PEAKVIEW ASSISTED LIVING AND MEMORY CARE

A licensure revisit was completed on 3/5/25 for all previous deficiencies cited on 9/20/23. A deficiency was cited.

Based on observation, record review, and interview, the residence failed to be responsible for complying with authorized practitioner's orders associated with medication administration, affecting one of four sample residents (#38) and one former resident (#45). This deficiency was cited previously during a licensure revisit on 9/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence administered medications per the practitioner's order. 2. Resident #38 was admitted to the residence on 6/19/23 with a diagnosis including chronic gastroesophageal reflux disease and absence of other specified parts of the digestive tract, postnasal drip, hyperlipidemia, and hypertension. A written practitioner's order, dated 11/24/24, directed the residence to administer pantoprazole sodium 40 mg tablet once daily. However, a January and February 2025 medication administration record (MAR) for Resident #38 read that the residence failed to administer the medication because it was unavailable on 1/28, 1/29, 1/30, 1/31, and 2/1/2025 for a total of five missed doses. The January and February 2024 MAR revealed the residence failed to administer the following medications as well:Cetirizine HCIVancomycinLosartanAlpha lipoic acidMetronidazole 3. Evidence revealed similar deficient practice for Former Resident #45. 4. InterviewsOn 3/5/25 at 8:20 a.m., Staff #31 stated it was the job of the qualified medication administration person (QMAP) to reorder the medication via fax. She stated that the practitioners failed to sign orders, and the pharmacy would not fill them. She stated that the residence failed to have all medications available for all residents. On 3/5/25 at approximately 3:00 p.m., the administrator, director of nursing (DON), and regional operations director acknowledged failure to have medications available for all residents. They stated that they had a system where QMAPs would telephone the practitioner or pharmacy; however, they were still unable to keep the medications in stock. They acknowledged that they failed to follow practitioner orders. They attributed the failure to keep medications in stock to the pharmacy and practitioner; however, they acknowledged that ultimately it is the responsibility of the residence.

A relicensure survey and complaint revisit was completed on 3/5/25 for all previous deficiencies cited on 9/20/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents and their room assignments, affecting 78 current residents. This deficiency was cited previously during a state licensure survey on 9/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. On 3/4/25 at approximately 8:45 a.m., the residence was asked to provide a resident roster. The resident roster had 81 residents listed. However, there were residents on the roster that no longer resided in the residence. On 3/5/24 at 11:30 a.m., the administrator stated a resident roster included the current resident's name, room number, date of birth, provider, and emergency contact information. She stated she was not aware the resident roster was not current. On 3/5/25 at approximately 1:30 p.m., the administrator provided a current resident roster showing the census was 78. On 3/5/24 at approximately 3:00 p.m. the administrator said the resident roster should have been up to date. She said she did not know it was not up to date. She said she thought the resident roster was current and they were in compliance with regulations.

Based on observation, record review, and interview, the residence failed to be responsible for complying with authorized practitioner's orders associated with medication administration, affecting one of four sample residents (#38) and one former resident (#45). This deficiency was cited previously during a state licensure survey and complaint on 9/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence administered medications per the practitioner's order. 2. Resident #38 was admitted to the residence on 6/19/23 with a diagnosis including chronic gastroesophageal reflux disease and absence of other specified parts of the digestive tract, postnasal drip, hyperlipidemia, and hypertension. A written practitioner's order, dated 11/24/24, directed the residence to administer pantoprazole sodium 40 mg tablet once daily. However, a January and February 2025 medication administration record (MAR) for Resident #38 read that the residence failed to administer the medication because it was unavailable on 1/28, 1/29, 1/30, 1/31, and 2/1/2025 for a total of five missed doses. The January and February 2024 MAR revealed the residence failed to administer the following medications as well:Cetirizine HCIVancomycinLosartanAlpha lipoic acidMetronidazole 3. Evidence revealed similar deficient practice for Former Resident #45. 4. InterviewsOn 3/5/25 at 8:20 a.m., Staff #31 stated it was the job of the qualified medication administration person (QMAP) to reorder the medication via fax. She stated that the practitioners failed to sign orders, and the pharmacy would not fill them. She stated that the residence failed to have all medications available for all residents. On 3/5/25 at approximately 3:00 p.m., the administrator, director of nursing (DON), and regional operations director acknowledged failure to have medications available for all residents. They stated that they had a system where QMAPs would telephone the practitioner or pharmacy; however, they were still unable to keep the medications in stock. They acknowledged that they failed to follow practitioner orders. They attributed the failure to keep medications in stock to the pharmacy and practitioner; however, they acknowledged that ultimately it is the responsibility of the residence.

A licensure revisit was completed on 9/20/23 for all previous deficiencies cited on 2/27/23. The residence is in compliance with all regulations surveyed.

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

A relicensure survey with complaint #CO32922 was completed on 9/20/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure each staff member received all required training prior to providing any care or services to residents, affecting four of four sample staff (#15-#18). Findings include: 1. Residence PolicyThe residence's New Team Member Orientation policy, dated 3/7/23, read the residence would provide new team member orientation to all new hires within 30 days of employment. 2. Record ReviewStaff #15, #16, #17, and #18 were hired on 7/10/23, 5/12/23, 5/16/23 and 8/22/23, respectively. The September 2023 staff schedule revealed the following:Staff #15 worked on 9/2, 9/9, 9/16, 9/17 and 9/18/23. Staff #16 worked on 9/3-9/6, 9/10-9/12 and 9/17-9/19/23. Staff #17 worked on 9/1, 9/2, 9/4, 9/8, 9/9, 9/11, 9/15, 9/16 and 9/18/23. Staff #18 worked on 9/4/23. Personnel files for Staff #15-#18 revealed no initial orientation training. On 9/20/23 at approximately 11:15 a.m., the business office manager provided a training sign up sheet that read Staff #15-#18 were required to sign up for the mandatory orientation training on 9/21/23. 3. InterviewOn 9/20/23 at 10:27 a.m., the administrator said Staff #15-#18 had not completed the required orientation training prior to providing any care or services to residents. She added the business office manager was responsible for ensuring the training was completed, as required.

Based on observation, record review and interview, the residence failed to place in a visible location an up-to-date list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation), so that the information was readily available to staff at all times, affecting 66 current residents. Findings include:1. Residence PolicyThe residence's Cardio-Pulmonary Resuscitation (CPR) and Obstructed Airway Response Policy, dated 7/31/23, read in part: "The community will post a list of all team members who have current certification in CPR first aid and obstructed airway, so the information is readily available. The list will be updated periodically and will indicate by team member whether the certification is in CPR, first aid and/or obstructed airway response."2. ObservationsOn 9/19/23 at 7:40 a.m., there was no list of all staff who had current CPR certification posted on the wall in the employee break room. On 9/19/23 at 9:36 a.m., there was a list of all staff who had current CPR certification posted on the wall in the employee break room. The list contained six staff members names: Staff #19-#23 and the administrator. On 9/20/23 at 7:52 a.m., Staff #24 was added to the list of staff who had current CPR certifications that was posted in the employee break room. 3. InterviewsOn 9/19/23 at approximately 7:45 a.m., Staff #22 stated he was CPR-certified and that there used to be a list posted in the break room but it was removed and she was unsure if the list had been posted again. On 9/19/23 at 2:18 p.m., the administrator said the business office manager (BOM) was responsible for updating the list of staff who had current certification in CPR. She added there should have been a posted list in the employee break room but it did not list all staff who were certified in CPR, as required.

Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents, their room assignments and emergency contact information, along with a diagram showing room locations, affecting 66 current residents. Findings include:On 9/19/23 at approximately 8:45 a.m., the residence was asked to provide a resident roster according to the regulations. On 9/19/23 at approximately 9:30 a.m., the administrator provided a list of residents and their room numbers. There was no emergency contact information listed or a diagram that showed room locations. On 9/20/23 at 10:27 a.m., the administrator stated a resident roster included resident name, room number, date of birth, the provider and emergency contact information. She stated she was not aware of the resident roster requirement, which included a diagram of the residence.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of seven residents (#33) and one former resident (#37). Findings include:1. Reference and Residence Policiesa. The residence's undated resident agreement, read, in part, "Our care services are regulated by the state. Subject to state regulations, the community will provide you with care services in accordance with your care plan, medication management plan." b. The residence's Medication Errors policy, dated 11/29/22, read, in part, "A medication error is any preventable event that may cause or lead to resident harm. The director of nursing (DON) is responsible to ensure that the medication error is reported to the physician, resident, and/or resident representative. Medication errors may include ... missed dose.'c. The residence's Medication Unavailable policy, dated May 2017, read, in part, "When medication or treatments are unavailable, the community will try and take steps to obtain the medication or treatment before the scheduled dose ... If the medication or treatment is not available within an acceptable time frame: Notify the physician to explore alternatives ... notify the resident and or legal responsible party and document the contact and comments in the observation notes ... If the medication is not available for 72 hours (exception antibiotics must be obtained within 24 hours) ... the community will authorize the purchase of the medications from the preferred pharmacy."2. Resident #33 was admitted to the residence on 7/12/22 with diagnoses including hypothyroidism. A written practitioner's order, dated 8/28/23, directed the residence to administer levothyroxine 50 mcg once daily. However, the September 2023 medication administration record (MAR) read the medication was not available and not administered on 9/1-9/18/23, for a total of 18 missed doses. On 9/20/23 at 9:09 a.m., an external hospice representative said the levothyroxine for Resident #33 was not not available and not administered due to a pharmacy error. On 9/20/23 at 9:11 a.m., the director of nursing said the levothyroxine had been unavailable and not administered to Resident #33 for approximately two weeks due to a pharmacy error. 3. Former Resident #37 was admitted to the residence on 5/6/23 with diagnoses including chronic pain. A written practitioner's order, dated 5/2/23, directed the residence to administer oxycodone 5 mg three times daily. However, the May 2023 MAR for Former Resident #37 read the medication was not available and not administered on 5/27 in the evening and 5/28-5/31/23 for a total of 13 missed doses. On 9/20/23 at 9:48 a.m., the memory care manager said the medication was not available and not in stock for Former Resident #37 for approximately one week in May 2023. On 9/20/23 at approximately 11:00 a.m., the administrator said she expected medications to be in stock and administered, as ordered.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.12 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicable. 10.9 Each first aid kit shall include, at a minimum, the following items: (A) Latex free disposable gloves, (B) Scissors, (C) Adhesive bandages, (D) Bandage tape, (E) Sterile gauze pads, (F) Flexible roller gauze, (G) Triangular bandages with safety pins, (H) A note pad with a pen or pencil, (I) A CPR barrier device or mask, and (J) Soap or waterless hand sanitizer. 22.4 Designated areas where smoking is allowed shall be equipped with fire resistant wastebaskets. Resident rooms occupied by smokers, even when house rules prohibit smoking in resident rooms, shall have fire resistant wastebaskets.

