ROSEMARK AT MAYFAIR PARK

A licensure complaint, prompted by #CO29465, was completed on 2/7/23. No deficiencies were cited.

A licensure revisit was completed on 2/7/23 for all previous deficiencies cited on 1/26/22. Deficiencies were cited.

Based on interviews and record review, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 43 current residents. Findings include:The Assisted Living Residences and Group Homes Mitigation and Outbreak Guidance, updated 1/12/23, required residences to:As outlined in CDC's guidance, facilities should assign at least one person with training in infection prevention control (IPC) to provide on-site management of infection prevention and control activities within the facility. Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one) and (period two). Multiple reports within the same reporting period will overwrite previous reporting and does not meet requirements for future reporting periods. Reporting period one (defined as days 1-14 of each month). Complete all facility questions. Reporting period two (defined as days 15-31 of each month). Complete all facility questions. On 2/7/23, review of the EMResource database revealed the former director of nursing was the IPC staff member. On 2/7/23 at approximately 11:30 a.m., the administrator stated she was not sure what the IPC training was or whether or not it was completed. On 2/7/23 at approximately 12:00 p.m., the former director of nursing stated she was not aware of the IPC training and it had not been completed.

Based on observation, record review and interview, the residence failed to ensure the qualified medication administration person (QMAP) did not mask medication, affecting five of six sample residents (#2, #22-#23, #27-#28) that medication pass was observed in the secure environment. This deficiency was cited previously during a state licensure survey 1/26/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. References Chapter VII regulations governing assisted living residences, part 2.26, defines medication administration as assisting a person in the ingestion, application, inhalation, or, using universal precautions, rectal or vaginal insertion of medication, including prescription drugs, according to the legibly written or printed directions of the attending physician or other authorized practitioner.. (B) Medication administration by a QMAP does not include judgment, evaluation, assessments, or injecting medication (unless otherwise authorized by law in response to an emergent situation.) 2. ObservationDuring morning medication administration on 2/7/23 from 7:27 a.m. to 8:30 a.m., Staff #23 crushed medications for sample residents (#2, #22, #23, #27, #28) and put them in pudding as follows:Staff #23 crushed Resident #28's medications, placed them in pudding and approached Resident #28 and told her the medication was candy. Resident #28 opened her mouth and Staff #23 spoon fed the crushed medication in the pudding. Staff #23 then crushed the medications for Resident #2 and placed them in pudding. Staff #23 went to Resident #2 in the dining area, told the resident that her medication was candy and administered the crushed medication in pudding. Staff #23 then crushed and administered medications in pudding without disclosing that it was medication to Resident #22, #23, and #27.3. InterviewsOn 2/7/23 at 7:27 a.m., Staff #23 stated that she had only worked at the residence for about a month, and she crushed medications for every resident in the secure environment and mixed their medications in pudding. On 2/7/23 at 8:16 a.m., Staff #23 stated that she told Residents #2, #22, #23, #27, and #28 that their medication was candy, because they were more disoriented and would not take the medication otherwise and "everyone liked candy." Staff #23 stated that the residents were not aware what medication was, however, they responded well to the words "candy" and "chocolate." Staff #23 stated that she was not trained to call medication candy, however, she found it helped residents to open their mouths and take their medication. On 2/7/23 at approximately 2:49 p.m., the director of nursing (DON) stated that QMAPs should not mask medication and should let residents know that they were being administered their medications. On 2/7/23 at 2:49 p.m., the administrator stated that QMAPS should mask medications by telling residents that their medication was candy to persuade them to take it. The administrator acknowledged that she was not aware that QMAPs were telling residents their medication was candy.

