run out of stock. He added the RCD was responsible for ensuring residents were administered their medications as ordered and expected QMAPs to reorder medications when seven days remained. The administrator stated the reason the citation was recited was due to lack of compliance.

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 and failed to ensure the medication administration record reflected the dosage of each medication, affecting one of seven sample residents (#43). This deficiency was cited previously during a licensure complaint survey 8/9/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's Medication Assistance policy, dated September 2021, read, in part, "The facility will capture all information required under Colorado regulation for each resident. The MAR (medication administration record) is initiated each time a medication is assisted or administered to a resident."Resident #43 was admitted to the residence on 9/24/21. A written practitioner's order, dated 1/23/23, directed the residence to administer oxycodone 5 mg half tablet every four hours for pain as needed. However, the March 2023 eMAR for Resident #43 read oxycodone 5 mg half tablet by mouth as needed. There was no frequency listed on the eMAR for qualified medication administration persons (QMAPs) to know how often to administer the medication. On 3/28/23 at 3:00 p.m. the resident care director (RCD) said the oxycodone on the eMAR should read how often the medication was required to be administered. On 3/28/23 at 3:00 p.m., the RCD stated that the night shift nurses audit the eMAR's when they work. She added her or her assistant were ultimately responsible to ensure the eMAR's are accurate. On 3/28/23 at 3:30 p.m., the administrator stated he expected the eMAR's for residents to be accurate and identical to the practitioner's order. He added, the reason the citation was recited was because the residence was out of compliance.

Based on record review and interview, the residence failed to ensure the documentation of on-going services provided by external service providers was included; and that the residents' records contained progress note that documented out of the ordinary events or issues regarding residents, affecting two of eight sample residents (#34, #42). Findings include:1. Resident #34 was admitted to the residence on 12/31/21. Progress notes for January and February 2023 for Resident #34 revealed the following:On 1/12/23 Resident #34 was discharged from the hospital. "(Family member) requested to nurse (sic) does a dressing change on the left hand infected every other day before his next appointment. (An unidentified staff member) recommended that (sic) (family member)called (sic) home health to do the dressing changes, because of the infection. (Family member) notified."The record for Resident #34 did not contain any external service provider notes after Resident #34 returned from the hospital on 1/12/23.2. Resident #42 was admitted to the residence on 9/21/22. On 3/28/23 at 7:28 a.m., Staff #37 stated Resident #42 fell, hit his head and needed stitches due to a recent fall. On 3/28/23 at 7:48 a.m., Resident #42 stated he fell approximately a week prior to the onsite visit. He added he lost his balance, fell and hit his head twice. On 3/28/23 at approximately 3:00 p.m., the resident care director (RCD) stated she was not informed that Resident #42 fell a week prior to the onsite visit. Progress notes for February and March 2023 in Resident #42's record revealed no documentation related to the fall Resident #42 sustained a week or so prior to the onsite visit on 3/28/23. On 3/28/23 at approximately 3:30 p.m. the administrator stated he expected staff to include progress notes, rehabilitation (external service provider) notes, and hospital notes in a resident record. He added, the reason the citation was recited was a residence system breakdown.

