S&S MEMORY CARE ASSISTED LIVING LLC

An administrative relicensure survey was completed on 2/24/26. No deficiencies were cited.

A revisit survey was completed on 8/2/24 for all previous deficiencies cited on 12/21/23. The facility is in compliance with all deficiencies that were cited.

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

A revisit survey was completed on 8/2/24 for all previous deficiencies cited on 12/21/23. The facility is in compliance with all deficiencies that were cited.

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

A recertification survey was completed on 12/21/23. Deficiences were cited.

Based on observation, record review and interview, the facility (residence) failed to not use restraints of any kind for the purposes of care or safety, affecting one of three sample participants (residents) (#3) that had been restrained since September 2023. 1. References a. Chapter VII regulations governing assisted living residences, part 2.42, defines "Restraint" as any method or device used to involuntarily limit freedom of movement including, but not limited to, bodily physical force, mechanical devices, chemicals or confinement.b. Chapter VII regulations governing assisted living residences, reads in part 12.14 that a device that facilitates a resident's well-being and/or independence may be used only if all of the following criteria are met:(A) The resident has the functional ability to alter his or her position;(B) The resident is able to remove the device to allow for normal movement;(C) The device improves the resident's physical or emotional state and allows the resident to participate in activities that would otherwise be difficult or impossible; and(D) There is an order from a practitioner for its use.(1) There shall also be interdisciplinary documentation from both the practitioner and a therapist describing the benefits and hazards associated with the device and information on its appropriate use.(2) A resident's continued use of such device shall be re-evaluated by both therapist and practitioner at least annually or whenever the resident experiences a significant change in status.(3) Documentation of compliance with this subpart (D) shall be retained in the resident's care plan.c. According to The National Consumer Voice, "Bed rails are frequently used in homes or long-term care facilities because they are believed to keep people safe. In reality, bed rails can be extremely harmful. Bed rails can cause strangulation or asphyxiation ... severe injury ... " The National Consumer Voice for Quality Long-Term Care (2022), retrieved from: https://theconsumervoice.org/issues/other-issues-and-resources/dangers-of-bed-rails#:~:text=Bed%20rails%20are%20frequently%20used,bed%20rail%20and%20the%20mattress. 2. Resident #3 was admitted to the residence on 2/18/23 with diagnoses including Alzheimer's Disease.a. ObservationOn 12/21/23 at approximately 8:30 a.m., Resident #3's hospital bed had a bed rail on the left side and the right side of Resident #3's bed was pushed against the wall which hindered Resident #3 from being able to move freely. On 12/21/23 at approximately 1:36 p.m., when prompted Resident #3 was unable to get out of bed or move the bed rail himself. b. Record ReviewThe residence's comprehensive assessment for Resident #3, dated 5/24/23, read Resident #3 was independent with all transfers, required two hour safety checks and had no devices for mobility or walking. The residence's care plan, which was also the residence's assessment for Resident #3 dated 9/21/23, read Resident #3 required full hands on and verbal assistance with ambulation needs, used a wheelchair and had a practitioner's order for restraints. However, no evidence of a practitioner's order for restraints was provided. Further, there were no additional falls since 8/24/23 since in September 2023 the bed rail restraint was put in place. c. InterviewsOn 12/21/23 at 8:28 a.m., Resident #3 stated he was unsure as to why his bed rail was up and did not remember how long the bed side rail had been up. On 12/21/23 at 1:36 p.m., the family member for Resident #3 stated the bed rail was put in place so Resident #3 did not fall out of bed and she was happy with it. She further stated the resident was not able to get up out of the bed on his own with the rail up or lower the rail on his own. The family member stated she was informed by Staff #3 that the Resident #3 had attempted to get out of bed the day of the onsite investigation; however, she did not want him getting up since the resident was too weak. On 12/21/23 at approximately 1:37 p.m., the external hospice nurse stated the bed rail was put in place by hospice on 9/26/23 for Resident #3 due to him having falls, and felt it would be beneficial for his safety. On 12/21/23 at 1:44 p.m., the administrator stated that Resident #3 would be unable to get up out of the bed due to the bed rail and since she tightened it down so he could not get up. The administrator stated tightening the bed rail "did not stop him from trying to get up." She further stated the family member and external hospice nurse put the bed rail in place to keep Resident #3 safe and stop him from falling and stated that the resident had not fallen since the bed rail was put in place. The administrator stated she had no documentation of an order for restraints or any rights modifications; however, was aware of the requirement. On 12/21/23 at approximately 2:36 p.m., the administrator stated bed rails were put in place for Resident #3 as an intervention following his falls, and stated the resident had not fallen since the bed rails were put in place. The administrator further stated she understood the safety risk of bed rails and stated risks she was aware of included Resident #3 getting body parts caught in the bed rail. The administrator stated she was unsure what to do since both Resident #3's family member and external hospice nurse wanted Resident #3 to have a bedrail.

