BETHESDA GARDENS LOVELAND

A licensure complaint, prompted by #CO41875 and #CO41597, was conducted on 3/31/26. Deficiencies were cited.

Based on a review of records and interviews, the residence failed to make the personal service of a system available to identify and report resident concerns that required an immediate, individualized approach, affecting one former sample resident (#10). (Cross-reference U2230)Specifically, on 2/2/26 at 7:27 p.m., emergency medical services (EMT) were contacted after Former Resident #10 (FR #10) had an unwitnessed fall. According to the EMT report, the resident reported head and back pain, and her vitals were taken. Former Resident #10's medical durable power of attorney (MDPOA) did not want the resident to be transported to the hospital. EMS inform residences staff of the risks of refusing and tells them the signs and symptoms to watch for. The residence staff signs the refusal form. FR#10 was to have Head Injury Checks every two hours. The checks were not done on 2/3/26 at 10:00 p.m. and 2/4/26 at 6:00 a.m., 2:00 p.m., and then retracted their answers at a later unknown date. The health services director (HSD) said staff were not required to wake up the resident at night to perform head injury checks. The instructions were to call 911 if any of the questions were answered yes. Questions included: Does the resident have any new unusual weakness in legs and arms? Has the resident vomited? Are you unable to wake the resident completely? Does the resident have trouble answering these questions: Who are you, and what happened to you? On 2/3/26 at 11:14 a.m., a progress note documented the resident was nauseous and asked for a bucket to vomit in and could not fully sit up. On 2/3/26 at 5:37 p.m., FR#10's family requested that the resident be sent to the hospital. EMS arrived and reported the resident was disoriented, not oriented to time, and was lethargic. Family members stated to EMS they discovered the patient approximately 30 minutes before EMS arrival and reported she had been unarousable during that time. The resident was transported to the hospital. There she was put in hospice and passed away from heart failure. Findings Include:The residence's "Fall Recovery" policy, updated 4/30/24, read in part: "4. If the Resident is confused, shaky, or shows signs of weakness, pain, or dizziness, call 911. Stay with the Resident. Do not raise the Resident's head as they might have a neck or back injury. Wait for Emergency Medical Services to check/assess for injury. 7. If the Resident hit their head, complete the Head Injury Check Form. Check the resident's alertness and vital signs every shift for 72 hours post fall and document in Resident's medical record."An emergency medical services (EMS) report for FR#10 dated 2/2/6 at 7:27 p.m. read in part: "Upon arrival, responders are met in the lobby by facility staff. Paperwork is obtained. Facility staff states that pt had an unwitnessed fall. Facility staff escorts responders up to pt's room. Pt is lying supine on the carpet floor between her bed and her dresser, accompanied by facility staff. Upon pt contact, pt states that she was coming back from changing her thermostat when she fell, hitting her head on the wall. Pt states that her head hurts and her back hurts. Pt consents to assessment. During assessment, pt's vitals are obtained, and a physical assessment is done. Pt is informed of the responder's findings. Pt states she does not want to go to the hospital and just wants help up. Pt is assisted to a standing position via 2-person underarm pick up to a standing position and sat in her wheelchair. Pt states she needs to use the restroom. Pt is wheeled into the restroom and evaluated, transferring without assistance to the toilet. Pt's MDPOA is contacted and informed of responders' findings. MDPOA states that pt recently had her blood pressure medication increased. MDPOA states that she does not want pt transported for further evaluation. MDPOA, pt, and facility staff are informed of the risks of refusing further evaluation at the hospital. Pt and facility staff are informedof signs and symptoms to watch for. Pt and facility staff understand, and facility staff sign the refusal form. Pt is evaluated ambulating back to her bed without assistance. Pt and facility staff are informed to call back or seek medical attention if necessary." A progress note dated 2/2/26 at 9:43 p.m., read in part: FR#10 had an unwitnessed fall when getting up to check the temperature of the room. She suffered a head injury to the back of the head, felt dizzy, and nauseous. Staff contacted emergency medical services (EMS), took his blood pressure (BP), and reported his oxygen saturation (02) level as "low". EMS consulted with FR#10 and FR#10's medical durable power of attorney (MDPOA), who decided not to take FR#10 to the emergency department (ED). A "Head Injury Checks" (HICs) form was completed for FR#10. The HICs form directed staff to check on 2/2/26 at 11:00 p.m. On 2/3/26 at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 10:00 p.m. On 2/4/26 at 6:00 a.m. and 2:00 p.m. A review of the HICs revealed that Staff #6 documented "No" on 2/3/26 at 10:00 p.m. and 2/4/26 at 6:00 a.m., 2:00 p.m., and then retracted their answers at a later unknown date. Review of the HICs revealed that during each check, staff were directed to "Answer each question with yes or no and initial at the bottom any time a Resident hits their head. Any question that is answered yes, staff are to call 911, nurse, or physician immediately." Questions included: Does the resident have any new unusual weakness in legs and arms?, has the resident vomited, Unable to wake the resident completely? Does the resident have trouble answering these questions: Who are you, and what happened to you?A review of the staff schedule revealed that Staff #2 worked the morning shift on 2/3/26 from 6:00 a.m. to 2:00 p.m. A progress note dated 2/3/26 at 11:14 a.m., completed by Staff #2, read: "[FR#10] refused all of her 9:00 a.m. medications on this day, she stated, 'I'm hurting all the time, I don't feel good, I'm still constipated, Did you know that?' Staff stated, ' I have your [buprenorphine buccal film] and acetaminophen for pain, and