A licensure revisit was completed on 9/20/23 for all previous deficiencies cited on 2/27/23. A deficiency was cited.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of seven residents (#33) and one former resident (#37). This deficiency was cited previously during a state licensure survey 2/27/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence Policiesa. The residence's undated resident agreement, read, in part, "Our care services are regulated by the state. Subject to state regulations, the community will provide you with care services in accordance with your care plan, medication management plan." b. The residence's Medication Errors policy, dated 11/29/22, read, in part, "A medication error is any preventable event that may cause or lead to resident harm. The director of nursing (DON) is responsible to ensure that the medication error is reported to the physician, resident, and/or resident representative. Medication errors may include ... missed dose.'c. The residence's Medication Unavailable policy, dated May 2017, read, in part, "When medication or treatments are unavailable, the community will try and take steps to obtain the medication or treatment before the scheduled dose ... If the medication or treatment is not available within an acceptable time frame: Notify the physician to explore alternatives ... notify the resident and or legal responsible party and document the contact and comments in the observation notes ... If the medication is not available for 72 hours (exception antibiotics must be obtained within 24 hours) ... the community will authorize the purchase of the medications from the preferred pharmacy."2. Resident #33 was admitted to the residence on 7/12/22 with diagnoses including hypothyroidism. A written practitioner's order, dated 8/28/23, directed the residence to administer levothyroxine 50 mcg once daily. However, the September 2023 medication administration record (MAR) read the medication was not available and not administered on 9/1-9/18/23, for a total of 18 missed doses. On 9/20/23 at 9:09 a.m., an external hospice representative said the levothyroxine for Resident #33 was not not available and not administered due to a pharmacy error. On 9/20/23 at 9:11 a.m., the director of nursing said the levothyroxine had been unavailable and not administered to Resident #33 for approximately two weeks due to a pharmacy error. 3. Former Resident #37 was admitted to the residence on 5/6/23 with diagnoses including chronic pain. A written practitioner's order, dated 5/2/23, directed the residence to administer oxycodone 5 mg three times daily. However, the May 2023 MAR for Former Resident #37 read the medication was not available and not administered on 5/27 in the evening and 5/28-5/31/23 for a total of 13 missed doses. On 9/20/23 at 9:48 a.m., the memory care manager said the medication was not available and not in stock for Former Resident #37 for approximately one week in May 2023. On 9/20/23 at approximately 11:00 a.m., the administrator said she expected medications to be in stock and administered, as ordered. The administrator said the residence's plan of correction was implemented but had failed.

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 9/20/23 for all previous deficiencies cited on 2/27/23. A deficiency was cited.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of seven residents (#33) and one former resident (#37). This deficiency was cited previously during a state licensure survey 2/27/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence Policiesa. The residence's undated resident agreement, read, in part, "Our care services are regulated by the state. Subject to state regulations, the community will provide you with care services in accordance with your care plan, medication management plan." b. The residence's Medication Errors policy, dated 11/29/22, read, in part, "A medication error is any preventable event that may cause or lead to resident harm. The director of nursing (DON) is responsible to ensure that the medication error is reported to the physician, resident, and/or resident representative. Medication errors may include ... missed dose.'c. The residence's Medication Unavailable policy, dated May 2017, read, in part, "When medication or treatments are unavailable, the community will try and take steps to obtain the medication or treatment before the scheduled dose ... If the medication or treatment is not available within an acceptable time frame: Notify the physician to explore alternatives ... notify the resident and or legal responsible party and document the contact and comments in the observation notes ... If the medication is not available for 72 hours (exception antibiotics must be obtained within 24 hours) ... the community will authorize the purchase of the medications from the preferred pharmacy."2. Resident #33 was admitted to the residence on 7/12/22 with diagnoses including hypothyroidism. A written practitioner's order, dated 8/28/23, directed the residence to administer levothyroxine 50 mcg once daily. However, the September 2023 medication administration record (MAR) read the medication was not available and not administered on 9/1-9/18/23, for a total of 18 missed doses. On 9/20/23 at 9:09 a.m., an external hospice representative said the levothyroxine for Resident #33 was not not available and not administered due to a pharmacy error. On 9/20/23 at 9:11 a.m., the director of nursing said the levothyroxine had been unavailable and not administered to Resident #33 for approximately two weeks due to a pharmacy error. 3. Former Resident #37 was admitted to the residence on 5/6/23 with diagnoses including chronic pain. A written practitioner's order, dated 5/2/23, directed the residence to administer oxycodone 5 mg three times daily. However, the May 2023 MAR for Former Resident #37 read the medication was not available and not administered on 5/27 in the evening and 5/28-5/31/23 for a total of 13 missed doses. On 9/20/23 at 9:48 a.m., the memory care manager said the medication was not available and not in stock for Former Resident #37 for approximately one week in May 2023. On 9/20/23 at approximately 11:00 a.m., the administrator said she expected medications to be in stock and administered, as ordered. The administrator said the residence's plan of correction was implemented but had failed.

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 9/20/23 for all previous deficiencies cited on 2/27/23. A deficiency was cited.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of seven residents (#33) and one former resident (#37). This deficiency was cited previously during a state licensure survey 2/27/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence Policiesa. The residence's undated resident agreement, read, in part, "Our care services are regulated by the state. Subject to state regulations, the community will provide you with care services in accordance with your care plan, medication management plan." b. The residence's Medication Errors policy, dated 11/29/22, read, in part, "A medication error is any preventable event that may cause or lead to resident harm. The director of nursing (DON) is responsible to ensure that the medication error is reported to the physician, resident, and/or resident representative. Medication errors may include ... missed dose.'c. The residence's Medication Unavailable policy, dated May 2017, read, in part, "When medication or treatments are unavailable, the community will try and take steps to obtain the medication or treatment before the scheduled dose ... If the medication or treatment is not available within an acceptable time frame: Notify the physician to explore alternatives ... notify the resident and or legal responsible party and document the contact and comments in the observation notes ... If the medication is not available for 72 hours (exception antibiotics must be obtained within 24 hours) ... the community will authorize the purchase of the medications from the preferred pharmacy."2. Resident #33 was admitted to the residence on 7/12/22 with diagnoses including hypothyroidism. A written practitioner's order, dated 8/28/23, directed the residence to administer levothyroxine 50 mcg once daily. However, the September 2023 medication administration record (MAR) read the medication was not available and not administered on 9/1-9/18/23, for a total of 18 missed doses. On 9/20/23 at 9:09 a.m., an external hospice representative said the levothyroxine for Resident #33 was not not available and not administered due to a pharmacy error. On 9/20/23 at 9:11 a.m., the director of nursing said the levothyroxine had been unavailable and not administered to Resident #33 for approximately two weeks due to a pharmacy error. 3. Former Resident #37 was admitted to the residence on 5/6/23 with diagnoses including chronic pain. A written practitioner's order, dated 5/2/23, directed the residence to administer oxycodone 5 mg three times daily. However, the May 2023 MAR for Former Resident #37 read the medication was not available and not administered on 5/27 in the evening and 5/28-5/31/23 for a total of 13 missed doses. On 9/20/23 at 9:48 a.m., the memory care manager said the medication was not available and not in stock for Former Resident #37 for approximately one week in May 2023. On 9/20/23 at approximately 11:00 a.m., the administrator said she expected medications to be in stock and administered, as ordered. The administrator said the residence's plan of correction was implemented but had failed.