Based on observation, record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting eight of ten sample residents (#2, #8, #19, #21-#24, #28). This deficiency was cited previously during a state licensure survey 1/26/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Residence PolicyThe residence's medication administration policy, dated 9/1/22, read in part: "all medications are administered (in accordance with) physician orders."2. Resident #23 was admitted to the residence on 10/25/21, with diagnoses including unspecified dementia with behavioral disturbance, hypothyroidism, bilateral inguinal hernia, essential hypertension, and type 2 diabetes mellitus. On 2/7/23 at 7:27 a.m., Staff #23 stated that she crushed each resident's medication in the secure environment since she had started working at the residence in January 2023, because everyone had swallowing difficulties with taking medication. On 2/7/23 at 8:19 a.m., Staff #23 crushed Resident #23's medication, which included ferrous sulfate, acetaminophen, preservision areds, vitamin d3, metropolol tartrate, levothyroxine sodium, aspirin famotidine, finasteride, and co-enzyme q10, mixed it in pudding and administered it to him. On 2/7/23 at 1:30 p.m., a crush order for Resident #23 was requested and not provided. On 2/7/23 at 1:56 p.m., Resident #23's family member stated that she had observed Resident #23's medication being crushed when she had come to the residence to visit, and was unsure why his medications were being crushed because Resident #23 had no swallowing difficulties. On 2/7/23 at 3:13 p.m., the director of nursing stated that Staff #23 should not have crushed Resident #23's medication at all since he did not have a medication crush order. The director of nursing stated that Resident #23 should not have had their medications crushed without a crush order.a. TamsulosinA written practitioner's order, dated 10/22/21, directed the residence to administer 0.4 mg of tamsulosin once daily. The February 2023 electronic medication administration record (eMAR), read that tamsulosin was not administered on 1/2/23, 1/30-2/2/23, and 2/4-2/5/23 for a total of seven missed doses. A progress note, dated 1/2/23, read in part: "waiting on pharmacy delivery."Progress notes, dated 1/30-2/2/23, and 2/4-2/5/23, read that the medication was not available and was on order with the pharmacy.b. RosuvastatinA written practitioner's order, dated 10/22/21, directed the residence to administer 10 mg of rosuvastatin once daily. The January and February 2023 eMARs were reviewed, and read that rosuvastatin was not administered on 1/6/23, 2/1-2/2/23, and 2/4-2/5/23 for a total of five missed doses. A progress note, dated 1/6/23, read in part: "medication not in medication cart."Progress notes, dated 2/1-2/2/23, and 2/4-2/5/23, read that the medication was on order with the pharmacy.c. Enzyme Q10A written practitioner's order, dated 10/22/21, directed the residence to administer 300 mg of enzyme q10 once daily. The January and February 2023 eMARs were reviewed, and read that enzyme q10 was not administered on 1/17/23, 1/22-1/23/23, and 1/25/23 for a total of four missed doses. Progress notes, dated 1/17/23, 1/22-1/23/23, and 1/25/23, read in part: "medication not available."d. Citalopram HydrobromideA written practitioner's order, dated 1/31/22, directed the residence to administer 15 mg of citalopram hydrobromide once daily. The January and February 2023 eMARs were reviewed, and read that citalopram hydrobromide was not administered on 2/4-2/5/23, for a total of two missed doses. Progress notes, dated 2/4-2/5/23, read in part: "medication on order."e. AcetaminophenA written practitioner's order, dated 1/24/23, directed the residence to administer 500 mg of acetaminophen twice daily. The January and February 2023 eMARs were reviewed, and read that acetaminophen was not administered on 1/24/23 in the evening and 1/25/23 in the morning, for a total of two missed doses. Progress notes, dated 1/24-1/25/23, read in part: "medication not in cart, waiting on delivery."f. Ferrous SulfateA written practitioner's order, dated 10/22/21, directed the residence to administer 325 mg of ferrous sulfate once daily. The January and February 2023 eMARs were reviewed, and read that ferrous sulfate was not administered on 1/11/23, for a total of one missed dose. A progress note, dated 1/11/23, read in part: "medication not available."g. LevothyroxineA written practitioner's order, dated 10/22/21, directed the residence to administer 50 mg of levothyroxine sodium once daily. The January and February 2023 eMARs were reviewed, and read that levothyroxine sodium was not administered on 1/15/23, for a total of one missed dose. A progress note, dated 1/15/23, read in part: "medication is not available but is on order."On 2/7/23 at 3:24 p.m., the director of nursing stated that she was not aware why Resident #23's medications were not administered on the days above. The administrator stated that it was likely due to pharmacy issues. 3. Resident #8 was admitted to the residence on 5/18/18, with diagnoses including major depressive disorder and alcoholic liver disease.a. OndansetronA written practitioner's order, dated 1/12/23, directed the residence to administer 4 mg of ondansetron two times daily. The January and February 2023 eMARs were reviewed, and read that ondansetron was not administered on 2/1/23 in the evening, 2/2/23 in the morning and evening, and 2/3/23 in the morning, for a total of four missed doses. Progress notes, dated 2/1-2/3/23, read that medication was not in the cart.b. ParoxetineA written practitioner's order, dated 1/31/23, directed the residence to administer 20 mg of paroxetine once daily. The January and February 2023 eMARs were reviewed, and read that paroxetine was not administered on 2/2/23, for a total of one missed dose. A progress note, dated 2/2/23, read in part: "medication not available."On 2/7/23 at 3:19 p.m., the director of nursing stated that she was not aware why Resident #8's medications were not administered on the days above. The administrator stated that it was likely due to pharmacy issues. 4. Resident #22 was admitted to the residence on 9/23/21, with diagnoses including vitamin d deficiency.a. MultivitaminA written practitioner order, dated 9/4/22, directed the residence to administer one tablet of multivitamin, once daily. The January and February 2023 eMARs were reviewed, and read that multivitamin was not administered on 1/13-1/15/23, and 1/17/23, for a total of four missed doses. Progress notes, dated 1/13-1/15/23, and 1/17/23, read that multivitamin was not available.b. AspirinA written practitioner order, dated 11/11/22, directed the residence to administer an 81 mg tablet of aspirin, once daily. The January and February 2023 eMARs were reviewed, and read aspirin was not administered on 1/17/23, for a total of one missed dose. A progress note dated 1/17/23, read that aspirin was not available. On 2/7/23 at 3:18 p.m., the director of nursing stated that she was not aware why Resident #22's medications were not administered on the days above. The administrator stated that it was likely due to pharmacy issues. 5. Resident #27 was admitted to the residence on 1/4/23, with diagnoses including Alzheimer's disease, atrial fibrillation and flutter, unspecified urinary incontinence, and anterior dislocation of left sternoclavicular joint. On 2/7/23 at 7:59 a.m., Staff #23 administered crushed medications which included lorazepam and tramadol, to Resident #27 and put in pudding. On 2/7/23 at 1:30 p.m., a crush order was requested and not provided. On 2/7/23 at 2:25 p.m., the administrator stated that she had reached out to hospice for a crush order for Resident #27 because they did not have one on site even though he did need his medication crushed due to swallowing difficulties. On 2/7/23 at 3:11 p.m., the director of nursing stated that there must have been a communication error with the external hospice agency, because they should have had a crush order but they did not. The director of nursing stated that Resident #27 should not have had their medications crushed without a crush order. 6. Resident #19 was admitted to the residence on 4/6/21.a. LevothyroxineA written practitioner's order, dated 1/21/23, directed the residence to administer levothyroxine sodium 75 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/24 and 1/25/23 for a total of two missed doses due to the medication being out of stock.b. ProbioticA written practitioner's order, dated 1/21/23, directed the residence to administer a probiotic capsule once daily. However, the January and February 2023 MAR read the medication was not administered on 1/29 and 2/1/23, for a total of two missed doses due to the medication not being available. On 2/7/23 at 2:09 p.m., the legal representative for Resident #19 stated she was not aware there were any medications out of stock for Resident #19. On 2/7/23 at 2:30 p.m., a medication cart audit revealed the medications were in stock. 7. Resident #2 was admitted to the residence on 4/9/21 with diagnoses including hypertension. A written practitioner's order, dated 1/21/23, directed the residence to administer warfarin sodium once daily at bedtime. However, the February 2023 MAR read the medication was not administered on 2/2-2/4/23, for a total of three missed doses due to the medication being not available. On 2/7/23 at 2:03 p.m., the legal representative for Resident #2 stated she was not aware that warfarin was not administered to the resident as ordered. On 2/7/23 at 2:49 p.m., the director of nursing stated she was not sure why the medication was not administered to the resident as ordered. On 2/7/23 at 2:30 p.m., a medication cart audit revealed the medication was in stock. 8. Resident #28 was admitted to the residence on 5/28/20 with diagnoses including hypertension and osteoporosis. A written practitioner's order, dated 11/14/22, directed the residence to administer alendronate sodium 70 mg once every Sunday. However, the January 2023 MAR read the medication was not administered on 1/29/23, for a total of one missed dose due to the medication being out of stock. On 2/7/23 at 1:55 p.m., the legal representative for Resident #28 stated she was not aware of any medication issues for Resident #28. On 2/7/23 at 2:30 p.m., a medication cart audit revealed the medication was in stock. 9. Resident #24 was admitted to the residence on 3/25/16. A written practitioner's order, dated 12/1/22, directed the residence to administer acetaminophen 650 mg three times a day. However, the January 2023 MAR read the residence did not administer the medication for all three doses on 1/1/23 due to the medication being out of stock for a total of three missed doses. On 2/7/23 at approximately 3:00 p.m., the director of nursing stated she was unsure why the residence ran out of the medication for Resident #24. She added that residents should not miss doses of prescribed medications. On 2/7/23 at approximately 3:00 p.m., the administrator stated that the nurse was responsible for reordering medications. She acknowledged that the residence failed to comply with Resident #24's orders and the resident should not have missed a dose of her prescribed medication. 10. Resident #21 was admitted to the residence on 7/11/19. A written practitioner's order, dated 1/14/23, directed the residence to administer vitamin D 50 mcg once daily. However, the January 2023 MAR read the residence did not administer the medication on 1/25/23 due to the medication being out of stock for a total of one missed dose. On 2/7/23 at approximately 3:00 p.m., the director of nursing stated she was unsure why the residence ran out of the medication for Resident #21. She added that residents should not miss doses of prescribed medications. On 2/7/23 at approximately 3:00 p.m., the administrator stated that the nurse was responsible for reordering medications. She acknowledged that the residence failed to comply with Resident #21's orders and the resident should not have missed doses of her prescribed medication. She stated she was not sure why the residence had not corrected the problem.

Based on observation, record review and interview, the residence failed to ensure qualified medication administration persons (QMAPs) followed national recognized protocols for basic infection control and prevention when preparing and administering medications, affecting six of six sample residents (#2, #8, #22-#23, #27-#28) that medication pass was observed in the secure environment. This deficiency was cited previously during a state licensure survey 1/26/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence policyThe residence's Medication Administration Policy, dated 9/1/22, read in part: "follow sanitary practices, and perform hand hygiene prior to medication preparation for each medication pass, perform hand hygiene after direct resident contact, and use sanitary techniques to place medications into a medicine cup."2. ObservationsOn 2/7/22 from 7:38 a.m. to 8:30 a.m., the following was observed:Staff #23 touched the medication cart and placed a medicated patch on a resident's back, administered medication to Resident #28 and then Resident #2 and did not perform hand hygiene between residents. Staff #23 then touched her nose, adjusted her shoe and administered medication to Resident #27 and did not perform hand hygiene afterwards. Staff #23 dropped a pill for Resident #8, scooped it in the medication cup with the blister package, administered it to Resident #8 and did not perform hand hygiene afterwards. Staff #23 rubbed her nose, picked a pen up off the floor, then prepared and administered medications to Resident #22 and Resident #23. Staff #23 did not perform hand hygiene after touching her nose and the floor, or between residents. Staff #23 placed a lidocaine patch on Resident #22's back and then fed Resident #2. She did not perform hand hygiene between residents. 3. InterviewsOn 2/7/23 at 8:32 a.m., Staff #23 stated that she was trained to perform hand hygiene between each resident when performing care or administering medication; however, she had forgotten to perform hand hygiene the day of the onsite survey, since she did not have hand sanitizer on top of the medication cart like she normally would. On 2/7/23 at approximately 2:49 p.m., the administrator stated that QMAPs should always perform hand hygiene when administering medication between residents, after touching themselves and objects. The administrator stated that QMAPs should not administer dropped medication and should destroy and get a new medication.

Based on record review and interview, the residence failed to accurately document each medication administration event at the time the event was completed, affecting three medications of one of ten sample residents (#22). This deficiency was cited previously during a state licensure survey 1/26/22. 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 #22 was admitted to the residence on 9/23/21, with a diagnosis of anxiety.a. MirtazapineA written practitioner's order, dated 12/20/22, directed the residence to administer 7.5 mg of mirtazapine once daily at bedtime. The January 2023 electronic medication administration record (eMAR) read there was a blank on 1/20/23.b. Lidocaine PatchA written practitioner order, dated 9/2/22, directed the residence to administer a lidocaine patch 4% every morning. The January eMAR read there was a blank on 1/20/23.c. AcetaminophenA written practitioner order, dated 12/19/22, directed the residence to administer a 500 mg of acetaminophen three times daily. The January and February 2023 eMARs were reviewed, and there was a blank on 1/1/23.2. InterviewOn 2/7/23 at approximately 2:49 p.m., the administrator stated that blanks in the eMAR mean that a medication was either not administered, or just not signed off on, but there was no way to know for sure. The administrator stated that she would expect all medications to be documented at the time they were administered.

PLEASE NOTE: The emergency rules regarding COVID-19 Vaccination were suspended effective 7/14/22. As such, a revisit could not be conducted for this event to determine compliance with the cited deficiency.