I can get you something for constipation. ' She then stated, ' Those don't work; I need something to vomit in. ' I handed her a trash bin to use. I also offered her [as needed] [ondansetron]. She refused as well. Multiple attempts were made to administer medications, and she still refused. The health services director (HSD), MDPOA, and [external hospice provider] were notified."A progress note dated 2/3/26 at 5:37 p.m., completed by Staff #6, read in part: "Resident's family requested that EMS be called due to the resident not responding to questions normally and not taking any medications for the whole day or eating any meals. I went in and checked the resident's BP, which was low for the resident. The family determined it was best to call EMS. EMS came and recorded her O2 [also low]. They suggested it would be best to take her out. They sent her to the ED. The family was very upset that they weren't notified about each refusal the resident had."An EMS report for FR#10 dated 2/3/26 at 5:37 p.m. read in part: "Upon arrival on scene at a large assisted living facility, the crew was met by facility staff and escorted to the patient's room. The patient was found lying on her left side on her bed. The patient was responsive to verbal stimuli, disoriented, lethargic, and in no apparent distress. Facility staff reported the patient was last seen at her baseline at approximately 2000 hours the previous evening. Family members stated they discovered the patient approximately 30 minutes before EMS arrival and reported she had been unarousable during that time. Due to the patient's presenting condition, the paramedic performed a full assessment and obtained a set of vital signs. Oxygen therapy was initiated, IV access was established, and both 3-lead and 12-lead EKGs were acquired. The patient was identified as having a valid Do Not Resuscitate / Do Not Intubate order with comfort care or treatment only. The paramedic located the DNR documentation and spoke directly with the patient's medical power of attorney, who had signed the DNR on the patient's behalf. The medical power of attorney stated she wished to honor the DNR/DNI but requested treatment, including oxygen and IV medications as appropriate. Following initiation of oxygen therapy in the patient's bedroom, the patient demonstrated an abrupt improvement in mental status as oxygen saturation increased from the 60s to the high 90s. The patient remained lethargic and not oriented to time. She denied other complaints at that time and initially refused treatment and transport. After discussion with family, the patient agreed to treatment and transport to the hospital. The patient was assisted and lifted onto the stretcher and moved to the ambulance. The crew initiated transport to the receiving facility."A primary care practitioner's (PCP) note for FR#10 dated 2/4/26 at 3:50 p.m. indicated that FR#10 had been admitted to the hospital for inpatient care. A progress note dated 2/5/26 at 10:37 a.m., completed by the HSD, read: "Spoke with [MDPOA] on this day, was told that resident was placed on hospice at [the hospital]. Is not doing well. Will reach back out for an update at a later date."A progress note dated 2/9/26 at 6:39 p.m., completed by the administrator, read: "[MDPOA] notified us that [FR#10] had passed away at the hospital due to heart failure."An interview with Staff #3 on 3/31/26 at 12:00 p.m. revealed that the staff did not complete the full HICs when completing the HICs form. She explained that the outgoing staff reported to her that FR#10 did not want to be awakened. Staff #3 stated that she did look for bleeding and breathing. Staff #2 stated in an interview on 3/31/26 at 12:20 p.m. that when she went in to check on FR#10, she tried multiple times to "get her up". She added that FR#10 reported feeling nauseous but could not vomit, would only eat some crackers, and was not able to "sit all the way up". Additionally, Staff #4 confirmed that she did not work at 4:00 p.m. and was unaware of when FR#10 went to the hospital. An interview with the HSD on 3/31/26 at 2:26 p.m. revealed that the times indicated by the form were approximations of the times when staff would have checked on FR#10, and that overnight staff were not required to wake the resident to perform the full check. She explained that the HIC form was from "corperete" and she had directed staff to perform visual checks for any obvious abnormalities. She confirmed that Staff #2 could not have performed and documented the 4:00 p.m. check because her shift ended at 2:00 p.m. She explained that the staff could have documented this by mistake, adding that Staff #6 also most likely completed the documentation by mistake. Additionally, the HSD stated that there was no way to confirm if a check was performed between 12:00 p.m. and 5:00 p.m. before FR#10 went out to the hospital, adding that a staff member should have checked in that time frame. Finally, the HSD confirmed that between 12:00 p.m. and 5:00 p.m., FR#10's status must have declined by an observable degree, and there should have been a progress note, adding that she should have been informed of the status reported by Staff #2 in the progress note on 2/3/26 at 11:14 a.m. The administrator stated in an interview on 3/31/26 at 3:55 p.m. that she could not confirm if staff were directed to perform HICs on FR#10, but could confirm that this was the standard protocol. She agreed that staff should immediately report any changes in the condition of a resident to the HSD unless it is immediately apparent that EMS should be contacted. She agreed that because Staff #2 did not report to the HSD, the resident's concerns, the personal service of a system of identification and reporting resident concerns that required an immediate individualized approach was not provided. The administrator added that FR#10 had "ups and downs"; she explained that FR#10 often refused medications, was resistant to care, was combative with staff, and complained of pain frequently; "upon one encounter, that would not necessarily be alarming for FR#10 to the staff." Finally, "I don't think they failed to report something that would be urgent or not out of the ordinary because this was the norm for FR#10."