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 3/28/23 for all previous deficiencies cited on 12/13/22. 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 105 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a consultant for six months. Following the completion of Event I39413 on 6/2/22, a complaint investigation, the department imposed a consultant for six months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the 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 I39413 and dated June 2, 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 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 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 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 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 consultant was required to complete the following, during the third, fourth and fifth month of the contract period: - Conduct onsite visits at least twice a month, 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 consultant will provide adequate training, mentoring, and monitoring, and prepare the Administrator to independently manage the Residence. The consultant was required to complete, during the sixth and final month of the contract period: - Prepare the Administrator to independently manage the Facility to ensure compliance with all applicable regulations governing assisted living residences. The Consultant shall make certain that the Administrator has tools and resources in place to maintain compliance. Additionally, the consultant was required to ensure, during the entire six month contract period, for each of the deficiencies identified in the Deficiency List, for Event I39413 and dated June 2, 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 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 consultant was required to submit a final report to the department, following the end of the contract period, that contained the prior information as well as the actions taken to ensure the administrator has tools and resources in place to maintain compliance. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 9/2/22.- Submit executed consultant contract to the department, due by 9/10/22.- Submit final consultant report, due by 4/15/23. Department records read the residence had chosen the consultant on 12/12/22, approximately three months after the required deadline. Additionally, the contract for the consultant was received on 1/3/23, approximately four months after the required deadline. Therefore, on the dates of the completion of the licensure revisit, (3/28/23), the consultant would have been in her second month as consultant for the residence. 2. Current deficient practiceDuring the 3/28/23 licensure revisit, the revisit established there was current deficient practice. Four deficiencies were recited, including tags 1468, 1510, 1514 and 1522. (Cross-reference Q1468, Q1510, Q1514 and Q1522.) 3. InterviewsOn 3/28/23 at 8:44 a.m. the resident care director (RCD) stated the residence was currently under an intermediate condition to maintain a consultant. She stated the consultant came to the residence weekly to assist the residence. The RCD stated the consultant helped with staff education, staff training and updating policies. She stated the consultant had had trained qualified medication administration persons (QMAPs) on processes that included electronic medication administration record (eMAR) documentation. The RCD stated the consultant reviewed the missed medication reports and discussed them with her. She stated the consultant did not assist with resident assessments, but did review fall reports. The RCD stated the consultant reviewed weekly reports that included residents that had been newly admitted, had fallen, had any incident reports and had recent hospitalizations. On 3/28/23 at 9:12 a.m., the administrator stated the residence had contracted with an independent consultant. He stated the consultant had assisted in policy development, review of the residence's current systems and staff accountability. On 3/28/23 at 12:52 p.m., the consultant stated she was aware of the residence's requirement to obtain a consultant for a six-month period. She stated she was aware during the consultant period the residence was required to maintain compliance with all regulations. In regards to tag 1468, the consultant stated the availability of medications for administration had still been a concern. She stated the residence had tried to implement a system that the QMAPs notified the nurse working the shift if a medication was unavailable. The consultant stated the RCD was ultimately responsible for ensuring all medications were available to be administered. The consultant stated she had completed training with the staff in regards to ordering medications at least seven days prior to running out of medications. In regards to tag 1510, the consultant stated she believed the residence had gotten better with documentation at the time of administration and accuracy of the eMAR. She stated the residence still had areas for improvement with the eMAR accuracy. In regards to tag 1514, the consultant stated that she had discussed weekly and quarterly audits with the administrator and RCD. She stated she believed the residence had additional time to complete the recent quarterly audit. She stated she was not aware the RCD had stated she was not aware of who should have completed the quarterly audits. The consultant stated the RCD was aware she should have conducted audits. In regards to tag 1522, the consultant stated the eMAR had a report section that showed when a resident refused medications. She stated medication refusals should have been reported to the nurse working and the nurse should have attempted to administer the medication. The consultant stated if the resident refused the medication again, the nurse should have documented the refusal. The consultant stated if refusing medications was a pattern for a resident the nurse should have notified the resident's practitioner. The consultant stated the notification should have been documented. She added if there was no documentation of a practitioner notification, staff may not have notified the practitioner. On 3/28/23 at 3:29 p.m., the administrator stated he was aware the residence was under an intermediate condition and required to obtain a consultant. The administrator stated he always tried to be in compliance with regulations; however, he was not aware that while under the intermediate condition he was required to maintain compliance with all regulations. On 3/28/23 at 4:11 p.m., the administrator stated based on the cited deficiencies discussed the residence had not followed the intermediate condition requirement to maintain compliance with all regulations.