An initial secure licensure survey was completed on 2/7/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure its quality management program (QMP) contained the required elements, affecting seven current residents. Findings include:1. Referencesa. Chapter II regulations governing health facilities, part 4.1.2, requires a quality management plan to be reviewed and approved on an annual basis, by the administrator or the administrator's designee. b. Chapter II regulations governing health facilities, part 4.1.2 (A), requires the QMP to include the following elements:Identification of quality management projects For the client safety component of the program, the plan shall identify: (a) The types of service delivery errors and potential for error that will be monitored, which shall be based, at minimum, on a review of negative resident outcomes that are unanticipated, resident grievances, deficiencies cited by regulatory agencies, occurrences and/or errors, and potential for errors reported by staff. (b) A process for staff to report service delivery error and potential for error within a prescribed period of time and a plan for how staff will be trained regarding such reporting. (c) The methods used to collect and analyze data in order to find patterns and trends. The plan shall also include how the administrator will be informed of such patterns and trends. (d) The method(s) used to select quality management projects.(e) The method(s) for selecting the service delivery practice(s) that will be reviewed.c. The residence's Quality Assurance Performance Improvement (QAPI) policy, undated, read in part: "Each assisted living community must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of outcomes of care and quality of life. The facility must maintain documentation of its QAPI program's implementation and facilities compliance with requirements to state agencies upon request."2. Record reviewOn 2/7/23, the residence provided documentation. The documentation read the residence identified the types of service delivery errors possible. However the QMP did not include:a. The types of service delivery errors and potential for error that will be monitored, which shall be based, at minimum, on a review of negative resident outcomes that are unanticipated, resident grievances, deficiencies cited by regulatory agencies, occurrences and/or errors, and potential for errors reported by staff. b. A process for staff to report service delivery error and potential for error within a prescribed period of time and a plan for how staff will be trained regarding such reporting. c. The methods used to collect and analyze data in order to find patterns and trends. The plan shall also include how the administrator will be informed of such patterns and trends. d. The method(s) used to select quality management projects.e. The method(s) for selecting the service delivery practice(s) that will be reviewed. 3. InterviewOn 2/7/23 at 2:49 p.m., the administrator stated the QMP included each department head working on quality assurance items. However, she confirmed the residence did not physically have monitoring documentation for current QMP projects.

Based on interviews and record review, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 43 current residents. Findings include:The Assisted Living Residences and Group Homes Mitigation and Outbreak Guidance, updated 1/12/23, required residences to:-As outlined in CDC's guidance, assign at least one person with training in infection prevention control (IPC) to provide on-site management of infection prevention and control activities within the facility. -Report in EMResource the name and contact information of the person responsible for on-site management of infectious disease prevention and response activities at your facility. On 2/7/23, review of the EMResource database revealed the former director of nursing was the IPC staff member. On 2/7/23 at approximately 11:30 a.m., the administrator stated she was not sure what the IPC training was or whether or not it was completed. On 2/7/23 at approximately 12:00 p.m., the former director of nursing stated she was not aware of the IPC training and it had not been completed.

Based on record review and interview, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire for three of three sample staff (#23, #24, #26), affecting 42 residents. Findings include:On 2/7/23, personnel files for Staff #23, #24, and #26 revealed they were hired on 1/9/23, 8/17/22, and 11/4/22 respectively. There was no documentation of a CBI criminal history report in their personnel files. Throughout the on-site visit on 2/7/23 from 7:00 a.m. to approximately 4:00 p.m., Staff #23, #24, and #26 were observed providing care and services to residents. On 2/7/23 at 9:50 a.m., the human resources director acknowledged the personnel files for Staff #23, #24, and #26 did not contain CBI criminal history reports. She stated she was not aware that CBI criminal history reports were required. On 2/7/23 at 10:35 a.m., the administrator stated she was not aware that CBI criminal history reports were required.

Based on record review and interview, the residence failed to have a readily available roster which included resident names and emergency contact information, affecting 43 current residents. Findings include:On 2/7/23 at approximately 7:30 a.m., the human resources director provided a resident roster, however, the roster included residents who no longer lived at the residence and was missing some newer residents. Additionally, the roster did not include emergency contact information or a diagram of the residence, as required. On 2/7/23 at approximately 8:00 a.m., the resident roster that would be provided in the event of an emergency was requested from the director of nursing and human resources director. On 2/7/23 at 8:32 a.m., Staff #24 stated she would have to request a resident roster from the director of nursing because she was not sure where to locate a resident roster. On 2/7/23 at 8:35 a.m., Staff #23 stated that she did not know the secure environment had a resident roster. Staff #23 stated that if they had a roster, she did not know where it was. On 2/7/23 at approximately 10:30 a.m., the director of nursing provided a resident roster that did not include emergency contact information or a diagram of the residence, as required. On 2/7/23 at approximately 2:43 p.m., the administrator stated the residence had an emergency binder at the front desk that contained an accurate resident roster. She stated staff should know where to locate the emergency binder. On 2/7/23 at 3:27 p.m., the administrator provided the resident roster located at the front desk, however, it did not include a diagram of the residence as required. On 2/7/23 at 3:27 p.m., the administrator stated she was not aware the resident roster was required to include a diagram of the residence.