Based on records review and interviews, the residence failed to update the comprehensive assessment when the resident's condition changed from baseline status, affecting one former sample resident (#10). (Cross-reference U1150 & U2230)Findings Include:The residence's "Falls Management" policy, updated 4/30/24, read in part: "11. Functional Assessment & Fall Risk Assessment: Completed for any Resident upon admission, annually, and updated after a fall."A review of the resident records revealed that Former Resident #10 (FR#10) was admitted to the residence on 1/17/25 with diagnoses of dementia in other diseases classified elsewhere without behavioral disturbance; hypertension; Alzheimer's disease; hyperlipidemia; other migraine, not intractable, without status migrainosus; unspecified mood (affective) disorder; other hereditary and idiopathic neuropathies; chronic pain syndrome; insomnia, unspecified. The comprehensive assessment for FR#10 was completed on 12/27/25 and indicated that she had had 'one fall a year ago". In an interview with the health services director (HSD) on 3/31/26 at 2:26 p.m., she confirmed that FR#10's fall with head injury constituted a change in her condition, as falls were not common. The administrator, in an interview on 3/31/26 at 3:35 p.m., agreed that FR#10's fall with head injury constituted a change in condition, adding that she was not sure if that would be a change in her baseline status. The administrator confirmed that she was aware of the requirement to update the comprehensive assessment each time the resident experienced a change in condition from baseline status.