Based on the record review, and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting seven of eight sample residents (#5, #6, #11, #34, #39, #43, #44). (Cross-reference Q1514)This deficiency was cited previously during a licensure complaint survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #5 was admitted to the residence on 12/1/21 with diagnoses including anxiety and unspecified dementia. a. Lorazepam A written practitioner's order, dated 8/2/22, directed the residence to administer lorazepam 1 mg four times a day. However, the March 2023 eMAR (electronic medication administration record) for Resident #5 read the medication was not available and not administered on 3/17-3/19 and 3/24/23, for a total of 16 doses.b. FamotidineA written practitioner's order, dated 5/27/22, directed the residence to administer famotidine 150 mg. However, the March 2023 eMAR for Resident #5 read the medication was not available and not administered on 3/13/23, for a total of one dose.c. OndansetronA written practitioner's order, dated 8/2/22, directed the residence to administer ondansetron hcl 4 mg. However, the March 2023 eMAR for Resident #5 read the medication was not available and not administered on 3/13/23, for a total of one dose. On 3/28/23 at 3:00 p.m., the Resident Care Director (RCD) stated she was not aware the medication was out of stock and not administered to Resident #5.2. Resident #6 was admitted to the residence on 7/1/21 with diagnoses including unspecified dementia. a. CitalopramA written practitioner's order, dated 8/30/22, directed the residence to administer citalopram 20 mg once daily. However, the March 2023 eMAR for Resident #6 read the medication was not available and not administered on 3/1-3/7, 3/17-3/24 and 3/28/23, for a total of 16 doses.b. Losartan A written practitioner's order, dated 8/30/22, directed the residence to administer losartan 100 mg once daily. However, the March 2023 eMAR for Resident #6 read the medication was not available and not administered on 3/1-3/6, 3/17-3/24 and 3/28/23, for a total of 15 doses. On 3/28/23 at 3:00 p.m., the RCD stated she was not aware the medication was out of stock and not administered to Resident #6.3. Resident #11 was admitted to the residence on 2/18/22. a. Oyster ShellA written practitioner's order, dated 2/17/23, directed the residence to administer oyster shell 500 mg once daily. However, the March 2023 eMAR for Resident #11 read the medication was not available and not administered on 3/1/23, for a total of one dose.b. FinasterideA written practitioner's order, dated 2/18/22, directed the residence to administer finasteride 5 mg once daily. However, the March 2023 eMAR for Resident #11 read the medication was not available and not administered on 3/2, 3/6, 3/14, and 3/18/23, for a total of four doses.c. NiacinA written practitioner's order, dated 2/18/22, directed the residence to administer niacin 500 mg once daily. However, the March 2023 eMAR for Resident #11 read the medication was not available and not administered on 3/3/23, for a total of one dose.d. Metoprolol SuccinateA written practitioner's order, dated 6/4/22, directed the residence to administer metoprolol succinate 25 mg once daily. However, the March 2023 eMAR for Resident #11 read the medication was not available and not administered on 3/14/23, for a total of one dose. On 3/28/23 at 3:00 p.m., the RCD stated she was not aware the medication was out of stock and not administered to Resident #11.4. Resident #39 was admitted to the residence on 4/9/21 with diagnoses including unspecified dementia and schizoaffective disorder.a. Citalopram A written practitioner's order, dated 7/28/21, directed the residence to administer citalopram 20 mg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/4-3/7 and 3/12/23, for a total of five doses.b. FluticasoneA written practitioner's order, dated 2/17/21, directed the residence to administer fluticasone 50 mcg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/4-3/7 and 3/12/23, for a total of five doses.c. Metoprolol A written practitioner's order, dated 12/8/21, directed the residence to administer metoprolol 50 mg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/4-3/5 and 3/7/23, for a total of three doses.d. Stomach ReliefA written practitioner's order, dated 8/14/22, directed the residence to administer stomach relief 262 mg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/7, 3/20-3/24 and 3/26/23, for a total of seven doses.e. Trazodone A written practitioner's order, dated 8/14/22, directed the residence to administer trazadone 50 mg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/7/23, for a total of one dose.f. Calcium A written practitioner's order, dated 3/19/23, directed the residence to administer calcium 600 mg once daily. However, the March 2023 eMAR for Resident #39 read the medication was not available and not administered on 3/20-3/24/23, for a total of five doses. 