Based on interview and record review, the residence failed to detail in each resident's care plan the individualized approach necessary to address fall risk, affecting five of five sample residents (#19, #22, #23, #27, #28) who fell. Specifically, Resident #19 was admitted to the residence on 4/6/21 with diagnoses including dementia and muscle weakness. The resident had a fall on 1/8/23 that resulted in a head injury. However, there was no evidence the care plan was updated with the individualized approach necessary to address fall risk. Further, the care plan did not acknowledge the resident was at risk for falls. Specifically, Resident #27 had a history of falls; however, the care plan did not detail the individualized approach necessary to address fall risk. Resident #27 had a fall on 1/6/23, hit his head, and sustained two skin tears on his arm. However, the care plan was not updated to detail the individualized approach necessary to address fall risk. Specifically, Resident #22 was admitted to the residence on 9/23/21 with diagnoses including Alzheimer's disease, neurocognitive disorder with Lewy bodies, difficulty in walking, lack of coordination, displaced fracture of left humerus, weakness and hypotension. However, the care plan did not detail the individualized approach necessary to address fall risk. Resident #22 sustained a fall on 11/28/22, the care plan was not updated to detail the individualized approach necessary to address fall risk and Resident #22 fell again on 12/19/22 and sustained bruising to the right fourth finger. Findings include:1. Residence PolicyThe residence's Fall Response Procedure policy, dated 9/1/22, read in part, "Should a resident fall, staff will provide immediate care and follow with care as indicated in the service plan."2. Resident #19 was admitted to the residence on 4/6/21 with diagnoses including dementia and muscle weakness. An undated care plan, read in part, the resident required one person transfer assistance. However, the care plan did not detail the individualized approach necessary to address fall risk. A progress note, dated 1/8/23, read in part, the resident was found on the floor of her bedroom after a fall. The fall resulted in a raised bump on her head and a bruise. On 2/7/23 at 7:52 a.m., Staff #24 stated Resident #19 was at risk for falls due to a history of falls. She stated staff were required to provide the resident with more frequent supervision to address the fall risk. On 2/7/23 at 2:09 p.m., the legal representative for Resident #19 stated the resident had a fall in the previous 30 days that resulted in a head injury. She also stated she was not aware of the staff interventions in place to mitigate the resident's falls. Additionally, she stated the resident had a history of falls. On 2/7/23 at 2:23 p.m., Staff #25 stated Resident #19 was at risk for falls due to a history of falls and poor safety awareness. He also stated that due to the resident's dementia diagnoses, she often forgot she was not able to physically transfer herself independently which resulted in a pattern of falls in the past few months. He stated the individualized approach necessary to address fall risk was to provide the resident with frequent safety checks during the overnight shift. On 2/7/23 at 2:49 p.m., the director of nursing (DON) stated the resident was at risk for falls at night and required two hour supervision checks. She also stated the former DON was responsible for updating care plans after falls. However, she was unaware as to why the care plan was not updated with the individualized approach necessary to address the resident's fall risk because she had only been employed at the residence for a week. On 2/7/23 at approximately 2:49 p.m., the administrator stated it was the former DON's responsibility to update care plans with the individualized approach necessary to address fall risk. However, she was not aware care plans were not updated as required. Additionally, the administrator acknowledged the resident was at risk for falls due to muscle weakness and a dementia diagnoses and it should have been care planned before and after her fall on 1/8/23.3. Resident #27 was admitted to the residence on 1/4/23, with diagnoses including Alzheimer's disease and anterior dislocation of left sternoclavicular joint. A care plan, dated 1/5/23, read in part, Resident #27 was a fall risk due to history of falls. However, the care plan did not include updated inverventions and did not detail the individualized approach necessary to address fall risk. An incident report, dated 1/6/23, read that the resident fell backwards, sustained two skin tears on his arms, and hit his head. A progress note, dated 1/7/23, read that Resident #27 had a fall on 1/6/23 and "sustained two skin tears on his right forearm."On 2/7/23 at 7:56 a.m., a fall mat was observed on the floor by Resident #27's bed. On 2/7/23 at 2:58 p.m., the administrator stated that Resident #27 was a fall risk, staff provided two hour checks and toileting assistance, the resident wore non-skid socks and had a fall mat by his bed. The administrator stated that she was unsure why none of these fall interventions were care-planned. The administrator stated that Resident #27 had physical and occupational therapy services due to his frequent falls. 4. Resident #22 was admitted to the residence on 9/23/21 with diagnoses including Alzheimer's disease, neurocognitive disorder with Lewy bodies, difficulty in walking, lack of coordination, displaced fracture of left humerus, weakness and hypotension. A care plan, dated 9/26/21, read the resident required monitoring for risk of falls due to hypotension and poor safety awareness. However, the care plan did not detail the individualized approach necessary to address fall risk. An incident report, dated 11/28/22, read in part, the resident lost her balance on the way to the dining area, and fell on the floor. A progress note, dated 12/19/22, read in part, the resident had a fall walking in the dining area and sustained bruising to her right fourth finger. On 2/7/23 at approximately 2:49 p.m., the administrator stated that Resident #22 was a fall risk but she was not sure of what interventions were in place. The administrator acknowledged that there should be detailed interventions in the resident's care plan. 5. Resident #23 was admitted to the residence on 10/25/21, with diagnoses including unspecified dementia with behavioral disturbance, essential hypertension, and osteoarthritis. A care plan, dated 10/25/21, read that Resident #23 was a fall risk and was encouraged to wear non-skid socks at bed time and tennis shoes during the day. However the care plan was not updated, and did not detail additional individualized interventions to address fall risk. An incident report, dated 1/23/23, read in part, the resident had a fall with skin tears. A progress note, dated 1/24/23, read in part, staff were notified of an unwitnessed fall that resulted in bilateral forearm skin tears. Resident's dressings were intact but the resident complained of mild discomfort in the lower back. The skin tears were assessed by the residence nurse. On 2/7/23 at 1:42 p.m., Resident #23's family member stated that Resident #23 had sustained a couple falls at the residence, but the most recent he remembered was on 1/24/23. On 2/7/23 at approximately 3:00 p.m., the administrator stated that she did not think that Resident #23 had a fall prior to his fall on 1/23/23. The DON stated that she was unsure whether one fall was enough to update the care plan. The administrator stated that she was unsure of Resident #23's fall interventions. 6. Resident #28 was admitted to the residence on 5/28/20 with diagnoses including osteoporosis. An undated care plan read in part, the resident required one person transfer assistance. However, the care plan did not detail the individualized approach necessary to address fall risk. A progress note, dated 10/24/22, read in part, the resident had a fall which resulted in an injured left wrist. The resident was transported to the emergency department. A progress note, dated 10/25/22, read in part, the resident required skilled nursing care for rehabilitation due to the injured left wrist. A progress note, dated 11/15/22, read in part, the resident was readmitted to the residence with a hard cast on her left wrist. A progress note, dated 12/26/22, read in part, the resident had a fall on 12/24/22. On 2/7/23 at 7:52 a.m., Staff #24 stated Resident #28 was at risk for falls due to a history of falls. She stated the individualized approach necessary to address fall risk included ensuring the resident was in common areas to be supervised by staff. On 2/7/23 at 1:55 p.m., the legal representative for Resident #28 stated the resident had a fall in October 2022 that resulted in a fractured wrist and a three week admission to a skilled nursing rehabilitation center. She confirmed the resident had a fall on 12/24/22 as well. Additionally, the legal representative stated the individualized approach necessary to address fall risk included two to three hour safety checks on the resident. On 2/7/23 at 2:23 p.m., Staff #25 stated Resident #28 was at risk for falls. He stated the resident was not allowed to be in her room without staff supervision to try to prevent falls. He stated the resident had poor safety awareness and a history of falls. On 2/7/23 at 2:49 p.m., the DON stated the resident was at risk for falls due to her history of falls. She stated the resident required two hour safety checks. Further, she confirmed the care plan was not updated as required with the individualized approach necessary to address fall risk as required.

Based on record review and interview, the residence failed to ensure the house rules listed all possible actions that might be taken by the residence if any rule was knowingly violated by a resident, and failed to address pets, affecting 43 current residents. Findings include:On 2/7/23 at approximately 11:43 a.m., the administrator provided the house rules for the residence. The house rules did not contain possible actions the assisted living residence may take if the resident knowingly violated any rule, and did not address pets. On 2/7/23 at 3:00 p.m., the administrator stated that she was unaware that the residence's house rules did not meet the requirement. The administrator acknowledged that she did know that actions needed to be included for if residents violated rules, and did not know that house rules needed to address pets.

Based on observation, interview and record review, the residence failed to ensure the process for raising and addressing grievances and complaints was placed in a visible on-site location with full contact information for all required agencies, affecting 43 current residents. Findings include:The residence Grievance Procedure policy, undated, read in part: "We are committed to providing the highest quality of care to residents in our facility. We want you to feel safe in a homelike environment. In order for us to assist you, please follow the procedure identified below if you have any concerns about your care, treatment by staff, or anything else related to your stay in our facility."On 2/7/23 from 7:00 a.m. to 4:00 p.m., there was no process for addressing grievances and complaints placed in a visible on-site location along with full contact information for the following agencies:The Adult Protection Services of the appropriate county Department of Social ServicesThe advocacy services of the area's agency on agingThe Colorado Department of Public Health and EnvironmentThe Colorado Department of Health Care Policy and Financing, in those cases where the assisted living residence is licensed to provide services specifically for persons with intellectual and developmental disabilities. On 2/7/23 at 1:55 p.m., the legal representative for Resident #28 stated she was not aware of the residence's grievance and complaint resolution process. She also stated she was not aware of how to contact the above mentioned agencies. On 2/7/23 at 2:09 p.m., the legal representative for Resident #19 stated she was not aware of the residence's grievance and complaint resolution process. She also stated she was not aware of how to contact the above mentioned agencies. On 2/7/23 at 2:49 p.m., the administrator confirmed the grievance and complaint procedure was not visibly posted anywhere in the residence. She also stated she was not aware of the elements that were required to go in the policy and procedure.

Based on observation, record review and interview, the residence failed to ensure the qualified medication administration person (QMAP) did not mask medication, affecting five of six sample residents (#2, #22, #23, #27, #28) that medication pass was observed in the secure environment. Findings include: 1. Reference Chapter VII regulations governing assisted living residences, part 2.26, defines medication administration as assisting a person in the ingestion, application, inhalation, or, using universal precautions, rectal or vaginal insertion of medication, including prescription drugs, according to the legibly written or printed directions of the attending physician or other authorized practitioner.. (B) Medication administration by a QMAP does not include judgment, evaluation, assessments, or injecting medication (unless otherwise authorized by law in response to an emergent situation.) 2. ObservationDuring morning medication administration on 2/7/23 from 7:27 a.m. to 8:30 a.m., Staff #23 crushed medications for sample residents (#2, #22, #23, #27, #28) and put them in pudding as follows:Staff #23 crushed Resident #28's medications, placed them in pudding and approached Resident #28 and told her the medication was candy. Resident #28 opened her mouth and Staff #23 spoon fed the crushed medication in the pudding. Staff #23 then crushed the medications for Resident #2 and placed them in pudding. Staff #23 went to Resident #2 in the dining area, told the resident that her medication was candy and administered the crushed medication in pudding. Staff #23 then crushed and administered medications in pudding without disclosing that it was medication to Resident #22, #23, and #27.3. InterviewsOn 2/7/23 at 7:27 a.m., Staff #23 stated that she had only worked at the residence for about a month, and she crushed medications for every resident in the secure environment and mixed their medications in pudding. On 2/7/23 at 8:16 a.m., Staff #23 stated that she told Residents #2, #22, #23, #27, and #28 that their medication was candy, because they were more disoriented and would not take the medication otherwise and "everyone liked candy." Staff #23 stated that the residents were not aware what medication was, however, they responded well to the words "candy" and "chocolate." Staff #23 stated that she was not trained to call medication candy, however, she found it helped residents to open their mouths and take their medication. On 2/7/23 at approximately 2:49 p.m., the director of nursing (DON) stated that QMAPs should not mask medication and should let residents know that they were being administered their medications. On 2/7/23 at 2:49 p.m., the administrator stated that QMAPS should not mask medications by telling residents that their medication was candy to persuade them to take it. The administrator acknowledged that she was not aware that QMAPs were telling residents their medication was candy.