Based on a review of records and interviews, the residence failed to ensure that each resident's care plan detailed specific personal service needs and the staff tasks necessary to meet them, affecting one current (#9) and one former (#10) sample resident. (Cross-reference U1146 & U2230)Findings Include:A review of the resident records revealed that Resident #9, admitted 11/24/25, and Former Resident #10 (FR#10), admitted 1/17/25, included care plans last updated 2/24/26 and 12/27/25, respectively. Review of the care plan for Resident #9 revealed no evidence of documented, detailed resident-specific interventions addressing multi-staff-assisted, verbal aggression, resistance to care, and incontinence care complications. Additionally, there was no evidence of clearly defined staff responsibilities or task assignments necessary to implement such interventions. Review of the progress notes from 2/1/26 to 3/31/26 revealed 35 entries indicating Resident #9 was resistant to care and verbally aggressive to staff. Also, revealing consistent incontinence care required with multiple attempts to assist being refused. On progress note dated 2/27/26 at 2/27/26 indicated that Resident #9 had a fall and staff had to contact emergency medical services (EMS) to assist with lifting the resident. Review of the care plan for FR#10 revealed no evidence of detailed, specific needs related to resistance to care, refusal of medications, and "ups and downs," nor "continuous complaints of pain" were found. Review of the progress notes from 1/4/26 to 2/9/26 revealed four entries indicating FR#10 had refused medications, complained of pain, or was resistant to care. An interview with Staff #5 on 3/31/26 at 8:00 a.m. revealed that Resident #9 required multi-staff assistance in most care situations. She explained that Resident #9 was a "bigger lady" and very resistant to care, "we had to call EMS to lift her because three of us couldn't do it". The administrator stated in an interview on 3/31/26 at 3:55 p.m. FR#10 had "ups and downs"; she explained that FR#10 often refused medications, was resistant to care, was combative with staff, and complained of pain frequently; "upon one encounter, that would not necessarily be alarming for FR#10 to the staff. On 3/31/26 at 4:29 p.m., the administration confirmed in an interview that neither Resident #9 nor FR#10's care plans included the specific details about their resistance to care, refusal of medications, and other behaviors. She also confirmed that the care plans did not include the specific staff tasks that would be required to effectively provide necessary care to residents.