A licensure revisit was completed on 2/27/23 for all previous deficiencies cited on 4/21/22. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with a department issued intermediate condition, affecting 64 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for 12 months. Following the completion of event 3AJB11 on 4/21/22, a complaint survey, the Department imposed a RN consultant for 12 months to address corrective measures for all citations 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 cited deficiencies identified in the deficiency list and evaluate the residence's current compliance with regulations as outlined in Chapters 2, 7 and 24. The RN consultant was required to complete the following, during the first two months of the contract period:Evaluate the residence's current compliance with corresponding regulations as outlined in Chapters 2, 7, and 24. Provide recommendations to the administrator on any additional areas of noncompliance. Implement a monitor program to be completed at least monthly to ensure the residence remains in compliance with previously cited deficiencies. The RN consultant was required to complete the following, during the third month of the contract period:Evaluate the residence's compliance with all regulations in Chapter 2, 7, and 24 and provide recommendations to the administrator on any additional areas of noncompliance. Implement a monitoring program to be completed monthly to ensure the residence remains in compliance with previously cited deficiencies. The RN consultant was required to complete the following, during the first six months of the contract period:Conduct onsite visits at least weekly and increase the frequency as necessary to assist the residence in maintaining compliance with Chapter 2, 7 and 24 regulations and to prepare the administrator to independently manage the residence. Additionally, the RN consultant was required to ensure, during the entire 12-month contract period, for each of the deficiencies identified in the Deficiency List, for Event 3AJB11 and dated April 1, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. The RN Consultant will make certain that the monitoring identified the scope of review, how a sample was identified for monitoring purposes, the total length of time the monitoring would continue, and how the monitoring would be documented. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 7/30/33.- Submit executed consultant contract to the department, due by 8/7/22.- Submit final consultant report, due by 8/15/23. The residence did not appeal the intermediate condition. Department records read the residence had chosen a RN consultant on 7/27/22; however, the department denied the residence's choice of RN consultant, as the consultant did not meet the minimum requirements. On 8/10/22, the residence submitted additional information regarding the residence's chosen consultant and the department approved the consultant. On 8/11/22, the residence notified the department that they were working on the consultant contract and it would be finalized and submitted soon. On 8/16/22, the residence informed the department that the RN consultant had notified them that she would not be able to fulfill the requirements for the RN consultant role. On 8/29/22, the residence submitted a consultant contract for a different RN consultant. Therefore, on the day of the completion of the revisit on 2/27/23, the RN consultant was in her sixth month as a consultant for the residence. During the 2/23-2/27/23 revisit, it was established there was current deficient practice. One deficiency was cited at a D level, a pattern of actual harm. (Cross-reference Q1180) 2. InterviewsOn 2/27/23 at 10:04 a.m., the RN Consultant said the reason the residence was still out of compliance with the intermediate condition was because the residence had high turnover with their clinical team. She added that the citation being recited was a work in progress. The RN consultant said the residence had not had three months of consistent compliance due to an inconsistent clinical team that was currently in place. On 2/27/23 at approximately 1:30 p.m., the administrator stated she was not aware the residence was out of compliance with the intermediate condition if the residence was cited with deficient practice. On 2/27/23 at approximately 1:30 p.m., the regional director of operations was not aware the residence was out of compliance with the intermediate condition if the residence was cited with deficient practice.

Based on observation, record review and interview, the residence failed to develop a fall management program that included the required elements and to detail in each resident's care plan the individualized approach necessary to address fall risk, affecting 64 current residents. This deficiency was cited previously during a licensure complaint on 4/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #19 fell 18 times from December 2022 to February 2023. Four of the falls resulted in either injury or pain for Resident #19 on 12/1/22, 1/22, 1/28, and 2/7/23. On 1/28 and 2/7/23, Resident #19 was transported to the hospital for evaluation after he had fallen and hit his head. The care plan for Resident #19 was updated with interventions as of 1/30/23. However, the care plan was not updated with individualized approaches necessary to address falls after Resident #19 fell on 2/5, 2/7, 2/15, and 2/16/23. Specifically, Resident #21 experienced six falls in February 2023, including a fall on 2/26/23 that resulted in a skin tear to his left elbow. The care plan, dated 2/4/23, read in part the resident was a fall risk. However, the care plan was not updated with individualized approaches necessary to address falls after the resident's falls on 2/4, 2/7, 2/21, and 2/26/23. Findings include: 1. Residence PolicyOn 2/27/23 at approximately 9:58 a.m.., the Fall Management Program was requested. On 2/27/23 at approximately 10:17 a.m., the administrator provided the Fall Management Program. Review of the fall management program revealed it did not address the following required elements:Providing fall management education and materials to residents and family members; Detailing in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment. 2. Resident #19 was admitted to the residence on 7/25/22. Progress notes for Resident #19 for December 2022, January and February 2023, revealed the following:On 12/1/22 at 4:58 a.m., the resident was found on the floor. On 12/1/22 at 3:09 p.m., the resident was found on the floor. A scratch was observed on his back. On 12/7/22 at 8:00 a.m., the resident was found on the floor in his room. On 12/7/22 at 6:48 p.m., the resident was found on the floor. On 12/7/22 at 11:00 p.m., the resident was found on the floor in the dining room. On 12/19/22, the resident lost his balance and fell when he tried to get up from the living room couch. On 12/21/22, the resident's knees gave out and he was found on the floor. On 12/29/22, the resident was kneeling on the floor with his head on his bed and could not get up. On 1/5/23, the resident was found on the floor in his room. On 1/16/23, the resident was found on the floor in his room. On 1/22/23, the resident was found on the floor in his room. He complained that his head hurt. On 1/28/23, the resident was found sitting on the floor and he said he hit his head and complained of pain to the lower right side of the head. Was sent out to the hospital. On 1/30/23, the resident was found on the floor in his room. On 2/2/23, the resident tripped over his walker and fell in the dining room. "Staff to ambulate with resident due to increased weakness."On 2/5/23, the resident was found on the floor in his room. On 2/7/23, the resident was found on the floor in his room face down and complained of pain on his right side. The resident was sent out to the hospital. On 2/15/23, the resident was found on the floor in his room. On 2/16/23, the resident was found on the floor in his bathroom. The care plan for Resident #19, dated 12/21/22, read Resident #19 was a fall risk and his care plan included individualized approaches to address fall risks after he had fallen seven times since 12/21/22. Additionally, "(Resident #19) is unsteady on his feet when rising quickly. He can go off balance when walking alone." The last fall intervention documented in the care plan was 1/30/23. No additional fall interventions were implemented or added to the care plan for Resident #19 after he fell five more times. A document titled Fall Prevention/Intervention Plan, in Resident #19's record read that additional fall interventions were implemented after the falls from 1/16 to 1/30/23 that included the residence contacted the practitioner to order a lower bed and a fall mat and for staff to be proactive with care tasks. No additional fall interventions were implemented to mitigate Resident #19's falls after 1/30/23 and after Resident #19 sustained five more falls that included one with injury where he was sent out to the hospital on 2/7/23. On 2/27/23 at 8:35 a.m., Staff #13 stated Resident #19 was a fall risk. On 2/27/23 at 8:57 a.m., Staff #14 stated that Resident #19 was a fall risk and she was not sure of the individualized approaches necessary to prevent falls for the resident. On 2/27/23 at 9:02 a.m., Staff #12 stated that Resident #19 was a fall risk; however, she did not know of the individualized approaches necessary to prevent falls for the resident. On 2/27/23 at approximately 10:45 a.m., Staff #12 was in the living room of the residence and watching television as Resident #19 struggled and walked with his walker sideways. Staff #12 was within eyesight and approximately six to 12 feet from Resident #19. Staff #12 did not intervene until the surveyor was able to get her attention. Staff #12 adjusted Resident #19's walker and walked back into the living room as Resident #19 walked in the other direction unaccompanied. On 1/27/23 at 12:18 p.m., the regional director of resident care (RDRC) stated she trained staff who worked with Resident #19 on his specific fall interventions. She added if staff observed Resident #19 pushing his walker sideways she expected them to intervene and walk alongside him. On 2/27/23 at approximately 1:30 p.m., the administrator stated she expected the care manager to follow all the interventions in the care plan. She added the care plan should be updated to reflect the interventions to help mitigate falls including staff training related to the individualized approaches for residents who have fallen. The administrator said she was not aware the residence's fall management policy was missing the required elements. 3. Resident #21 was admitted to the residence on 10/14/22. The residence care plan, dated 2/4/23, read the resident was a fall risk and was updated with individualized approaches necessary to address fall risk after each of five falls from 11/1/22 to 1/24/23. However, the care plan was not updated after the resident sustained five falls in February 2023. Review of progress notes revealed the following:On 2/4/23 at 6:10 a.m., the resident sustained a fall. On 2/4/23 at 3:30 p.m., the resident sustained a fall. On 2/7/23, the resident fell twice. On 2/21/23, the resident sustained a fall. On 2/26/23, the resident sustained a fall with injury. Review of incident reports revealed the following:On 2/4/23 at 5:55 a.m., the resident sustained a fall. On 2/4/23 at 3:30 p.m., the resident sustained a fall. On 2/21/23 at 12:45 p.m., the resident sustained a fall. On 2/26/23 at 12:15 a.m., the resident sustained a fall that resulted in a skin tear to his left elbow. On 2/23/23 at 2:01 p.m., the responsible party for Resident #21 stated the resident was a fall risk. He added the resident had sustained a few bruises from falls. On 2/23/23 at 2:50 p.m., an external hospice provider stated that Resident #21 was a fall risk. She added she was unsure whether or not the residence had systems in place to help mitigate the resident's fall risk. On 2/27/23 at 8:33 a.m., Staff #13 stated that Resident #21 was a fall risk. On 2/27/23 at 8:51 a.m., Staff #14 stated that Resident #21 was a fall risk. She stated she was unaware of individualized approaches in place to address the resident's falls and was unaware the resident had had falls at the residence. On 2/27/23 at 9:02 a.m., Staff #12 stated she did not know whether or not Resident # 21 was a fall risk and did not know of individualized approaches in place to address the resident's falls because she had worked at the residence for one month. On 2/27/23 at 1:21 p.m., the administrator stated the care plan for Resident #21 should have been updated with individualized approaches to address the resident's fall risk after each fall. 4. Resident #22 was admitted to the residence on 11/4/22 with diagnoses including dementia. The residence's care plan, dated 2/5/23, read the resident was a fall risk and included individualized approaches necessary to address fall risk such as increased rounding and educating the resident. However, the care plan was not updated after the resident sustained a fall on 2/12/23. A progress note, dated 2/12/23, read the resident sustained a fall without injury. On 2/27/23 at 9:57 a.m., the responsible party for Resident #22 stated he was a fall risk. On 2/27/23 at 8:33 a.m., Staff #13 stated that Resident #22 was a fall risk. On 2/27/23 at 8:51 a.m., Staff #14 stated that Resident #22 was a fall risk. She stated she was unaware of individualized approaches in place to address the resident's falls. On 2/27/23 at 9:02 a.m., Staff #12 stated she did not know whether or not Resident #22 was a fall risk and did not know individualized approaches in place to address the resident's falls because she had worked at the residence for one month. On 2/27/23 at 1:21 p.m., the administrator stated the care plan for Resident #22 should have been updated with individualized approaches to address the resident's fall risk after each fall. On 2/27/23 at 12:18 p.m., the RDRC stated that care plans needed to be updated after each fall. She stated that the residence updated care plans after each fall; however, the care plans did not reflect the updated date. On 2/27/23 at 1:21 p.m., the administrator stated the residence care plans needed to be updated with individualized approaches necessary to prevent falls after each fall. She stated the nurse was responsible for updating care plans. The administrator stated that the residence's electronic system did reflect updated dates on care plans or prompted the user to create a new care plan that reflected the new date. She added that she had only worked at the residence for a month and could be incorrect.