Based on interview and record review, the residence failed to ensure only medications that had been ordered by an authorized practitioner were administered to residents, affecting five of 10 sample residents (#2, #19, #24, #27, #28). 1. Residence PolicyThe residence's medication policy, dated 9/1/22, read in part: "all medications are administered (in accordance with) physician orders."On 2/7/23 at 9:54 a.m., written practitioner's orders were requested for Residents #2, #19, #24, #27, and #28.2. Resident #19 was admitted to the residence on 4/6/21 with diagnoses including dementia, osteoporosis, and vitamin D deficiency.a. OsycoThe January 2023 MAR read in part, the resident was administered osyco 500+D tablet 200-500 mg once daily on 1/1-1/10 and 1/12-1/20/23, for a total of 19 doses. However, the residence was unable to provide a written practitioner's order dated prior to 1/21/23.b. D-MannoseThe January 2023 MAR read in part, the resident was administered D-Mannose 500 mg once daily on 1/1-1/9 and 1/11-1/20/23, for a total of 19 doses. However, the residence was unable to provide a written practitioner's order dated prior to 1/21/23.c. Methylphenidate HCLThe January 2023 MAR read in part, the resident was administered methylphenidate HCL 5 mg once daily on 1/1-1/18/23, for a total of 18 doses. However, the residence was unable to provide a written practitioner's order dated prior to 1/21/23.d. Memantine HCLThe January 2023 MAR read in part, the resident was administered memantine HCL 10 mg once daily on 1/1-1/10, 1/12, 1/13, 1/16-1/18/23, for a total of 15 doses. However, the residence was unable to provide a written practitioner's order dated prior to 1/21/23.e. Lidocaine patchThe January 2023 MAR read in part, the resident was administered a lidocaine patch once daily on 1/1-1/4 and 1/7-1/19/23, for a total of 13 doses. However, the residence was unable to provide a written practitioner's order dated prior to 1/21/23.3. Resident #2 was admitted to the residence on 4/9/21 with diagnoses including hypertension.a. AtorvastatinThe January 2023 MAR read in part, the resident was administered atorvastatin 20 mg once daily at bedtime on 1/1-1/19/23, for a total of 19 doses. However, the residence was unable to provide a written practitioner's order dated prior to 1/21/23.b. Donepezil HCLThe January 2023 MAR read in part, the resident was administered donepezil HCL 10 mg once daily at bedtime on 1/1-1/19/23, for a total of 19 doses. However, the residence was unable to provide a written practitioner's order dated prior to 1/21/23.c. SeroquelThe January 2023 MAR read in part, the resident was administered seroquel 25 mg once daily at bedtime on 1/1-1/19/23, for a total of 19 doses. However, the residence was unable to provide a written practitioner's order dated prior to 1/21/23.d. WarfarinThe January 2023 MAR read in part, the resident was administered warfarin sodium 2.5 mg once daily at bedtime on 1/1-1/4 and 1/8-1/14/23, for a total of 11 doses. However, the residence was unable to provide a written practitioner's order dated prior to 1/21/23.4. Resident #27 was admitted to the residence on 1/4/23, with diagnoses including Alzheimer's disease, atrial fibrillation and flutter, unspecified urinary incontinence, and anterior dislocation of left sternoclavicular joint. On 2/7/23 at 7:59 a.m., Staff #23 administered crushed tramadol and senna to Resident #27 and put in pudding. On 2/7/23 at 1:30 p.m., tramadol, cefuroxime, and senna orders for Resident #27 were requested and not provided. A review of the January and February 2023 eMARs for Resident #27 revealed that medications were administered without an order as follows:a. Tramadol 50 mg tablet two times daily, on 1/5/23 in the morning, 1/6-1/16/23, 1/17/23 in the evening, 1/18-1/19/23, 1/20/23 in the morning, 1/21-2/6/23, and 2/7/23 in the morning.b. Senna 8.6-50 mg tablet once daily, on 1/6/23-1/18/23, 1/20-2/6/23, and 2/7/23 in the morning.c. Cefuroxime axetil 500 mg two timesdaily, on 1/6-1/10/23, and 1/12/23 in the morning. On 2/7/23 at 3:11 p.m., the director of nursing stated that there must have been a communication error with hospice because they had a list of orders for Resident #27's senna, tramadol, and cefuroxime axetil, but they did not have signed orders. The director of nursing stated that she was had the orders signed by hospice for Resident #27, the day of the onsite visit. 5. Resident #28 was admitted to the residence on 5/28/20. The January and February 2023 MAR read in part, the resident was administered stimulant laxative twice daily in the morning on 1/1-1/3, 1/5, 1/9-1/31, 2/1-2/7 and in the evening on 1/1, 1/2, 1/4-1/10, 1/12-2/6/23, for a total of 69 doses. However, the residence was unable to provide a written practitioner's order for the medication. On 2/723 at 2:49 p.m., the administrator stated she was not aware why Resident #28 was missing an order for her stimulant laxative. 6. Resident #24 was admitted to the residence on 3/25/16.a. LisinoprilThe January and February 2023 MAR read in part, the resident was administered lisinopril 10 mg once daily on 1/1-2/7/23, for a total of 38 doses. However, the residence was unable to provide a written practitioner's order for the medication.b. Alendronate sodiumThe January and February 2023 MAR read in part, the resident was administered alendronate sodium 70 mg once daily on 1/2, 1/9, 1/16, 1/30, and 2/6 for a total of five doses. However, the residence was unable to provide a written practitioner's order for the medication. On 2/7/23 at 2:49 p.m., the director of nursing confirmed she was unable to locate written practitioners orders for Residents #2, #19, #24, #27, and #28 as required and the medications were administered without a signed practitioner order. On 2/7/23 at approximately 2:49 p.m., the administrator stated she was unable to locate the missing written practitioner's orders for Resident #2, #19, #24, #27, and #28 as required and the medications were administered without a signed practitioner order.