Based on records review and interviews, the residence failed to ensure that the resident's record contained progress notes that included information on the resident's status and well-being, and any out of the ordinary event or issue that affected the resident's physical condition, personally observed or was reported to staff, affecting one former sample resident (#10). (Cross-reference U1110, U1146, U1150)Findings Include:The residence's "Fall Recovery" policy, updated 4/30/24, read in part: "7. If the Resident hit their head, complete the Head Injury Check Form. Check the resident's alertness and vital signs every shift for 72 hours post fall and document in Resident's medical record."A progress note dated 2/2/26 at 9:43 p.m., read in part: Former Resident #10 (FR#10) had an unwitnessed fall when getting up to check the temperature of the room. She suffered a head injury to the back of the head, felt dizzy, and nauseous. A "Head Injury Checks" (HICs) form was completed for FR#10. The HICs form directed staff to check on 2/2/26 at 11:00 p.m. On 2/3/26 at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., and 10:00 p.m. On 2/4/26 at 6:00 a.m. and 2:00 p.m. A review of the HICs revealed that Staff #6 documented "No" on 2/3/26 at 10:00 p.m. and 2/4/26 at 6:00 a.m., 2:00 p.m., and then retracted their answers at a later unknown date. Review of the HICs revealed that during each check, staff were directed to "Answer each question with yes or no and initial at the bottom any time a Resident hits their head. Any question that is answered yes, staff are to call 911, nurse, or physician immediately." On 2/3/26 at 4:00 p.m., Staff #2 signed off "No" on nine assessment points from "any blood or watery fluid from nose or ears?" to "does Resident have trouble answering these questions: What is your name? What happened to you?" A review of the staff schedule revealed that Staff #2 worked the morning shift on 2/3/26 from 6:00 a.m. to 2:00 p.m. A progress note dated 2/3/26 at 11:14 a.m., completed by Staff #2, read in part: [FR#10] refused all of her 9:00 a.m. medications and stated, "I'm hurting all the time, I don't feel good, I'm still constipated, Did you know that?" Staff offered FR#10 her medications, to which she said, "Those don't work; I need something to vomit in." Staff provided a trash bin to use. Additionally, the staff noted that the health services director (HSD), MDPOA, and [external hospice provider] were notified."Staff #2 stated in an interview on 3/31/26 at 12:20 p.m. that when she went in to check on FR#10, she tried multiple times to "get her up". She added that FR#10 reported feeling nauseous but could not vomit, would only eat some crackers, and was not able to "sit all the way up". Additionally, Staff #4 confirmed that she did not work at 4:00 p.m. and was unaware of when FR#10 went to the hospital. An interview with the HSD on 3/31/26 at 2:26 p.m. confirmed that Staff #2 could not have performed and documented the 4:00 p.m. check because her shift ended at 2:00 p.m. She explained that the staff could have documented this by mistake, adding that Staff #6 also most likely completed the documentation by mistake. The HSD confirmed that between 12:00 p.m. and 5:00 p.m., FR#10's status must have declined by an observable degree, and there should have been a progress note, adding that she should have been informed of the status reported by Staff #2 in the progress note on 2/3/26 at 11:14 a.m. The administrator agreed in an interview on 3/31/26 at 3:35 p.m. that staff are required to document anything out of the ordinary about the resident's status. She was unable to confirm if FR#10 had a decline in status between 12:00 p.m. and 5:00 p.m. on 2/3/26. She agreed that if an observable change had been noticed by staff, that observation should have been documented. Finally, the administrator confirmed that Staff #3 could not have completed the HIC's on 2/3/26 at 4:00 p.m. because she only worked from 6:00 a.m. to 2:00 p.m.

A revisit survey was completed on 8/29/24 for all previous deficiencies cited on 6/26/24. The facility is in compliance with all deficiencies that were cited.

A relicensure survey with complaints #CO34605, #CO36206 and #CO36471, was completed on 6/26/24. Deficiences were cited.

Based on interview and record review, the residence failed to accurately document each medication administration at the time the event was completed for each resident, affecting one of three sample residents whose medications were reviewed (#2). Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated 5/26/22 read in part: "record in the designated area on the medication administration record (MAR) by the following means: initials (mean) given ... on the back of the MAR, note if (a medication) was held, refused, or sent along with a resident."2. Resident #2 was admitted to the residence on 5/26/21 with diagnoses that included osteoarthritis and chronic obstructive pulmonary disease. a. AlbuterolA written practitioner's order, dated 3/12/24, directed the residence to administer albuterol 90 mcg/act two puffs by mouth four times daily. However, the June 2024 electronic medication administration record (eMAR), contained a blank space on 6/16/24 for the 12:00 p.m. dose, for a total of one inaccurately documented dose.b. Calcium Carbonate/Vitamin D3A written practitioner's order, dated 3/12/24, directed the residence to administer calcium carbonate/vitamin D3 600 mg daily. However, the June 2024 eMAR, contained a blank space on 6/16/24, for a total of one inaccurately documented dose. 3. InterviewOn 6/26/24 at 2:10 p.m., the administrator stated a blank space in the eMAR meant a qualified medication administration person did not accurately record whether the medication was administered. The administrator stated she would have expected staff to have recorded on Resident #2's eMAR at the time of the administration event.

Based on interview and record review, the residence failed to ensure the administrator and qualified medication administration persons supervisor audited the accuracy and completeness of the medication administration records affecting 105 current residents. 1. Record review On 6/26/24, documentation of weekly medication audits revealed the resident care coordinator completed weekly medication audits but the administrator did not participate at all. 2. InterviewOn 6/26/24 at approximately 2:15 p.m., the administrator said took the administrator position on April 2024. She said she had not participated in a medication audit since she became the administrator. The administrator said she did not have evidence that the former administrator participated in quarterly medication audits. The administrator was unable to state why the former administrator did not document quarterly medication audits.