5. Resident #44 was admitted to the residence on 2/1/20 with diagnoses including diabetes and Alzheimer's disease. a. Atorvastatin Calcium A written practitioner's order, dated 1/23/23, directed the residence to administer atorvastatin calcium 10 mg once daily. However, the March 2023 eMAR for Resident #44 read the medication was not available and not administered on 3/1-3/7/23, for a total of seven doses.b. Metoprolol Succinate A written practitioner's order, dated 1/23/23, directed the residence to administer metoprolol 50 mg once daily. However, the March 2023 eMAR for Resident #44 read the medication was not available and not administered on 3/2-3/3, 3/5-3/6 and 3/8/23, for a total of five doses.c. Escitalopram Oxalate A written practitioner's order, dated 2/21/23, directed the residence to administer escitalopram oxalate 10 mg once daily. However, the March 2023 eMAR for Resident #44 read the medication was not available and not administered on 3/19/23, for a total of one dose.d. LisinoprilA written practitioner's order, dated 1/23/23, directed the residence to administer lisinopril 20 mg once daily. However, the March 2023 eMAR for Resident #44 read the medication was not available and not administered on 3/19/23, for a total of one dose. On 3/28/23 at 3:00 p.m., the RCD stated she was not aware the medication was out of stock and not administered to Resident #44.6. Resident #43 was admitted to the residence on 9/24/21 with diagnoses including spinal stenosis, osteoarthritis in right hip, benign prostatic hyperplasia and left artificial hip. a. Folic AcidA written practitioner's order, dated 1/23/23, directed the residence to administer folic acid 0.4 mcg once daily. However, the March 2023 eMAR for Resident #43 read the medication was not available and not administered on 3/1, 3/3-3/10, 3/13-3/14, 3/16-3/19 and 3/21-3/27/23, for a total of 22 doses. On 3/28/23 at 3:00 p.m., the RCD stated she was not aware the medication was out of stock and not administered to Resident #43.b. Trospium ChlorideA written practitioner's order, dated 1/23/23, directed the residence to administer trospium chloride 20 mg once daily. However, the March 2023 eMAR for Resident #43 read the medication was not available and not administered on 3/1, 3/3-3/10, 3/13-3/16, 3/18-3/19 and 3/21-3/27/23, for a total of 21 missed doses. 7. Resident #34 was admitted to the residence on 12/31/21.a. Lidocaine PatchA written practitioner's order, dated 2/3/23, directed the residence to administer lidocaine patch 5% once daily. However, the March 2023 eMAR for Resident #34 read the medication was not available and not administered on 3/13, 3/15-3/19, 3/22-3/25 and 3/27/23, for a total of 10 doses.b. Polyethylene GlycolA written practitioner's order, dated 2/3/23, directed the residence to administer polyethylene glycol 3350 oral powder twice daily. However, the March 2023 eMAR for Resident #34 read the medication was not available and not administered on 3/2/23 in the morning. 8. Interviews On 3/28/23 at 3:00 p.m., the RCD stated when the eMAR read a medication was not available that meant the medication was not in stock and not available to administer. She added she expected the wellness nurses to notify her when a medication for a resident was out of stock and not administered, as required. The RCD said she expected the QMAP to order medication for residents when seven days of medications remained and she expected medications to be administered as ordered. On 3/28/23 at approximately 3:30 p.m., the administrator stated he expected medications to be administered as ordered and not run out of stock. He added the RCD was responsible for ensuring residents were administered their medications as ordered and expected QMAPs to reorder medications when seven days remained. The administrator stated the reason the citation was recited was due to lack of compliance.