Based on observation, record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting eight of ten sample residents (#2, #8, #19, #21-#24, #28). Findings include: 1. Residence PolicyThe residence's medication administration policy, dated 9/1/22, read in part: "all medications are administered (in accordance with) physician orders."2. Resident #23 was admitted to the residence on 10/25/21, with diagnoses including unspecified dementia with behavioral disturbance, hypothyroidism, bilateral inguinal hernia, essential hypertension, and type 2 diabetes mellitus. On 2/7/23 at 7:27 a.m., Staff #23 stated that she crushed each resident's medication in the secure environment since she had started working at the residence in January 2023, because everyone had swallowing difficulties with taking medication. On 2/7/23 at 8:19 a.m., Staff #23 crushed Resident #23's medication, which included ferrous sulfate, acetaminophen, preservision areds, vitamin d3, metropolol tartrate, levothyroxine sodium, aspirin famotidine, finasteride, and co-enzyme q10, mixed it in pudding and administered it to him. On 2/7/23 at 1:30 p.m., a crush order for Resident #23 was requested and not provided. On 2/7/23 at 1:56 p.m., Resident #23's family member stated that she had observed Resident #23's medication being crushed when she had come to the residence to visit, and was unsure why his medications were being crushed because Resident #23 had no swallowing difficulties. On 2/7/23 at 3:13 p.m., the director of nursing stated that Staff #23 should not have crushed Resident #23's medication at all since he did not have a medication crush order. The director of nursing stated that Resident #23 should not have had their medications crushed without a crush order.a. TamsulosinA written practitioner's order, dated 10/22/21, directed the residence to administer 0.4 mg of tamsulosin once daily. The February 2023 electronic medication administration record (eMAR), read that tamsulosin was not administered on 1/2/23, 1/30-2/2/23, and 2/4-2/5/23 for a total of seven missed doses. A progress note, dated 1/2/23, read in part: "waiting on pharmacy delivery."Progress notes, dated 1/30-2/2/23, and 2/4-2/5/23, read that the medication was not available and was on order with the pharmacy.b. RosuvastatinA written practitioner's order, dated 10/22/21, directed the residence to administer 10 mg of rosuvastatin once daily. The January and February 2023 eMARs were reviewed, and read that rosuvastatin was not administered on 1/6/23, 2/1-2/2/23, and 2/4-2/5/23 for a total of five missed doses. A progress note, dated 1/6/23, read in part: "medication not in medication cart."Progress notes, dated 2/1-2/2/23, and 2/4-2/5/23, read that the medication was on order with the pharmacy.c. Enzyme Q10A written practitioner's order, dated 10/22/21, directed the residence to administer 300 mg of enzyme q10 once daily. The January and February 2023 eMARs were reviewed, and read that enzyme q10 was not administered on 1/17/23, 1/22-1/23/23, and 1/25/23 for a total of four missed doses. Progress notes, dated 1/17/23, 1/22-1/23/23, and 1/25/23, read in part: "medication not available."d. Citalopram HydrobromideA written practitioner's order, dated 1/31/22, directed the residence to administer 15 mg of citalopram hydrobromide once daily. The January and February 2023 eMARs were reviewed, and read that citalopram hydrobromide was not administered on 2/4-2/5/23, for a total of two missed doses. Progress notes, dated 2/4-2/5/23, read in part: "medication on order."e. AcetaminophenA written practitioner's order, dated 1/24/23, directed the residence to administer 500 mg of acetaminophen twice daily. The January and February 2023 eMARs were reviewed, and read that acetaminophen was not administered on 1/24/23 in the evening and 1/25/23 in the morning, for a total of two missed doses. Progress notes, dated 1/24-1/25/23, read in part: "medication not in cart, waiting on delivery."f. Ferrous SulfateA written practitioner's order, dated 10/22/21, directed the residence to administer 325 mg of ferrous sulfate once daily. The January and February 2023 eMARs were reviewed, and read that ferrous sulfate was not administered on 1/11/23, for a total of one missed dose. A progress note, dated 1/11/23, read in part: "medication not available."g. LevothyroxineA written practitioner's order, dated 10/22/21, directed the residence to administer 50 mg of levothyroxine sodium once daily. The January and February 2023 eMARs were reviewed, and read that levothyroxine sodium was not administered on 1/15/23, for a total of one missed dose. A progress note, dated 1/15/23, read in part: "medication is not available but is on order."On 2/7/23 at 3:24 p.m., the director of nursing stated that she was not aware why Resident #23's medications were not administered on the days above. The administrator stated that it was likely due to pharmacy issues. 3. Resident #8 was admitted to the residence on 5/18/18, with diagnoses including major depressive disorder and alcoholic liver disease.a. OndansetronA written practitioner's order, dated 1/12/23, directed the residence to administer 4 mg of ondansetron two times daily. The January and February 2023 eMARs were reviewed, and read that ondansetron was not administered on 2/1/23 in the evening, 2/2/23 in the morning and evening, and 2/3/23 in the morning, for a total of four missed doses. Progress notes, dated 2/1-2/3/23, read that medication was not in the cart.b. ParoxetineA written practitioner's order, dated 1/31/23, directed the residence to administer 20 mg of paroxetine once daily. The January and February 2023 eMARs were reviewed, and read that paroxetine was not administered on 2/2/23, for a total of one missed dose. A progress note, dated 2/2/23, read in part: "medication not available."On 2/7/23 at 3:19 p.m., the director of nursing stated that she was not aware why Resident #8's medications were not administered on the days above. The administrator stated that it was likely due to pharmacy issues. 4. Resident #22 was admitted to the residence on 9/23/21, with diagnoses including vitamin d deficiency.a. MultivitaminA written practitioner order, dated 9/4/22, directed the residence to administer one tablet of multivitamin, once daily. The January and February 2023 eMARs were reviewed, and read that multivitamin was not administered on 1/13-1/15/23, and 1/17/23, for a total of four missed doses. Progress notes, dated 1/13-1/15/23, and 1/17/23, read that multivitamin was not available.b. AspirinA written practitioner order, dated 11/11/22, directed the residence to administer an 81 mg tablet of aspirin, once daily. The January and February 2023 eMARs were reviewed, and read aspirin was not administered on 1/17/23, for a total of one missed dose. A progress note dated 1/17/23, read that aspirin was not available. On 2/7/23 at 3:18 p.m., the director of nursing stated that she was not aware why Resident #22's medications were not administered on the days above. The administrator stated that it was likely due to pharmacy issues. 5. Resident #27 was admitted to the residence on 1/4/23, with diagnoses including Alzheimer's disease, atrial fibrillation and flutter, unspecified urinary incontinence, and anterior dislocation of left sternoclavicular joint. On 2/7/23 at 7:59 a.m., Staff #23 administered crushed medications which included lorazepam and tramadol, to Resident #27 and put in pudding. On 2/7/23 at 1:30 p.m., a crush order was requested and not provided. On 2/7/23 at 2:25 p.m., the administrator stated that she had reached out to the external hospice agency for a crush order for Resident #27 because they did not have one on site even though he did need his medication crushed due to swallowing difficulties. On 2/7/23 at 3:11 p.m., the director of nursing stated that there must have been a communication error with the external hospice agency, because they should have had a crush order but they did not. The director of nursing stated that Resident #27 should not have had their medications crushed without a crush order. 6. Resident #19 was admitted to the residence on 4/6/21.a. LevothyroxineA written practitioner's order, dated 1/21/23, directed the residence to administer levothyroxine sodium 75 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/24 and 1/25/23 for a total of two missed doses due to the medication being out of stock.b. ProbioticA written practitioner's order, dated 1/21/23, directed the residence to administer a probiotic capsule once daily. However, the January and February 2023 MAR read the medication was not administered on 1/29 and 2/1/23, for a total of two missed doses due to the medication not being available. On 2/7/23 at 2:09 p.m., the legal representative for Resident #19 stated she was not aware there were any medications out of stock for Resident #19. On 2/7/23 at 2:30 p.m., a medication cart audit revealed the medications were in stock. 7. Resident #2 was admitted to the residence on 4/9/21 with diagnoses including hypertension. A written practitioner's order, dated 1/21/23, directed the residence to administer warfarin sodium once daily at bedtime. However, the February 2023 MAR read the medication was not administered on 2/2-2/4/23, for a total of three missed doses due to the medication being not available. On 2/7/23 at 2:03 p.m., the legal representative for Resident #2 stated she was not aware that warfarin was not administered to the resident as ordered. On 2/7/23 at 2:49 p.m., the director of nursing stated she was not sure why the medication was not administered to the resident as ordered. On 2/7/23 at 2:30 p.m., a medication cart audit revealed the medication was in stock. 8. Resident #28 was admitted to the residence on 5/28/20 with diagnoses including hypertension and osteoporosis. A written practitioner's order, dated 11/14/22, directed the residence to administer alendronate sodium 70 mg once every Sunday. However, the January 2023 MAR read the medication was not administered on 1/29/23, for a total of one missed dose due to the medication being out of stock. On 2/7/23 at 1:55 p.m., the legal representative for Resident #28 stated she was not aware of any medication issues for Resident #28. On 2/7/23 at 2:30 p.m., a medication cart audit revealed the medication was in stock. 9. Resident #24 was admitted to the residence on 3/25/16. A written practitioner's order, dated 12/1/22, directed the residence to administer acetaminophen 650 mg three times a day. However, the January 2023 MAR read the residence did not administer the medication for all three doses on 1/1/23 due to the medication being out of stock for a total of three missed doses. On 2/7/23 at approximately 3:00 p.m., the director of nursing stated she was unsure why the residence ran out of the medication for Resident #24. She added that residents should not miss doses of prescribed medications. On 2/7/23 at approximately 3:00 p.m., the administrator stated that the nurse was responsible for reordering medications. She acknowledged that the residence failed to comply with Resident #24's orders and the resident should not have missed a dose of her prescribed medication. 10. Resident #21 was admitted to the residence on 7/11/19. A written practitioner's order, dated 1/14/23, directed the residence to administer vitamin D 50 mcg once daily. However, the January 2023 MAR read the residence did not administer the medication on 1/25/23 due to the medication being out of stock for a total of one missed dose. On 2/7/23 at approximately 3:00 p.m., the director of nursing stated she was unsure why the residence ran out of the medication for Resident #21. She added that residents should not miss doses of prescribed medications. On 2/7/23 at approximately 3:00 p.m., the administrator stated that the nurse was responsible for reorderingmedications. She acknowledged that the residence failed to comply with Resident #21's orders and the resident should not have missed doses of her prescribed medication.

Based on observation, record review and interview, the residence failed to ensure qualified medication administration persons (QMAPs) followed national recognized protocols for basic infection control and prevention when preparing and administering medications, affecting six of six sample residents (#2, #8, #22-#23, #27-#28) that medication pass was observed in the secure environment. Findings include:1. Residence policyThe residence's Medication Administration Policy, dated 9/1/22, read in part: "follow sanitary practices, and perform hand hygiene prior to medication preparation for each medication pass, perform hand hygiene after direct resident contact, and use sanitary techniques to place medications into a medicine cup."2. ObservationsOn 2/7/22 from 7:38 a.m. to 8:30 a.m., the following was observed:Staff #23 touched the medication cart and placed a medicated patch on a resident's back, administered medication to Resident #28 and then Resident #2 and did not perform hand hygiene between residents. Staff #23 then touched her nose, adjusted her shoe and administered medication to Resident #27 and did not perform hand hygiene afterwards. Staff #23 dropped a pill for Resident #8, scooped it in the medication cup with the blister package, administered it to Resident #8 and did not perform hand hygiene afterwards. Staff #23 rubbed her nose, picked a pen up off the floor, then prepared and administered medications to Resident #22 and Resident #23. Staff #23 did not perform hand hygiene after touching her nose and the floor, or between residents. Staff #23 placed a lidocaine patch on Resident #22's back and then fed Resident #2. She did not perform hand hygiene between residents. 3. InterviewsOn 2/7/23 at 8:32 a.m., Staff #23 stated that she was trained to perform hand hygiene between each resident when performing care or administering medication; however, she had forgotten to perform hand hygiene the day of the onsite survey, since she did not have hand sanitizer on top of the medication cart like she normally would. On 2/7/23 at approximately 2:49 p.m., the administrator stated that QMAPs should always perform hand hygiene when administering medication between residents, after touching themselves and objects. The administrator stated that QMAPs should not administer dropped medication and should destroy and get a new medication.