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

A licensure revisit was completed on 2/27/23 for all previous deficiencies cited on 8/2/22. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with a department issued intermediate condition, affecting 64 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for 12 months. Following the completion of event 3AJB11 on 4/21/22, a complaint survey, the Department imposed a RN consultant for 12 months to address corrective measures for all citations 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 cited deficiencies identified in the deficiency list and evaluate the residence's current compliance with regulations as outlined in Chapters 2, 7 and 24. The RN consultant was required to complete the following, during the first two months of the contract period:Evaluate the residence's current compliance with corresponding regulations as outlined in Chapters 2, 7, and 24. Provide recommendations to the administrator on any additional areas of noncompliance. Implement a monitor program to be completed at least monthly to ensure the residence remains in compliance with previously cited deficiencies. The RN consultant was required to complete the following, during the third month of the contract period:Evaluate the residence's compliance with all regulations in Chapter 2, 7, and 24 and provide recommendations to the administrator on any additional areas of noncompliance. Implement a monitoring program to be completed monthly to ensure the residence remains in compliance with previously cited deficiencies. The RN consultant was required to complete the following, during the first six months of the contract period:Conduct onsite visits at least weekly and increase the frequency as necessary to assist the residence in maintaining compliance with Chapter 2, 7 and 24 regulations and to prepare the administrator to independently manage the residence. Additionally, the RN consultant was required to ensure, during the entire 12-month contract period, for each of the deficiencies identified in the Deficiency List, for Event 3AJB11 and dated April 1, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. The RN Consultant will make certain that the monitoring identified the scope of review, how a sample was identified for monitoring purposes, the total length of time the monitoring would continue, and how the monitoring would be documented. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 7/30/33.- Submit executed consultant contract to the department, due by 8/7/22.- Submit final consultant report, due by 8/15/23. The residence did not appeal the intermediate condition. Department records read the residence had chosen a RN consultant on 7/27/22; however, the department denied the residence's choice of RN consultant, as the consultant did not meet the minimum requirements. On 8/10/22, the residence submitted additional information regarding the residence's chosen consultant and the department approved the consultant. On 8/11/22, the residence notified the department that they were working on the consultant contract and it would be finalized and submitted soon. On 8/16/22, the residence informed the department that the RN consultant had notified them that she would not be able to fulfill the requirements for the RN consultant role. On 8/29/22, the residence submitted a consultant contract for a different RN consultant. Therefore, on the day of the completion of the revisit on 2/27/23, the RN consultant was in her sixth month as a consultant for the residence. During the 2/23-2/27/23 revisit, it was established there was current deficient practice. Two deficiencies were cited: 1430 and 1468. (Cross-reference Q1430, Q1468) 2. InterviewsOn 2/27/23 at 10:04 a.m., the RN Consultant said the reason the residence was still out of compliance with the intermediate condition was because the residence had high turnover with their clinical team. She added that the citations being recited were a work in progress. The RN Consultant said she was aware the residence was not in compliance with tags 1430, and 1468 because the residence struggled with completing clinical items. The RN consultant said the residence had not had three months of consistent compliance due to an inconsistent clinical team that was currently in place. On 2/27/23 at approximately 1:30 p.m., the administrator stated she was not aware the residence was out of compliance with the intermediate condition if the residence was cited with deficient practice. On 2/27/23 at approximately 1:30 p.m., the regional director of operations was not aware the residence was out of compliance with the intermediate condition if the residence was cited with deficient practice.