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 and failed to ensure the medication administration record reflected the dosage of each medication, affecting one of seven sample residents (#43). (Cross-reference Q1514)This deficiency was cited previously during a licensure complaint survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's Medication Assistance policy, dated September 2021, read, in part, "The facility will capture all information required under Colorado regulation for each resident. The MAR (medication administration record) is initiated each time a medication is assisted or administered to a resident."Resident #43 was admitted to the residence on 9/24/21. A written practitioner's order, dated 1/23/23, directed the residence to administer oxycodone 5 mg half tablet every four hours for pain as needed. However, the March 2023 eMAR for Resident #43 read oxycodone 5 mg half tablet by mouth as needed. There was no frequency listed on the eMAR for qualified medication administration persons (QMAPs) to know how often to administer the medication. On 3/28/23 at 3:00 p.m. the resident care director (RCD) said the oxycodone on the eMAR should read how often the medication was required to be administered. On 3/28/23 at 3:00 p.m., the RCD stated that the night shift nurses audit the eMAR's when they work. She added her or her assistant were ultimately responsible to ensure the eMAR's are accurate. On 3/28/23 at 3:30 p.m., the administrator stated he expected the eMAR's for residents to be accurate and identical to the practitioner's order. He added, the reason the citation was recited was because the residence was out of compliance.

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records, affecting seven of eight sample residents (#5, #6, #11, #34, #39, #43, #44). (Cross-reference Q1468, Q1510, Q1522)This deficiency was cited previously during a licensure complaint survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's Medication Assistance policy, dated September 2021, read, in part, "At the minimum, a med cart is reviewed each night by the night shift MS (medication supervisor) /MA (medication assistant) (LPN [licensed practicing nurse], if applicable). In doing so, the MS/MA (LPN, if applicable) is checking for re-orders, expired meds and availability of PRN (as needed) meds."On 3/28/23 at 7:20 a.m., the residence's most recently quarterly audit of the MARs, controlled substance lists, medication error reports and medication disposal records were requested. Review of the department database on 3/27/23 revealed the name of the administrator of record and further revealed he had held this position since 6/20/22. On 3/28/23 at approximately 10:00 a.m., an audit that was conducted on 3/21/23 by the residence's preferred pharmacy was provided. There was no evidence to show that the QMAP supervisor and administrator participated in the audit. On 3/28/23 at 9:54 a.m., the resident care director (RCD) stated the residence pharmacy completed audits quarterly and the night nurse completed weekly audits. The RCD said she was unable to find the nurse's night audit documentation. The RCD stated she was the QMAP supervisor and only compared orders to the MARs. She added the administrator was not a part of the audits. The RCD stated the reason the citation was recited was because the residence did not have a policy and procedure in place ensure audits were completed, as required. She added there was miscommunication on what the expectations were. Despite the administrator being listed as the administrator of record for the residence since June 2022, the administrator stated on 3/28/23 at 3:30 p.m. that a medication audit included a thorough medication reconciliation to ensure there were no blank spaces for the adminsitration of medication and to review what medications were administered or not. The administrator stated he just learned the day of the onsite visit on 3/28/23 that he was required to be a part of the medication audits along with his RCD. He added the reason the citation was recited was because of medication errors.

Based on record review and interview, the residence failed to notify residents' authorized practitioner of patterns of medication refusals, affecting one of seven sample residents (#34). (Cross-reference Q1514)This deficiency was cited previously during a licensure complaint survey 12/13/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's Medication Assistance policy, dated September 2021, read, in part, "If a resident refuses a prescribed medication, the MS/MA (medication supervisor/medication aide) initials the corresponding block in the MAR (medication administration record). Note in the MAR that the resident refused the medication and dispose of the medication as appropriate. The residence care director (RCD) is to be notified immediately who must then notify the prescriber immediately."Resident #34 was admitted to the residence on 12/31/21. A written practitioner's order, dated 2/3/23, directed the residence to administer polyethylene glycol 3350 oral powder twice daily. However, the March 2023 MAR for Resident #34 read the medication was refused on 3/1 in the evening, 3/2 in the evening, 3/4-3/5, 3/6-3/7 in the evening, 3/9-3/10 in the evening, 3/11-3/16, 3/19-3/20 in the evening and 3/21-3/27/23 in the morning and evening, for a total of 38 doses refused. On 3/28/23 at 3:00 p.m., the resident care director (RCD) stated the residence had not notified the practitioner of Resident #34's repeated refusal of polyethylene glycol. The RCD said she expected staff to write a progress note in Resident #34's record that indicated his refusal. On 3/28/23 at approximately 3:30 p.m., the administrator stated the reason this citation was recited was due to a breakdown in residence systems.

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