Based on record review and interview, the residence failed to hold regular family council meetings at least quarterly, affecting 25 residents who resided in the secure environment. Findings include:On 2/7/23 at approximately 7:46 a.m., the residence's last three family council meeting minutes were requested. However, no such meeting minutes were provided. On 2/7/23 at approximately 11:30 a.m., the administrator stated the residence did not hold family council meetings and had not since she started her position in the summer of 2022. She stated she had not realized family council meetings were not being held 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 7.10.3 The assisted living residence shall develop and follow written policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency including, but not limited to, a long-term power failure. 12.10 Each resident care plan shall:(A) Be developed with input from the resident and the resident's representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers along with care coordination arrangements; and(F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident's personal choices and needs. 13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items: (A) The right to privacy and confidentiality, including:(1) The right to have private and unrestricted communications with any person of choice;(2) The right to private telephone calls or use of electronic communication;(3) The right to receive mail unopened;(4) The right to have visitors at any time; and(5) The right to private, consensual sexual activity.(B) The right to civil and religious liberties, including:(1) The right to be treated with dignity and respect;(2) The right to be free from sexual, verbal, physical or emotional abuse, humiliation, intimidation, or punishment;(3) The right to be free from neglect;(4) The right to live free from financial exploitation, restraint as defined in this chapter, and involuntary confinement except as allowed by the secure environment requirements of this chapter;(5) The right to vote;(6) The right to exercise choice in attending and participating in religious activities;(7) The right to wear clothing of choice unless otherwise indicated in the care plan; and(8) The right to care and services that are not conditioned or limited because of a resident's disability, sexual orientation, ethnicity, and/or personal preferences.(C) The right to personal and community engagement, including:(1) The right to socialize with other residents and participate in assisted living residence activities, in accordance with the applicable care plan;(2) The right to full use of the assisted living residence common areas in compliance with written house rules;(3) The right to participate in resident meetings, voice grievances, and recommend changes in policies and services without fear of reprisal;(4) The right to participate in activities outside the assisted living residence and request assistance with transportation; and(5) The right to use of the telephone including access to operator assistance for placing collect telephone calls.(a) At least one telephone accessible to residents utilizing an auxiliary aid shall be available if the assisted living residence is occupied by one or more residents utilizing such an aid.(D) The right to choice and personal involvement regarding care and services, including:(1) The right to be informed and participate in decision making regarding care and services, in coordination with family members who may have different opinions;(2) The right to be informed about and formulate advance directives;(3) The right to freedom of choice in selecting a health care service or provider;(4) The right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services which are made available by the assisted living residence;(a) For residents with limited English proficiency or impairments that inhibit communication, the assisted living residence shall find a way to facilitate communication of care needs.(5) The right to make decisions and choices in the management of personal affairs, funds, and property in accordance with resident ability;(6) The right to refuse to perform tasks requested by the assisted living residence or staff in exchange for room, board, other goods or services;(7) The right to have advocates, including members of community organizations whose purposes include rendering assistance to the residents;(8) The right to receive services in accordance with the resident agreement and the care plan; and(9) The right to thirty (30) calendar days written notice of changes in services provided by the assisted living residence including, but not limited to, involuntarily change of room or changes in charges for a service. Exceptions to this notice are:(a) Changes in the resident ' s medical acuity that result in a documented decline in condition and that constitute an increase in care necessary to protect the health and safety of the resident; and(b) Requests by the resident or the family for additional services to be added to the care plan. 14.15 The assisted living residence shall ensure each resident's right to privacy and dignity with respect to medication monitoring and administration. 14.16 Each resident shall have the right to refuse medications. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. 17.14 Staff who assist feeding a resident shall be trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional qualified by education and training to assess choking risks, such as a registered nurse, speech language pathologist, or registered dietitian.(A) The assisted living residence shall not allow staff to assist feeding a resident if the resident has difficulty chewing and swallowing, or has a history of chronic choking or coughing while eating or drinking.(B) If a resident who is receiving feeding assistance experiences a change in eating and swallowing that is a decline from baseline as identified in the individualized resident care plan, staff shall stop providing assistance, document the issue in the resident's record and ensure that the resident's practitioner is notified.(1) Unless temporary measures are ordered by the practitioner, feeding assistance shall not be resumed until a medical evaluation has been performed and the assisted living residence has documentation from the practitioner that it is safe to resume. 18.8 Resident records shall contain, but not be limited to, the following items:(A) Face Sheet;(B) Practitioner order;(C) Individualized resident care plan;(D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs;(1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them.(E) Medication Administration Record;(F) Documentation of on-going services provided by external service providers including, but not limited to, family members, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants, and caregivers;(G) Advance directives, if applicable, with extra copies; and(H) Final disposition of resident including, if applicable, date, time, and circumstances of a resident's death, along with the name of the person to whom the body is released. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following:(A) A description of the resident's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact;(B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR's plan to protect the resident from unwanted visitation by other residents;(C) Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and(D) Documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents.

A licensure revisit was completed on 2/7/23 for all previous deficiencies cited on 1/26/22. Deficiencies were cited.