Based on interview and record review, the residence failed to ensure only medication that had been ordered by an authorized practitioner was prepared for a resident, affecting five medications for one sample resident (#21). This deficiency was cited previously during a licensure complaint on 8/2/22. 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 2/1/23, read in part, the residence would only administer medications with a primary care provider's signed order. 2. Resident #21 was admitted to the resident on 10/14/22 with diagnoses including constipation and osteoarthritis. a. LorazepamThe February 2023 medication administration record (MAR) read in part, the resident was administered lorazepam 0.5 mg once daily on 2/1-2/22/23, for a total of 22 doses. However, the residence was unable to provide a written practitioner's order for the medication.b. Senna The February 2023 MAR read in part, the resident was administered senna 8.6 mg once daily on 2/1-2/22/23, for a total of 22 doses. However, the residence was unable to provide a written practitioner's order for the medication.c. Trazodone The February 2023 MAR read in part, the resident was administered trazodone 50 mg once daily on 2/1-2/22/23, for a total of 22 doses. However, the residence was unable to provide a written practitioner's order for the medication.d. Sertraline The February 2023 MAR read in part, the resident was administered sertraline 50 mg once daily on 2/9-2/22/23, for a total of 14 doses. However, the residence was unable to provide a written practitioner's order for the medication.e. Escitalopram 10 mgThe February 2023 MAR read in part, the resident was administered escitalopram 10 mg once daily on 2/1-2/8/23, for a total of eight doses. However, the residence was unable to provide a written practitioner's order for the medication. On 2/23/23 at 12:18 p.m., the regional director of resident care stated the residence did not have any authorized practitioner's orders for Resident #21's medications. She stated the residence attempted to contact the practitioner in January 2023 and the resident's hospice provider in February 2023 for authorized practitioner's orders; however, orders were not provided. On 2/27/23 at approximately 1:21 p.m., the administrator acknowledged the residence administered Resident #21's medications without authorized practitioner's orders. She stated the residence should not have administered medications without authorized practitioner's orders.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting five of six sample residents (#18, #19, #22, #23, #24) and two of two former residents (#28 and #29). This deficiency was cited previously during a licensure complaint on 8/2/22. 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 #24 was admitted to the residence on 2/1/23.a. EliquisA written practitioner's order, dated 2/8/23, directed the residence to administer Eliquis 2.5 mg twice daily. However, the February 2023 MAR for Resident #24 read the medication was not available for the morning dose on 2/9 and 2/13, and for the evening dose on 2/9 and 2/10/23, for a total of four missed doses.b. MucinexA written practitioner's order, dated 2/15/23, directed the residence to administer Mucinex 600 mg twice daily. However, the February 2023 MAR for Resident #24 read the medication was not available for the morning dose on 2/18 and the evening dose on 2/19 and 2/20/23, for a total of three missed doses.c. BisacodylA written practitioner's order, dated 1/20/23, directed the residence to administer bisacodyl 5 mg once daily. However, the February 2023 MAR for Resident #24 read the medication was not available on 2/23/23, for a total of one missed dose. On 2/23/23 at 12:18 p.m., the regional director of resident care (RDRC) stated the residence should not have run out of Resident #24's medications. On 2/27/23 at approximately 1:30 p.m., the administrator stated the residence should not have stopped administering the medication before it was discontinued by the practitioner. 2. Resident #23 was admitted to the residence on 1/26/23 with diagnoses including dementia with behavioral disturbance. a. DivalproexA written practitioner's order, dated 2/1/23, directed the residence to administer divalproex 250 mg twice daily. However,the February 2023 MAR for Resident #23 read the medication was not available and not administered on 2/19 evening dose, 2/20, 2/21 and 2/22/22 morning and evening doses for a total of seven missed doses. b. DonepezilA written practitioner's order, dated 2/1/23, directed the residence to administer donepezil 5 mg once daily. However, the February 2023 MAR for Resident #23 read the medication was not available and not administered on 2/21 and 2/22/23 for a total of two missed doses. 3. Resident #18 was admitted to the residence on 11/19/19 with diagnoses including hypothyroidism and angina. a. LevothyroxineA written practitioner's order, dated 6/28/22, directed the residence to administer levothyroxine 88 mcg once daily. However, the August 2022 MAR for Resident #18 had blank spaces on 8/15 and 8/24/22. On 2/23/23 at 1:09 p.m., an external pharmacy representative (EPR) stated on 7/12/22 there was a 30 day supply of levothyroxine 88 mcg delivered to the residence. She added, it would have run out on 8/11/22. The EPR said the next time it was reordered was 8/23/22. The EPR confirmed that the levothyroxine 88 mcg was delivered to the residence on 7/13/22 at 4:27 p.m. The next delivery for levothyroxine 88 mcg was on 8/24/22 at 4:34 a.m. On 2/27/23 at 11:03 a.m., the family member of Resident #18 stated when the levothyroxine ran out on 8/11/22, the medication was not available and not in stock in August 2022 and as a result, Resident #18 did not receive her levothyroxine for approximately a week in August 2022. Another written practitioner's order, dated 10/14/22, directed the residence to discontinue levothyroxine 88 mcg and start levothyroxine 100 mcg once daily. However, the February 2023 MAR for Resident #18 read the medication was not available and not administered on 2/11 and 2/12/23 for a total of two missed doses.b. Metamucil Fiber GummiesA written practitioner's order, dated 8/16/22, directed the residence to administer Metamucil fiber once daily. However, the February 2023 MAR for Resident #18 read the medication was not available and not administered on 2/5/23.4. Former Resident #28 was admitted to the residence on 10/15/21.a. Acetaminophen A written practitioner's order, dated 9/1/22, directed the residence to administer acetaminophen 500 mg three times daily. However, the September 2022 MAR for Former Resident #28 read the medication was not on the MAR until 9/7 in the evening and not administered from 9/1 to 9/7/22 for a total of 18 missed doses. On 2/27/23 at 12:20 p.m., the RDRC said she expected the medication to be on the MAR and administered before 9/7/22 for Former Resident #28.b. OxycodoneA written practitioner's order, dated 9/1/22, directed the residence to administer oxycodone 5 mg twice daily. However, the September 2022 MAR for Resident #28 read the medication was not available and not administered on 9/4/22 morning dose. 5. Former Resident #29 was admitted to the residence on 7/16/20.a. Acidophilus A written practitioner's order, dated 8/22/22, directed the residence to administer acidophilus freeze dried capsule twice daily. However, the August and September 2022 MARs for Former Resident #29 read the medication was not available and not administered on 8/30/22 evening dose and 8/31/22 morning and evening dose, 9/1-9/4 morning and evening doses, 9/5 evening dose, 9/11 evening dose, 9/12-9/13 morning and evening dose, 9/20-9/21 morning and evening dose and 9/21/22 morning dose, for a total of 22 missed doses. b. MelatoninA written practitioner's order, dated 8/22/22, directed the residence to administer melatonin 5 mg once daily. However, the August 2022 MAR for Former Resident #29 read the medication was not available and not administered on 8/28-8/30/22 for a total of three missed doses. 6. Resident #19 was admitted to the residence on 7/25/22.a. FinasterideA written practitioner's order, dated 1/24/23, directed the residence to administer finasteride 5 mg once daily. However, the February 2023 MAR for Resident #19 read the medication was not available and not administered on 2/1/23.b. AspercremeA written practitioner's order, dated 1/24/23, directed the residence to administer Aspercreme 4% once daily. However, the February 2023 MAR for Resident #19 read the medication was not available and not administered on 2/23/23.c. Pataday Ophthalmic SolutionA written practitioner's order, dated 1/24/23, directed the residence to administer pasta ophthalmic solution 0.1% twice daily. However, the February 2023 MAR for Resident #19 read the medication as not available and not administered on 2/4/23. 7. Resident #22 was admitted to the residence on 11/4/22. A written practitioner order, dated 12/1/22, directed the residence to administer omeprazole 20 mg daily. However, the February 2023 MAR for Resident #22 read the medication was not available and not administered on 2/21 and 2/22/23, for a total of 24 missed doses. On 2/27/23 at 8:35 a.m., Staff #13 stated the residence should not have run out of Resident #22's medication. On 2/27/23 at approximately 12:45 p.m., the RDRC stated that if an MAR for a resident listed the medication as not available that meant the medication was not administered, as ordered. She added that medications were received monthly on a cycle fill and when medications were running low staff pulled the label on the medication and reordered the medication when three tablets remained. On 2/27/23 at 8:35 a.m., Staff #13 stated that it was not appropriate for the residence to run out of prescribed medications for residents. She added that qualified medication administration persons (QMAPs) were responsible for reordering medications when there was approximately a week left of tablets in the medication pack. On 2/27/23 at approximately 1:30 p.m., the administrator stated she expected QMAP staff to order medication when seven tablets remained. 8. InterviewOn 2/27/23 at approximately 1:30 p.m., the administrator stated it was not appropriate for the residence to run out of prescribed medications for residents.