A revisit survey was completed on 3/12/24 for all previous deficiencies cited on 8/28/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 3/12/24 for all previous deficiencies cited on 8/28/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 3/12/24 for all previous deficiencies cited on 8/28/23. The facility is in compliance with all deficiencies that were cited.

A licensure revisit was completed on 8/28/23 for all previous deficiencies cited on 11/10/22. 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 sample residents (#20). (Cross-reference Q1514)This deficiency was cited previously during a state relicensure survey 6/9/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence Policiesa. The residence's Medication Administration Error policy, dated 2/21/13, read, in part that a medication error included when a drug was not dispensed. Notification of the non-compliance included omission of a drug for which the reason and justification was not documented, and physician orders were implemented. b. The residence's medication System policy, dated 1/1/15, read, "New medication will be delivered as soon as possible to the lawfully authorized staff on duty. The staff will check the medication against the physician's order for accuracy in labeling." 2. Resident #20 was admitted to the residence on 7/2/18. A written practitioner's order, dated 8/15/23, directed the residence to administer senna plus 8.6 twice daily. However, the August 2023 electronic medication administration record (eMAR) for Resident #20 read the medication was not available and not administered on 8/23 evening dose, 8/24-8/27 both doses and 8/28/23 morning dose, for a total of 10 missed doses. Progress notes for August 2023 for Resident #20 revealed the following:8/21/23: "Senna not sent out in cycle fill, (practitioner) informed."8/28/23: "Still have not received missing cycle medication, senna for BID (twice daily) dosing."On 8/28/23 at approximately 2:00 p.m., the health service director (HSD) acknowledged that the medication was not available and not administered, as required.

A licensure revisit was completed on 8/28/23 for all previous deficiencies cited on 6/9/22. Deficiencies were cited.

Based on record review and interview, the residence failed to update the comprehensive assessment for each resident whenever the resident's condition changed from baseline status, affecting one sample resident (#20). This deficiency was cited previously during a state relicensure survey 6/9/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's Functional Assessments policy, dated January 1, 2013 read in part, functional assessments were to be completed every three months until there was no change in level of care for two consecutive assessments, then the assessment was to be reviewed every six months, upon change in condition or after hospitalization. 2. Resident #20 was admitted to the residence on 7/2/18. Progress notes for Resident #20's for June and July 2023 revealed the following:6/20/23: Resident #20 was observed on the floor next to her kitchen table. Resident #20 complained of extreme pain in her left arm. 7/6/23: Resident #20 was transferred to an inpatient rehabilitation (rehab) facility. 7/7/23: Resident #20 was planned to be discharged back to the residence on 7/17/23. 7/17/23: Resident #20 returned to the residence from rehab due to a fractured left elbow. 7/18/23: Resident #20 unable to check her own glucose levels. There was no updated comprehensive assessment in the record for Resident #20 after she returned from rehab on 7/17/23. Additional progress notes for Resident #20 in July and August 2023 revealed the following:7/28/23: Unable to do her own blood sugars as of 7/28/23. 8/2/23: Resident #20 was out of her sling, walking independently and able to do her own insulin checks. There was no evidence in the record for Resident #20 of an updated comprehensive assessment after 7/28/23.3. InterviewsOn 8/28/23 at approximately 2:00 p.m., the health service director (HSD) stated Resident #20 was not ready to return to the residence on 7/17/23 because she required more assistance with activities of daily living and should not have been discharged from rehab back to the residence. She added, Resident #20 was unable to use her left arm when she returned to the residence on 7/17/23, used a sling and she was unable to perform her own blood sugar checks. The HSD confirmed she did not complete a change in condition assessment upon Resident #20's return from rehab on 7/17/23. On 8/28/23 at approximately 4:15 p.m., the administrator stated that an assessment was not completed when Resident #20 returned from rehab on 7/17/23.