Based on observation record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting eight of 10 sample residents (#2, #8, #19, #21-#24 and #28). This deficiency was cited previously during a state licensure survey 1/26/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Residence PolicyThe residence's medication administration policy, dated 9/1/22, read in part: "all medications are administered (in accordance with) physician orders."2. Resident #23 was admitted to the residence on 10/25/21, with diagnoses including unspecified dementia with behavioral disturbance, hypothyroidism, bilateral inguinal hernia, essential hypertension, and type 2 diabetes mellitus. On 2/7/23 at 7:27 a.m., Staff #23 stated that she crushed each resident's medication in the secure environment since she had started working at the residence in January 2023, because everyone had swallowing difficulties with taking medication. On 2/7/23 at 8:19 a.m., Staff #23 crushed Resident #23's medication, which included ferrous sulfate, acetaminophen, preservision areds, vitamin d3, metropolol tartrate, levothyroxine sodium, aspirin famotidine, finasteride, and co-enzyme q10, mixed it in pudding and administered it to him. On 2/7/23 at 1:30 p.m., a crush order for Resident #23 was requested and not provided. On 2/7/23 at 1:56 p.m., Resident #23's family member stated that she had observed Resident #23's medication being crushed when she had come to the residence to visit, and was unsure why his medications were being crushed because Resident #23 had no swallowing difficulties. On 2/7/23 at 3:13 p.m., the director of nursing stated that Staff #23 should not have crushed Resident #23's medication at all since he did not have a medication crush order. The director of nursing stated that Resident #23 should not have had their medications crushed without a crush order.a. TamsulosinA written practitioner's order, dated 10/22/21, directed the residence to administer 0.4 mg of tamsulosin once daily. The February 2023 electronic medication administration record (eMAR), read that tamsulosin was not administered on 1/2/23, 1/30-2/2/23, and 2/4-2/5/23 for a total of seven missed doses. A progress note, dated 1/2/23, read in part: "waiting on pharmacy delivery."Progress notes, dated 1/30-2/2/23, and 2/4-2/5/23, read that the medication was not available and was on order with the pharmacy.b. RosuvastatinA written practitioner's order, dated 10/22/21, directed the residence to administer 10 mg of rosuvastatin once daily. The January and February 2023 eMARs were reviewed, and read that rosuvastatin was not administered on 1/6/23, 2/1-2/2/23, and 2/4-2/5/23 for a total of five missed doses. A progress note, dated 1/6/23, read in part: "medication not in medication cart."Progress notes, dated 2/1-2/2/23, and 2/4-2/5/23, read that the medication was on order with the pharmacy.c. Enzyme Q10A written practitioner's order, dated 10/22/21, directed the residence to administer 300 mg of enzyme q10 once daily. The January and February 2023 eMARs were reviewed, and read that enzyme q10 was not administered on 1/17/23, 1/22-1/23/23, and 1/25/23 for a total of four missed doses. Progress notes, dated 1/17/23, 1/22-1/23/23, and 1/25/23, read in part: "medication not available."d. Citalopram HydrobromideA written practitioner's order, dated 1/31/22, directed the residence to administer 15 mg of citalopram hydrobromide once daily. The January and February 2023 eMARs were reviewed, and read that citalopram hydrobromide was not administered on 2/4-2/5/23, for a total of two missed doses. Progress notes, dated 2/4-2/5/23, read in part: "medication on order."e. AcetaminophenA written practitioner's order, dated 1/24/23, directed the residence to administer 500 mg of acetaminophen twice daily. The January and February 2023 eMARs were reviewed, and read that acetaminophen was not administered on 1/24/23 in the evening and 1/25/23 in the morning, for a total of two missed doses. Progress notes, dated 1/24-1/25/23, read in part: "medication not in cart, waiting on delivery."f. Ferrous SulfateA written practitioner's order, dated 10/22/21, directed the residence to administer 325 mg of ferrous sulfate once daily. The January and February 2023 eMARs were reviewed, and read that ferrous sulfate was not administered on 1/11/23, for a total of one missed dose. A progress note, dated 1/11/23, read in part: "medication not available."g. LevothyroxineA written practitioner's order, dated 10/22/21, directed the residence to administer 50 mg of levothyroxine sodium once daily. The January and February 2023 eMARs were reviewed, and read that levothyroxine sodium was not administered on 1/15/23, for a total of one missed dose. A progress note, dated 1/15/23, read in part: "medication is not available but is on order."On 2/7/23 at 3:24 p.m., the director of nursing stated that she was not aware why Resident #23's medications were not administered on the days above. The administrator stated that it was likely due to pharmacy issues. 3. Resident #8 was admitted to the residence on 5/18/18, with diagnoses including major depressive disorder and alcoholic liver disease.a. OndansetronA written practitioner's order, dated 1/12/23, directed the residence to administer 4 mg of ondansetron two times daily. The January and February 2023 eMARs were reviewed, and read that ondansetron was not administered on 2/1/23 in the evening, 2/2/23 in the morning and evening, and 2/3/23 in the morning, for a total of four missed doses. Progress notes, dated 2/1-2/3/23, read that medication was not in the cart.b. ParoxetineA written practitioner's order, dated 1/31/23, directed the residence to administer 20 mg of paroxetine once daily. The January and February 2023 eMARs were reviewed, and read that paroxetine was not administered on 2/2/23, for a total of one missed dose. A progress note, dated 2/2/23, read in part: "medication not available."On 2/7/23 at 3:19 p.m., the director of nursing stated that she was not aware why Resident #8's medications were not administered on the days above. The administrator stated that it was likely due to pharmacy issues. 4. Resident #22 was admitted to the residence on 9/23/21, with diagnoses including vitamin d deficiency.a. MultivitaminA written practitioner order, dated 9/4/22, directed the residence to administer one tablet of multivitamin, once daily. The January and February 2023 eMARs were reviewed, and read that multivitamin was not administered on 1/13-1/15/23, and 1/17/23, for a total of four missed doses. Progress notes, dated 1/13-1/15/23, and 1/17/23, read that multivitamin was not available.b. AspirinA written practitioner order, dated 11/11/22, directed the residence to administer an 81 mg tablet of aspirin, once daily. The January and February 2023 eMARs were reviewed, and read aspirin was not administered on 1/17/23, for a total of one missed dose. A progress note dated 1/17/23, read that aspirin was not available. On 2/7/23 at 3:18 p.m., the director of nursing stated that she was not aware why Resident #22's medications were not administered on the days above. The administrator stated that it was likely due to pharmacy issues. 5. Resident #27 was admitted to the residence on 1/4/23, with diagnoses including Alzheimer's disease, atrial fibrillation and flutter, unspecified urinary incontinence, and anterior dislocation of left sternoclavicular joint. On 2/7/23 at 7:59 a.m., Staff #23 administered crushed medications which included lorazepam and tramadol, to Resident #27 and put in pudding. On 2/7/23 at 1:30 p.m., a crush order was requested and not provided. On 2/7/23 at 2:25 p.m., the administrator stated that she had reached out to hospice for a crush order for Resident #27 because they did nothave one on site even though he did need his medication crushed due to swallowing difficulties. On 2/7/23 at 3:11 p.m., the director of nursing stated that there must have been a communication error with the external hospice agency, because they should have had a crush order but they did not. The director of nursing stated that Resident #27 should not have had their medications crushed without a crush order. 4. Resident #19 was admitted to the residence on 4/6/21.a. LevothyroxineA written practitioner's order, dated 1/21/23, directed the residence to administer levothyroxine sodium 75 mg once daily. However, the January 2023 MAR read the medication was not administered on 1/24 and 1/25/23 for a total of two missed doses due to the medication being out of stock.b. ProbioticA written practitioner's order, dated 1/21/23, directed the residence to administer a probiotic capsule once daily. However, the January and February 2023 MAR read the medication was not administered on 1/29 and 2/1/23, for a total of two missed doses due to the medication not being available. On 2/7/23 at 2:09 p.m., the legal representative stated she was not aware there were any medications out of stock for Resident #19. On 2/7/23 at 2:30 p.m., a medication cart audit revealed the medications were in stock. 5. Resident #2 was admitted to the residence on 4/9/21 with diagnoses including hypertension. A written practitioner's order, dated 1/21/23, directed the residence to administer warfarin sodium once daily at bedtime. However, the February 2023 MAR read the medication was not administered on 2/2-2/4/23, for a total of three missed doses due to the medication being not available. On 2/7/23 at 2:03 p.m., the legal representative for Resident #2 stated she was not aware that warfarin was not administered to the resident as ordered. On 2/7/23 at 2:49 p.m., the DON stated she was not sure why the medication was not administered to the resident as ordered. On 2/7/23 at 2:30 p.m., a medication cart audit revealed the medication was in stock. 6. Resident #28 was admitted to the residence on 5/28/20 with diagnoses including hypertension and osteoporosis. A written practitioner's order, dated 11/14/22, directed the residence to administer alendronate sodium 70 mg once every Sunday. However, the January 2023 MAR read the medication was not administered on 1/29/23, for a total of one missed dose due to the medication being out of stock. On 2/7/23 at 1:55 p.m., the legal representative for Resident #28 stated she was not aware of any medication issues for Resident #28. On 2/7/23 at 2:30 p.m., a medication cart audit revealed the medication was in stock. 7. Resident #24 was admitted to the residence on 3/25/16. A written practitioner's order, dated 12/1/22, directed the residence to administer acetaminophen 650 mg three times a day. However, the January 2023 MAR read the residence did not administer the medication for all three doses on 1/1/23 due to the medication being out of stock for a total of three missed doses. On 2/7/23 at approximately 3:00 p.m., the director of nursing stated she was unsure why the residence ran out of the medication for Resident #24. She added that residents should not miss doses of prescribed medications. On 2/7/23 at approximately 3:00 p.m., the administrator stated that the nurse was responsible for reordering medications. She acknowledged that the residence failed to comply with Resident #24's orders and the resident should not have missed a dose of her prescribed medication. 8. Resident #21 was admitted to the residence on 7/11/19. A written practitioner's order, dated 1/14/23, directed the residence to administer vitamin D 50 mcg once daily. However, the January 2023 MAR read the residence did not administer the medication on 1/25/23 due to the medication being out of stock for a total of one missed dose. On 2/7/23 at approximately 3:00 p.m., the director of nursing stated she was unsure why the residence ran out of the medication for Resident #21. She added that residents should not miss doses of prescribed medications. On 2/7/23 at approximately 3:00 p.m., the administrator stated that the nurse was responsible for reordering medications. She acknowledged that the residence failed to comply with Resident #21's orders and the resident should not have missed doses of her prescribed medication. On 2/7/23 at approximately 3:45 p.m., the adminsitrator stated she was not sure why the medication issues had not been corrected.

Based on record review and interview, the residence failed to accurately document each medication administration event at the time the event was completed, affecting one of ten sample residents (#22). This deficiency was cited previously during a state licensure survey 1/26/22. 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 #22 was admitted to the residence on 9/23/21, with a diagnosis of anxiety.a. MirtazapineA written practitioner's order, dated 12/20/22, directed the residence to administer 7.5 mg of mirtazapine once daily at bedtime. The January 2023 electronic medication administration record (eMAR) read there was a blank on 1/20/23.b. Lidocaine PatchA written practitioner order, dated 9/2/22, directed the residence to administer a lidocaine patch 4% every morning. The January eMAR read there was a blank on 1/20/23.c. AcetaminophenA written practitioner order, dated 12/19/22, directed the residence to administer a 500 mg of acetaminophen three times daily. The January and February 2023 eMARs were reviewed, and there was a blank on 1/1/23.2. InterviewOn 2/7/23 at approximately 2:49 p.m., the administrator stated that blanks in the eMAR mean that a medication was either not administered, or just not signed off on, but there was no way to know for sure. The administrator stated that she would expect all medications to be documented at the time they were administered.