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

A licensure revisit was completed on 2/27/23 for all previous deficiencies cited on 8/2/22. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with a department issued intermediate condition, affecting 64 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for 12 months. Following the completion of event 3AJB11 on 4/21/22, a complaint survey, the Department imposed a RN consultant for 12 months to address corrective measures for all citations 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 cited deficiencies identified in the deficiency list and evaluate the residence's current compliance with regulations as outlined in Chapters 2, 7 and 24. The RN consultant was required to complete the following, during the first two months of the contract period:Evaluate the residence's current compliance with corresponding regulations as outlined in Chapters 2, 7, and 24. Provide recommendations to the administrator on any additional areas of noncompliance. Implement a monitor program to be completed at least monthly to ensure the residence remains in compliance with previously cited deficiencies. The RN consultant was required to complete the following, during the third month of the contract period:Evaluate the residence's compliance with all regulations in Chapter 2, 7, and 24 and provide recommendations to the administrator on any additional areas of noncompliance. Implement a monitoring program to be completed monthly to ensure the residence remains in compliance with previously cited deficiencies. The RN consultant was required to complete the following, during the first six months of the contract period:Conduct onsite visits at least weekly and increase the frequency as necessary to assist the residence in maintaining compliance with Chapter 2, 7 and 24 regulations and to prepare the administrator to independently manage the residence. Additionally, the RN consultant was required to ensure, during the entire 12-month contract period, for each of the deficiencies identified in the Deficiency List, for Event 3AJB11 and dated April 1, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. The RN Consultant will make certain that the monitoring identified the scope of review, how a sample was identified for monitoring purposes, the total length of time the monitoring would continue, and how the monitoring would be documented. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 7/30/33.- Submit executed consultant contract to the department, due by 8/7/22.- Submit final consultant report, due by 8/15/23. The residence did not appeal the intermediate condition. Department records read the residence had chosen a RN consultant on 7/27/22; however, the department denied the residence's choice of RN consultant, as the consultant did not meet the minimum requirements. On 8/10/22, the residence submitted additional information regarding the residence's chosen consultant and the department approved the consultant. On 8/11/22, the residence notified the department that they were working on the consultant contract and it would be finalized and submitted soon. On 8/16/22, the residence informed the department that the RN consultant had notified them that she would not be able to fulfill the requirements for the RN consultant role. On 8/29/22, the residence submitted a consultant contract for a different RN consultant. Therefore, on the day of the completion of the revisit on 2/27/23, the RN consultant was in her sixth month as a consultant for the residence. During the 2/23-2/27/23 revisit, it was established there was current deficient practice. One deficiency was cited: 1468. (Cross-reference Q1468) 2. InterviewsOn 2/27/23 at 10:04 a.m., the RN Consultant said the reason the residence was still out of compliance with the intermediate condition was because the residence had high turnover with their clinical team. She added that the citation being recited was a work in progress. The RN Consultant said she was aware the residence was not in compliance with tag 1468 because the residence struggled with completing clinical items. The RN consultant said the residence had not had three months of consistent compliance due to an inconsistent clinical team that was currently in place. On 2/27/23 at approximately 1:30 p.m., the administrator stated she was not aware the residence was out of compliance with the intermediate condition if the residence was cited with deficient practice. On 2/27/23 at approximately 1:30 p.m., the regional director of operations was not aware the residence was out of compliance with the intermediate condition if the residence was cited with deficient practice.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting five of six sample residents (#18, #19, #22, #23, #24) and two of two former residents (#28 and #29). This deficiency was cited previously during a licensure complaint on 8/2/22. 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 #24 was admitted to the residence on 2/1/23.a. EliquisA written practitioner's order, dated 2/8/23, directed the residence to administer Eliquis 2.5 mg twice daily. However, the February 2023 MAR for Resident #24 read the medication was not available for the morning dose on 2/9 and 2/13, and for the evening dose on 2/9 and 2/10/23, for a total of four missed doses.b. MucinexA written practitioner's order, dated 2/15/23, directed the residence to administer Mucinex 600 mg twice daily. However, the February 2023 MAR for Resident #24 read the medication was not available for the morning dose on 2/18 and the evening dose on 2/19 and 2/20/23, for a total of three missed doses.c. BisacodylA written practitioner's order, dated 1/20/23, directed the residence to administer bisacodyl 5 mg once daily. However, the February 2023 MAR for Resident #24 read the medication was not available on 2/23/23, for a total of one missed dose. On 2/23/23 at 12:18 p.m., the regional director of resident care (RDRC) stated the residence should not have run out of Resident #24's medications. On 2/27/23 at approximately 1:30 p.m., the administrator stated the residence should not have stopped administering the medication before it was discontinued by the practitioner. 2. Resident #23 was admitted to the residence on 1/26/23 with diagnoses including dementia with behavioral disturbance. a. DivalproexA written practitioner's order, dated 2/1/23, directed the residence to administer divalproex 250 mg twice daily. However,the February 2023 MAR for Resident #23 read the medication was not available and not administered on 2/19 evening dose, 2/20, 2/21 and 2/22/22 morning and evening doses for a total of seven missed doses. b. DonepezilA written practitioner's order, dated 2/1/23, directed the residence to administer donepezil 5 mg once daily. However, the February 2023 MAR for Resident #23 read the medication was not available and not administered on 2/21 and 2/22/23 for a total of two missed doses. 3. Resident #18 was admitted to the residence on 11/19/19 with diagnoses including hypothyroidism and angina. a. LevothyroxineA written practitioner's order, dated 6/28/22, directed the residence to administer levothyroxine 88 mcg once daily. However, the August 2022 MAR for Resident #18 had blank spaces on 8/15 and 8/24/22. On 2/23/23 at 1:09 p.m., an external pharmacy representative (EPR) stated on 7/12/22 there was a 30 day supply of levothyroxine 88 mcg delivered to the residence. She added, it would have run out on 8/11/22. The EPR said the next time it was reordered was 8/23/22. The EPR confirmed that the levothyroxine 88 mcg was delivered to the residence on 7/13/22 at 4:27 p.m. The next delivery for levothyroxine 88 mcg was on 8/24/22 at 4:34 a.m. On 2/27/23 at 11:03 a.m., the family member of Resident #18 stated when the levothyroxine ran out on 8/11/22, the medication was not available and not in stock in August 2022 and as a result, Resident #18 did not receive her levothyroxine for approximately a week in August 2022. Another written practitioner's order, dated 10/14/22, directed the residence to discontinue levothyroxine 88 mcg and start levothyroxine 100 mcg once daily. However, the February 2023 MAR for Resident #18 read the medication was not available and not administered on 2/11 and 2/12/23 for a total of two missed doses.b. Metamucil Fiber GummiesA written practitioner's order, dated 8/16/22, directed the residence to administer Metamucil fiber once daily. However, the February 2023 MAR for Resident #18 read the medication was not available and not administered on 2/5/23.4. Former Resident #28 was admitted to the residence on 10/15/21.a. Acetaminophen A written practitioner's order, dated 9/1/22, directed the residence to administer acetaminophen 500 mg three times daily. However, the September 2022 MAR for Former Resident #28 read the medication was not on the MAR until 9/7 in the evening and not administered from 9/1 to 9/7/22 for a total of 18 missed doses. On 2/27/23 at 12:20 p.m., the RDRC said she expected the medication to be on the MAR and administered before 9/7/22 for Former Resident #28.b. OxycodoneA written practitioner's order, dated 9/1/22, directed the residence to administer oxycodone 5 mg twice daily. However, the September 2022 MAR for Resident #28 read the medication was not available and not administered on 9/4/22 morning dose. 5. Former Resident #29 was admitted to the residence on 7/16/20.a. Acidophilus A written practitioner's order, dated 8/22/22, directed the residence to administer acidophilus freeze dried capsule twice daily. However, the August and September 2022 MARs for Former Resident #29 read the medication was not available and not administered on 8/30/22 evening dose and 8/31/22 morning and evening dose, 9/1-9/4 morning and evening doses, 9/5 evening dose, 9/11 evening dose, 9/12-9/13 morning and evening dose, 9/20-9/21 morning and evening dose and 9/21/22 morning dose, for a total of 22 missed doses. b. MelatoninA written practitioner's order, dated 8/22/22, directed the residence to administer melatonin 5 mg once daily. However, the August 2022 MAR for Former Resident #29 read the medication was not available and not administered on 8/28-8/30/22 for a total of three missed doses. 6. Resident #19 was admitted to the residence on 7/25/22.a. FinasterideA written practitioner's order, dated 1/24/23, directed the residence to administer finasteride 5 mg once daily. However, the February 2023 MAR for Resident #19 read the medication was not available and not administered on 2/1/23.b. AspercremeA written practitioner's order, dated 1/24/23, directed the residence to administer Aspercreme 4% once daily. However, the February 2023 MAR for Resident #19 read the medication was not available and not administered on 2/23/23.c. Pataday Ophthalmic SolutionA written practitioner's order, dated 1/24/23, directed the residence to administer pasta ophthalmic solution 0.1% twice daily. However, the February 2023 MAR for Resident #19 read the medication as not available and not administered on 2/4/23. 7. Resident #22 was admitted to the residence on 11/4/22. A written practitioner order, dated 12/1/22, directed the residence to administer omeprazole 20 mg daily. However, the February 2023 MAR for Resident #22 read the medication was not available and not administered on 2/21 and 2/22/23, for a total of 24 missed doses. On 2/27/23 at 8:35 a.m., Staff #13 stated the residence should not have run out of Resident #22's medication. On 2/27/23 at approximately 12:45 p.m., the RDRC stated that if an MAR for a resident listed the medication as not available that meant the medication was not administered, as ordered. She added that medications were received monthly on a cycle fill and when medications were running low staff pulled the label on the medication and reordered the medication when three tablets remained. On 2/27/23 at 8:35 a.m., Staff #13 stated that it was not appropriate for the residence to run out of prescribed medications for residents. She added that qualified medication administration persons (QMAPs) were responsible for reordering medications when there was approximately a week left of tablets in the medication pack. On 2/27/23 at approximately 1:30 p.m., the administrator stated she expected QMAP staff to order medication when seven tablets remained. 8. InterviewOn 2/27/23 at approximately 1:30 p.m., the administrator stated it was not appropriate for the residence to run out of prescribed medications for residents.

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

A licensure complaint, prompted by #CO29979, #CO29993, #CO30776 and #CO30777, was completed on 2/26/23. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with a department issued intermediate condition, affecting 64 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a registered nurse (RN) consultant for 12 months. Following the completion of event 3AJB11 on 4/21/22, a complaint survey, the Department imposed a RN consultant for 12 months to address corrective measures for all citations 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 cited deficiencies identified in the deficiency list and evaluate the residence's current compliance with regulations as outlined in Chapters 2, 7 and 24. The RN consultant was required to complete the following, during the first two months of the contract period:Evaluate the residence's current compliance with corresponding regulations as outlined in Chapters 2, 7, and 24. Provide recommendations to the administrator on any additional areas of noncompliance. Implement a monitor program to be completed at least monthly to ensure the residence remains in compliance with previously cited deficiencies. The RN consultant was required to complete the following, during the third month of the contract period:Evaluate the residence's compliance with all regulations in Chapter 2, 7, and 24 and provide recommendations to the administrator on any additional areas of noncompliance. Implement a monitoring program to be completed monthly to ensure the residence remains in compliance with previously cited deficiencies. The RN consultant was required to complete the following, during the first six months of the contract period:Conduct onsite visits at least weekly and increase the frequency as necessary to assist the residence in maintaining compliance with Chapter 2, 7 and 24 regulations and to prepare the administrator to independently manage the residence. Additionally, the RN consultant was required to ensure, during the entire 12-month contract period, for each of the deficiencies identified in the Deficiency List, for Event 3AJB11 and dated April 1, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. The RN Consultant will make certain that the monitoring identified the scope of review, how a sample was identified for monitoring purposes, the total length of time the monitoring would continue, and how the monitoring would be documented. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 7/30/33.- Submit executed consultant contract to the department, due by 8/7/22.- Submit final consultant report, due by 8/15/23. The residence did not appeal the intermediate condition. Department records read the residence had chosen a RN consultant on 7/27/22; however, the department denied the residence's choice of RN consultant, as the consultant did not meet the minimum requirements. On 8/10/22, the residence submitted additional information regarding the residence's chosen consultant and the department approved the consultant. On 8/11/22, the residence notified the department that they were working on the consultant contract and it would be finalized and submitted soon. On 8/16/22, the residence informed the department that the RN consultant had notified them that she would not be able to fulfill the requirements for the RN consultant role. On 8/29/22, the residence submitted a consultant contract for a different RN consultant. Therefore, on the day of the completion of the complaint investigation on 2/27/23, the RN consultant was in her sixth month as a consultant forthe residence. During the 2/23-2/27/23 complaint investigation, the investigation established there was current deficient practice. Four deficiencies were cited, including tags 1430, 1468 and 1514. Additionally, tag 1180 was cited at a D level, a pattern of actual harm. (Cross-reference Q1180, Q1430, Q1468, Q1514) 2. InterviewsOn 2/27/23 at 10:04 a.m., the RN Consultant said the reason the residence was still out of compliance with the intermediate condition was because the residence had high turnover with their clinical team. She added that the citations being recited were a work in progress. The RN Consultant said she was aware the residence was not in compliance with tags 1180, 1430, and 1468 because the residence struggled with completing clinical items. The RN consultant said the residence had not had three months of consistent compliance due to an inconsistent clinical team that was currently in place. On 2/27/23 at approximately 1:30 p.m., the administrator stated she was not aware the residence was out of compliance with the intermediate condition if the residence was cited with deficient practice. On 2/27/23 at approximately 1:30 p.m., the regional director of operations was not aware the residence was out of compliance with the intermediate condition if the residence was cited with deficient practice.