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 sample residents (#20). (Cross-reference Q1514)This deficiency was cited previously during a state relicensure survey 6/9/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence Policiesa. The residence's Medication Administration Error policy, dated 2/21/13, read, in part that a medication error included when a drug was not dispensed. Notification of the non-compliance included omission of a drug for which the reason and justification was not documented, and physician orders were implemented. b. The residence's medication System policy, dated 1/1/15, read, "New medication will be delivered as soon as possible to the lawfully authorized staff on duty. The staff will check the medication against the physician's order for accuracy in labeling." 2. Resident #20 was admitted to the residence on 7/2/18. A written practitioner's order, dated 8/15/23, directed the residence to administer senna plus 8.6 twice daily. However, the August 2023 electronic medication administration record (eMAR) for Resident #20 read the medication was not available and not administered on 8/23 evening dose, 8/24-8/27 both doses and 8/28/23 morning dose, for a total of 10 missed doses. Progress notes for August 2023 for Resident #20 revealed the following:8/21/23: "Senna not sent out in cycle fill, (practitioner) informed."8/28/23: "Still have not received missing cycle medication, senna for BID (twice daily) dosing."On 8/28/23 at approximately 2:00 p.m., the health service director (HSD) acknowledged that the medication was not available and not administered, as required.

Based on record review and interview, the administrator failed to, along with the qualified medication administration person (QMAP) supervisor, audit and document the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting six of six sample residents ( #13, #19, #20-#22, #27). ((Cross-reference Q1468)This deficiency was cited previously during a state relicensure survey 6/9/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 8/28/23 at 9:35 a.m., the health services director (HSD) stated she and the resident care coordinators were responsible for physically auditing the medication carts. Additionally, she confirmed that she was unaware the administrator was required to participate in the physical audits of medication carts and that the administrator had not done so. On 8/29/23 at 2:15 p.m., Resident Care Coordinator #1 stated the audits had been done quarterly by herself and HSD, and the administrator had not participated. On 8/28/23 at approximately 4:00 p.m., HSD stated resident care coordinator #2, one of the residence's qualified medication supervisor (QMAP) supervisors, had completed the medication audits with her. On 8/28/23 at 4:45 p.m., the administrator stated that she did not go to the carts physically to participate in the audits but simply looked over the audit findings. Further, she stated she was unaware of the regulation that the administrator and QMAP supervisor must, in tandem, complete the medication audits each quarter.

A licensure revisit was completed on 8/28/23 for the previous deficiency cited on 6/9/22. The residence is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO31287, #CO32341, #CO32745, #CO33010 was completed on 8/28/23. Deficiencies were cited.

Based on record review and interview, the residence failed to update the comprehensive assessment for each resident whenever the resident's condition changed from baseline status, affecting one sample resident (#20). Findings include:1. Residence PolicyThe residence's Functional Assessments policy, dated January 1, 2013 read in part, functional assessments were to be completed every three months until there was no change in level of care for two consecutive assessments, then the assessment was to be reviewed every six months, upon change in condition or after hospitalization. 2. Resident #20 was admitted to the residence on 7/2/18. Progress notes for Resident #20's for June and July 2023 revealed the following:6/20/23: Resident #20 was observed on the floor next to her kitchen table. Resident #20 complained of extreme pain in her left arm. 7/6/23: Resident #20 was transferred to an inpatient rehabilitation (rehab) facility. 7/7/23: Resident #20 was planned to be discharged back to the residence on 7/17/23. 7/17/23: Resident #20 returned to the residence from rehab due to a fractured left elbow. 7/18/23: Resident #20 unable to check her own glucose levels. There was no updated comprehensive assessment in the record for Resident #20 after she returned from rehab on 7/17/23. Additional progress notes for Resident #20 in July and August 2023 revealed the following:7/28/23: Unable to do her own blood sugars as of 7/28/23. 8/2/23: Resident #20 was out of her sling, walking independently and able to do her own insulin checks. There was no evidence in the record for Resident #20 of an updated comprehensive assessment after 7/28/23.3. InterviewsOn 8/28/23 at approximately 2:00 p.m., the health service director (HSD) stated Resident #20 was not ready to return to the residence on 7/17/23 because she required more assistance with activities of daily living and should not have been discharged from rehab back to the residence. She added, Resident #20 was unable to use her left arm when she returned to the residence on 7/17/23, used a sling and she was unable to perform her own blood sugar checks. The HSD confirmed she did not complete a change in condition assessment upon Resident #20's return from rehab on 7/17/23. On 8/28/23 at approximately 4:15 p.m., the administrator stated that an assessment was not completed when Resident #20 returned from rehab on 7/17/23.