Based on observation, record review and interview, the residence failed to develop a fall management program that included the required elements and to detail in each resident's care plan the individualized approach necessary to address fall risk, affecting 64 current residents. Specifically, Resident #19 fell 18 times from December 2022 to February 2023. Four of the falls resulted in either injury or pain for Resident #19 on 12/1/22, 1/22, 1/28, and 2/7/23. On 1/28 and 2/7/23, Resident #19 was transported to the hospital for evaluation after he had fallen and hit his head. The care plan for Resident #19 was updated with interventions as of 1/30/23. However, the care plan was not updated with individualized approaches necessary to address falls after Resident #19 fell on 2/5, 2/7, 2/15, and 2/16/23. Specifically, Resident #21 experienced six falls in February 2023, including a fall on 2/26/23 that resulted in a skin tear to his left elbow. The care plan, dated 2/4/23, read in part the resident was a fall risk. However, the care plan was not updated with individualized approaches necessary to address falls after the resident's falls on 2/4, 2/7, 2/21, and 2/26/23. Findings include: 1. Residence PolicyOn 2/27/23 at approximately 9:58 a.m.., the Fall Management Program was requested. On 2/27/23 at approximately 10:17 a.m., the administrator provided the Fall Management Program. Review of the fall management program revealed it did not address the following required elements:Providing fall management education and materials to residents and family members; Detailing in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment. 2. Resident #19 was admitted to the residence on 7/25/22. Progress notes for Resident #19 for December 2022, January and February 2023, revealed the following:On 12/1/22 at 4:58 a.m., the resident was found on the floor. On 12/1/22 at 3:09 p.m., the resident was found on the floor. A scratch was observed on his back. On 12/7/22 at 8:00 a.m., the resident was found on the floor in his room. On 12/7/22 at 6:48 p.m., the resident was found on the floor. On 12/7/22 at 11:00 p.m., the resident was found on the floor in the dining room. On 12/19/22, the resident lost his balance and fell when he tried to get up from the living room couch. On 12/21/22, the resident's knees gave out and he was found on the floor. On 12/29/22, the resident was kneeling on the floor with his head on his bed and could not get up. On 1/5/23, the resident was found on the floor in his room. On 1/16/23, the resident was found on the floor in his room. On 1/22/23, the resident was found on the floor in his room. He complained that his head hurt. On 1/28/23, the resident was found sitting on the floor and he said he hit his head and complained of pain to the lower right side of the head. Was sent out to the hospital. On 1/30/23, the resident was found on the floor in his room. On 2/2/23, the resident tripped over his walker and fell in the dining room. "Staff to ambulate with resident due to increased weakness."On 2/5/23, the resident was found on the floor in his room. On 2/7/23, the resident was found on the floor in his room face down and complained of pain on his right side. The resident was sent out to the hospital. On 2/15/23, the resident was found on the floor in his room. On 2/16/23, the resident was found on the floor in his bathroom. The care plan for Resident #19, dated 12/21/22, read Resident #19 was a fall risk and his care plan included individualized approaches to address fall risks after he had fallen seven times since 12/21/22. Additionally, "(Resident #19) is unsteady on his feet when rising quickly. He can go off balance when walking alone." The last fall intervention documented in the care plan was 1/30/23. No additional fall interventions were implemented or added to the care plan for Resident #19 after he fell five more times. A document titled Fall Prevention/Intervention Plan, in Resident #19's record read that additional fall interventions were implemented after the falls from 1/16 to 1/30/23 that included the residence contacted the practitioner to order a lower bed and a fall mat and for staff to be proactive with care tasks. No additional fall interventions were implemented to mitigate Resident #19's falls after 1/30/23 and after Resident #19 sustained five more falls that included one with injury where he was sent out to the hospital on 2/7/23. On 2/27/23 at 8:35 a.m., Staff #13 stated Resident #19 was a fall risk. On 2/27/23 at 8:57 a.m., Staff #14 stated that Resident #19 was a fall risk and she was not sure of the individualized approaches necessary to prevent falls for the resident. On 2/27/23 at 9:02 a.m., Staff #12 stated that Resident #19 was a fall risk; however, she did not know of the individualized approaches necessary to prevent falls for the resident. On 2/27/23 at approximately 10:45 a.m., Staff #12 was in the living room of the residence and watching television as Resident #19 struggled and walked with his walker sideways. Staff #12 was within eyesight and approximately six to 12 feet from Resident #19. Staff #12 did not intervene until the surveyor was able to get her attention. Staff #12 adjusted Resident #19's walker and walked back into the living room as Resident #19 walked in the other direction unaccompanied. On 1/27/23 at 12:18 p.m., the regional director of resident care (RDRC) stated she trained staff who worked with Resident #19 on his specific fall interventions. She added if staff observed Resident #19 pushing his walker sideways she expected them to intervene and walk alongside him. On 2/27/23 at approximately 1:30 p.m., the administrator stated she expected the care manager to follow all the interventions in the care plan. She added the care plan should be updated to reflect the interventions to help mitigate falls including staff training related to the individualized approaches for residents who have fallen. The administrator said she was not aware the residence's fall management policy was missing the required elements. 3. Resident #21 was admitted to the residence on 10/14/22. The residence care plan, dated 2/4/23, read the resident was a fall risk and was updated with individualized approaches necessary to address fall risk after each of five falls from 11/1/22 to 1/24/23. However, the care plan was not updated after the resident sustained five falls in February 2023. Review of progress notes revealed the following:On 2/4/23 at 6:10 a.m., the resident sustained a fall. On 2/4/23 at 3:30 p.m., the resident sustained a fall. On 2/7/23, the resident fell twice. On 2/21/23, the resident sustained a fall. On 2/26/23, the resident sustained a fall with injury. Review of incident reports revealed the following:On 2/4/23 at 5:55 a.m., the resident sustained a fall. On 2/4/23 at 3:30 p.m., the resident sustained a fall. On 2/21/23 at 12:45 p.m., the resident sustained a fall. On 2/26/23 at 12:15 a.m., the resident sustained a fall that resulted in a skin tear to his left elbow. On 2/23/23 at 2:01 p.m., the responsible party for Resident #21 stated the resident was a fall risk. He added the resident had sustained a few bruises from falls. On 2/23/23 at 2:50 p.m., an external hospice provider stated that Resident #21 was a fall risk. She added she was unsure whether or not the residence had systems in place to help mitigate the resident's fall risk. On 2/27/23 at 8:33 a.m., Staff #13 stated that Resident #21 was a fall risk. On 2/27/23 at 8:51 a.m., Staff #14 stated that Resident #21 was a fall risk. She stated she was unaware of individualized approaches in place to address the resident's falls and was unaware the resident had had falls at the residence. On 2/27/23 at 9:02 a.m., Staff #12 stated she did not know whether or not Resident # 21 was a fall risk and did not knowof individualized approaches in place to address the resident's falls because she had worked at the residence for one month. On 2/27/23 at 1:21 p.m., the administrator stated the care plan for Resident #21 should have been updated with individualized approaches to address the resident's fall risk after each fall. 4. Resident #22 was admitted to the residence on 11/4/22 with diagnoses including dementia. The residence's care plan, dated 2/5/23, read the resident was a fall risk and included individualized approaches necessary to address fall risk such as increased rounding and educating the resident. However, the care plan was not updated after the resident sustained a fall on 2/12/23. A progress note, dated 2/12/23, read the resident sustained a fall without injury. On 2/27/23 at 9:57 a.m., the responsible party for Resident #22 stated he was a fall risk. On 2/27/23 at 8:33 a.m., Staff #13 stated that Resident #22 was a fall risk. On 2/27/23 at 8:51 a.m., Staff #14 stated that Resident #22 was a fall risk. She stated she was unaware of individualized approaches in place to address the resident's falls. On 2/27/23 at 9:02 a.m., Staff #12 stated she did not know whether or not Resident #22 was a fall risk and did not know individualized approaches in place to address the resident's falls because she had worked at the residence for one month. On 2/27/23 at 1:21 p.m., the administrator stated the care plan for Resident #22 should have been updated with individualized approaches to address the resident's fall risk after each fall. On 2/27/23 at 12:18 p.m., the RDRC stated that care plans needed to be updated after each fall. She stated that the residence updated care plans after each fall; however, the care plans did not reflect the updated date. On 2/27/23 at 1:21 p.m., the administrator stated the residence care plans needed to be updated with individualized approaches necessary to prevent falls after each fall. She stated the nurse was responsible for updating care plans. The administrator stated that the residence's electronic system did reflect updated dates on care plans or prompted the user to create a new care plan that reflected the new date. She added that she had only worked at the residence for a month and could be incorrect.

Based on interview and record review, the residence failed to ensure only medication that had been ordered by an authorized practitioner was prepared for a resident, affecting five medications for one sample resident (#21). (Cross-reference Q1514)Findings include: 1. Residence policyThe residence's Medication Administration policy, dated 2/1/23, read in part, the residence would only administer medications with a primary care provider's signed order. 2. Resident #21 was admitted to the resident on 10/14/22 with diagnoses including constipation and osteoarthritis. a. LorazepamThe February 2023 medication administration record (MAR) read in part, the resident was administered lorazepam 0.5 mg once daily on 2/1-2/22/23, for a total of 22 doses. However, the residence was unable to provide a written practitioner's order for the medication.b. Senna The February 2023 MAR read in part, the resident was administered senna 8.6 mg once daily on 2/1-2/22/23, for a total of 22 doses. However, the residence was unable to provide a written practitioner's order for the medication.c. Trazodone The February 2023 MAR read in part, the resident was administered trazodone 50 mg once daily on 2/1-2/22/23, for a total of 22 doses. However, the residence was unable to provide a written practitioner's order for the medication.d. Sertraline The February 2023 MAR read in part, the resident was administered sertraline 50 mg once daily on 2/9-2/22/23, for a total of 14 doses. However, the residence was unable to provide a written practitioner's order for the medication.e. Escitalopram 10 mgThe February 2023 MAR read in part, the resident was administered escitalopram 10 mg once daily on 2/1-2/8/23, for a total of eight doses. However, the residence was unable to provide a written practitioner's order for the medication. On 2/23/23 at 12:18 p.m., the regional director of resident care stated the residence did not have any authorized practitioner's orders for Resident #21's medications. She stated the residence attempted to contact the practitioner in January 2023 and the resident's hospice provider in February 2023 for authorized practitioner's orders; however, orders were not provided. On 2/27/23 at approximately 1:21 p.m., the administrator acknowledged the residence administered Resident #21's medications without authorized practitioner's orders. She stated the residence should not have administered medications without authorized practitioner's orders.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting five of six sample residents (#18, #19, #22, #23, #24) and two of two former residents (#28 and #29). (Cross-reference Q1514)Findings include: 1. Resident #24 was admitted to the residence on 2/1/23.a. EliquisA written practitioner's order, dated 2/8/23, directed the residence to administer Eliquis 2.5 mg twice daily. However, the February 2023 MAR for Resident #24 read the medication was not available for the morning dose on 2/9 and 2/13, and for the evening dose on 2/9 and 2/10/23, for a total of four missed doses.b. MucinexA written practitioner's order, dated 2/15/23, directed the residence to administer Mucinex 600 mg twice daily. However, the February 2023 MAR for Resident #24 read the medication was not available for the morning dose on 2/18 and the evening dose on 2/19 and 2/20/23, for a total of three missed doses.c. BisacodylA written practitioner's order, dated 1/20/23, directed the residence to administer bisacodyl 5 mg once daily. However, the February 2023 MAR for Resident #24 read the medication was not available on 2/23/23, for a total of one missed dose. On 2/23/23 at 12:18 p.m., the regional director of resident care (RDRC) stated the residence should not have run out of Resident #24's medications. On 2/27/23 at approximately 1:30 p.m., the administrator stated the residence should not have stopped administering the medication before it was discontinued by the practitioner. 2. Resident #23 was admitted to the residence on 1/26/23 with diagnoses including dementia with behavioral disturbance. a. DivalproexA written practitioner's order, dated 2/1/23, directed the residence to administer divalproex 250 mg twice daily. However,the February 2023 MAR for Resident #23 read the medication was not available and not administered on 2/19 evening dose, 2/20, 2/21 and 2/22/22 morning and evening doses for a total of seven missed doses. b. DonepezilA written practitioner's order, dated 2/1/23, directed the residence to administer donepezil 5 mg once daily. However, the February 2023 MAR for Resident #23 read the medication was not available and not administered on 2/21 and 2/22/23 for a total of two missed doses. 3. Resident #18 was admitted to the residence on 11/19/19 with diagnoses including hypothyroidism and angina. a. LevothyroxineA written practitioner's order, dated 6/28/22, directed the residence to administer levothyroxine 88 mcg once daily. However, the August 2022 MAR for Resident #18 had blank spaces on 8/15 and 8/24/22. On 2/23/23 at 1:09 p.m., an external pharmacy representative (EPR) stated on 7/12/22 there was a 30 day supply of levothyroxine 88 mcg delivered to the residence. She added, it would have run out on 8/11/22. The EPR said the next time it was reordered was 8/23/22. The EPR confirmed that the levothyroxine 88 mcg was delivered to the residence on 7/13/22 at 4:27 p.m. The next delivery for levothyroxine 88 mcg was on 8/24/22 at 4:34 a.m. On 2/27/23 at 11:03 a.m., the family member of Resident #18 stated when the levothyroxine ran out on 8/11/22, the medication was not available and not in stock in August 2022 and as a result, Resident #18 did not receive her levothyroxine for approximately a week in August 2022. Another written practitioner's order, dated 10/14/22, directed the residence to discontinue levothyroxine 88 mcg and start levothyroxine 100 mcg once daily. However, the February 2023 MAR for Resident #18 read the medication was not available and not administered on 2/11 and 2/12/23 for a total of two missed doses.b. Metamucil Fiber GummiesA written practitioner's order, dated 8/16/22, directed the residence to administer Metamucil fiber once daily. However, the February 2023 MAR for Resident #18 read the medication was not available and not administered on 2/5/23.4. Former Resident #28 was admitted to the residence on 10/15/21.a. Acetaminophen A written practitioner's order, dated 9/1/22, directed the residence to administer acetaminophen 500 mg three times daily. However, the September 2022 MAR for Former Resident #28 read the medication was not on the MAR until 9/7 in the evening and not administered from 9/1 to 9/7/22 for a total of 18 missed doses. On 2/27/23 at 12:20 p.m., the RDRC said she expected the medication to be on the MAR and administered before 9/7/22 for Former Resident #28.b. OxycodoneA written practitioner's order, dated 9/1/22, directed the residence to administer oxycodone 5 mg twice daily. However, the September 2022 MAR for Resident #28 read the medication was not available and not administered on 9/4/22 morning dose. 5. Former Resident #29 was admitted to the residence on 7/16/20.a. Acidophilus A written practitioner's order, dated 8/22/22, directed the residence to administer acidophilus freeze dried capsule twice daily. However, the August and September 2022 MARs for Former Resident #29 read the medication was not available and not administered on 8/30/22 evening dose and 8/31/22 morning and evening dose, 9/1-9/4 morning and evening doses, 9/5 evening dose, 9/11 evening dose, 9/12-9/13 morning and evening dose, 9/20-9/21 morning and evening dose and 9/21/22 morning dose, for a total of 22 missed doses. b. MelatoninA written practitioner's order, dated 8/22/22, directed the residence to administer melatonin 5 mg once daily. However, the August 2022 MAR for Former Resident #29 read the medication was not available and not administered on 8/28-8/30/22 for a total of three missed doses. 6. Resident #19 was admitted to the residence on 7/25/22.a. FinasterideA written practitioner's order, dated 1/24/23, directed the residence to administer finasteride 5 mg once daily. However, the February 2023 MAR for Resident #19 read the medication was not available and not administered on 2/1/23.b. AspercremeA written practitioner's order, dated 1/24/23, directed the residence to administer Aspercreme 4% once daily. However, the February 2023 MAR for Resident #19 read the medication was not available and not administered on 2/23/23.c. Pataday Ophthalmic SolutionA written practitioner's order, dated 1/24/23, directed the residence to administer pasta ophthalmic solution 0.1% twice daily. However, the February 2023 MAR for Resident #19 read the medication as not available and not administered on 2/4/23. 7. Resident #22 was admitted to the residence on 11/4/22. A written practitioner order, dated 12/1/22, directed the residence to administer omeprazole 20 mg daily. However, the February 2023 MAR for Resident #22 read the medication was not available and not administered on 2/21 and 2/22/23, for a total of 24 missed doses. On 2/27/23 at 8:35 a.m., Staff #13 stated the residence should not have run out of Resident #22's medication. On 2/27/23 at approximately 12:45 p.m., the RDRC stated that if an MAR for a resident listed the medication as not available that meant the medication was not administered, as ordered. She added that medications were received monthly on a cycle fill and when medications were running low staff pulled the label on the medication and reordered the medication when three tablets remained. On 2/27/23 at 8:35 a.m., Staff #13 stated that it was not appropriate for the residence to run out of prescribed medications for residents. She added that qualified medication administration persons (QMAPs) were responsible for reordering medications when there was approximately a week left of tablets in the medication pack. On 2/27/23 at approximately 1:30 p.m., the administrator stated she expected QMAP staff to order medication when seven tablets remained. 8. InterviewOn 2/27/23 at approximately 1:30 p.m., the administrator stated it was not appropriate for the residence to run out of prescribed medications for residents.

Based on record review and interview, the administrator failed to, along with the qualified medication administration personnel (QMAP) supervisor, audit the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, and failed to investigate and resolve any irregularities, affecting six of six sample residents (#18, #19, #21, #22, #23, #24) and two of two former residents (#28, #29). (Cross-reference Q1430, Q1468)Findings include:On 2/27/23 at 8:48 a.m., a document titled Order Administration Tracking, dated 1/1-1/30/23, was provided. However, the document did not include the name of a QMAP supervisor nor documentation about the accuracy and completeness of the MARs, controlled substance list, medication error reports, medication disposal records, or investigations of any irregularities. Review of Resident #18, #19, #21, #22, #23, #24's February 2023 MAR's revealed the residence failed to comply with practitioner's orders. Additionally, the residence failed to comply with practitioner orders for Former Resident's #28's September 2022 MAR and #29's August MAR. On 2/27/23 at 10:04 a.m., the registered nurse (RN) consultant stated she was aware the residence was not in compliance with medication audits. On 2/27/23 at approximately 10:20 a.m., a medication audit completed by an external pharmacy was provided. On 2/27/23 at 1:21 p.m., the administrator stated the residence had an external pharmacy audit their medication carts. She stated the assisted living manager was the QMAP supervisor. The administrator added that she had not participated in a medication audit.