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 sample residents (#20). (Cross-reference Q1514)Findings include:1. Residence Policiesa. The residence's Medication Administration Error policy, dated 2/21/13, read, in part that a medication error included when a drug was not dispensed. Notification of the non-compliance included omission of a drug for which the reason and justification was not documented, and physician orders were implemented. b. The residence's medication System policy, dated 1/1/15, read, "New medication will be delivered as soon as possible to the lawfully authorized staff on duty. The staff will check the medication against the physician's order for accuracy in labeling." 2. Resident #20 was admitted to the residence on 7/2/18. A written practitioner's order, dated 8/15/23, directed the residence to administer senna plus 8.6 twice daily. However, the August 2023 electronic medication administration record (eMAR) for Resident #20 read the medication was not available and not administered on 8/23 evening dose, 8/24-8/27 both doses and 8/28/23 morning dose, for a total of 10 missed doses. Progress notes for August 2023 for Resident #20 revealed the following:8/21/23: "Senna not sent out in cycle fill, (practitioner) informed."8/28/23: "Still have not received missing cycle medication, senna for BID (twice daily) dosing."On 8/28/23 at approximately 2:00 p.m., the health service director (HSD) acknowledged that the medication was not available and not administered, as required.

Based on record review and interview, the administrator failed to, along with the qualified medication administration person (QMAP) supervisor, audit and document the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting six of six sample residents ( #13, #19, #20-#22, #27). ((Cross-reference Q1468)Findings include:On 8/28/23 at 9:35 a.m., the health services director (HSD) stated she and the resident care coordinators were responsible for physically auditing the medication carts. Additionally, she confirmed that she was unaware the administrator was required to participate in the physical audits of medication carts and that the administrator had not done so. On 8/29/23 at 2:15 p.m., Resident Care Coordinator #1 stated the audits had been done quarterly by herself and HSD, and the administrator had not participated. On 8/28/23 at approximately 4:00 p.m., HSD stated resident care coordinator #2, one of the residence's qualified medication supervisor (QMAP) supervisors, had completed the medication audits with her. On 8/28/23 at 4:45 p.m., the administrator stated that she did not go to the carts physically to participate in the audits but simply looked over the audit findings. Further, she stated she was unaware of the regulation that the administrator and QMAP supervisor must, in tandem, complete the medication audits each quarter.

Based on record review and interview, the residence failed to ensure resident records contained progress notes regarding any out-of-the-ordinary event or issue that affected a resident's physical, behavioral, cognitive, and/or functional condition, along with the action taken by staff to address that resident's changing needs, affecting one sample resident (#20). Findings include:Resident #20 was admitted to the residence on 7/2/18. Progress notes for Resident #20 in July and August 2023 revealed the following:7/17/23: Resident #20 returned to the residence today from a rehabilitation (rehab) stay for fractured elbow. 7/18/23: Resident #20 was unable to check her own blood glucose levels. 7/28/23: "We still do not have an anticipated return date fir (sic) (Resident #20)."8/7/23: Resident #20 returned to the residence. On 8/28/23 at 2:06 p.m., the health services director (HSD) said Resident #20 was sent back to a rehab facility after her initial return to the residence on 7/17/23 because she was still unable to check her blood sugar levels and her arm was in a sling. She added she was not at the residence when Resident #20 returned in August 2023 but expected residence staff to have documented a progress note when the resident returned and confirmed they had not. On 8/28/23 at 4:15 p.m., the administrator stated she would expect a progress note or reason why Resident #20 was not in the residence.