Based on record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting three of three sample participants (residents) (#1-#3). Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.29, requires each qualified medication administration person, nurse, or practitioner to accurately document each medication administration or monitoring event at the time the event is completed for each resident. The residence's undated Medication Administration policy, read in part: "each qualified medication administration person shall accurately document each medication administration or monitoring event at the time it is completed for each resident."Resident #2 was admitted to the residence on 1/1/21 with a diagnosis of Dementia. AcetaminophenA written practitioner's order dated 3/22/22 directed the residence to administer acetaminophen 500 mg two tablets three times daily. The December 2023 electronic medication administration record (eMAR) had blank spaces for both the morning and afternoon dose on 12/7/23. OmeprazoleA written practitioner's order dated 3/22/22 directed the residence to administer omeprazole 40 mg two tablets once daily. The December 2023 eMAR had a blank space on 12/7/23. MethimazoleA written practitioner's order dated 3/22/22 directed the residence to administer methimazole 5 mg one and a half tablets once daily. The December 2023 eMAR had a blank space on 12/7/23. There was similar deficient practice for Residents #1 and #3. On 12/21/23 at 3:04 p.m., the administrator stated the blank spaces in the eMAR meant that staff did not sign off their initials at the time of administration as required. The administrator stated she was aware of the requirement for staff to initial at the time of administration and would have expected staff to have done so. 2. Chapter VII regulations governing assisted living residences, part 14.11, requires only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. The residence's undated Medication Administration policy, read in part: "all medication orders shall be documented in writing."A. Resident #2 was admitted to the residence on 1/1/21 with a diagnosis of Dementia. The December 2023 electronic medication administration record (eMAR) read the residence administered medications to Resident #2 as follows:Morphine sulfate 20 mg three times daily on 12/1-12/6, in the afternoon on 12/7 and 12/8-12/20/23. Lorazepam 0.25 mg once at bedtime on 12/1-12/20/23. Seroquel 25 mg once daily on 12/1-12/20/23. Thick it solution nectar-honey thick three times daily on 12/1-12/6, 12/8-12/20 and in the morning on 12/21/23. However, the resident record for Resident #2 included no written practitioner's orders for the above administered medications. B. There was similar deficient practice for Resident #1 and #3. C. InterviewsOn 12/21/23 at approximately 1:33 p.m., the administrator stated she was missing signed orders for Resident #1- Resident #3 for the above medications. The administrator stated Resident #2 was admitted with missing signed practitioner's orders and stated Resident #2's family member who passed away in September 2023, took the resident to her appointments and would not provide documentation which included orders. The administrator stated she was unsure where Resident #1's magnesium order was and was unsure why Resident #3 did not have an albuterol order onsite to administer the medication for three days in December. On 12/21/23 at approximately 3:05 p.m., the administrator stated she was responsible for ensuring practitioner's orders were readily available on site, and acknowledged Resident #1-#3 should have had signed orders for all medications being administered. 3. Chapter VII regulations governing assisted living residences, part 14.31, requires the administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review. On 12/21/23 at 8:23 a.m., documentation of medication audits from the previous three quarters was requested but not provided. On 12/21/23 at 11:16 a.m., the administrator stated she was aware of the requirement for medication audits to be completed quarterly; however, stated she had forgotten to do them. 4. Chapter VII regulations governing assisted living residents, part 14.21, requires that the assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. On 12/21/23 at 9:00 a.m., the surveyor attempted to ask Resident #2 questions. Resident #2 was unable to respond. A written practitioner's order, dated 4/25/22, directed the residence to administer systane ophthalmic drops in each eye twice daily PRN. However, the December 2023 electronic medication administration record (eMAR) read the residence administered systane PRN and provided no documentation of the reason, on 12/1-12/6 and 12/8-12/21/23 for a total of 20 doses. On 12/21/23 at approximately 3:00 p.m., contrary to what the residence's December eMAR read, the administrator stated she had thought Resident #2 was on a scheduled dose of systane and so she had received systane daily. The administrator stated Resident #2 was incapable of requesting PRN medication due to Dementia. The administrator stated she would expect the medication to have been administered in accordance with the medication order.

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 Medical Assistance Section 8.400 Long Term Care, Nursing Facility Care, Adult Day Care Services. 8.484.4 (A) Provider-Owned or -Controlled Residential Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.484.5: 2. Individuals have the right to dignity and privacy, including in their living/sleeping units. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.400.8.495.4 (1) (C) The participant's choice to live in an ACF shall afford the participant the opportunity to responsibly contribute to the home in meaningful ways and shall avoid reducing personal choice and initiative. The participant's individual behaviors shall not negatively impact the harmony of the ACF. C. Participants shall be informed of their rights, according to 6 CCR 1011-1, Chapter VII, Section 13. Pursuant to 6 CCR 1011-1, Chapter VII, Section 13.1, the policy on resident rights shall be in a visible location so that they are always available to participants and visitors. These rights include but are not limited to: Participants have the right to dignity and privacy, including in their living/sleeping units.

A relicensure survey was completed on 12/21/23. Deficiences were cited.

Based on record review, and interviews, the residence failed to ensure applicants complied with Colorado Adult Protective Service Data Systems (CAPS) requirements prior to hiring staff who provided care to the residents for two of three sample staff (#1-#2), affecting seven current residents. Findings include:1. References a. According to Colorado Revised Statutes (2020) Title 26 Human Services Code,"... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult.b. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado Adult Protective Services data system pursuant to section 26-3.1-111.c. Chapter VII regulations governing assisted living residences, part 2.7, defines an "At-risk person" as any person who is 70 years of age or older or any person who is 18 years of age or older and meets one or more of the following criteria: (D) Is a person with an intellectual and developmental disability as defined in Section 25.5-10-202, C.R.S.; (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.2. Record Review a. Personnel Files and ScheduleThe personnel records for Staff #1 and #2 revealed no evidence of CAPS checks. Staff #1 was hired on 8/30/23 and Staff #2 on 8/17/23. The November and December 2023 staff schedules revealed Staff #2 worked from 10:00 a.m. to 6:00 p.m. 37 times as follows: 11/1-11/3, 11/6-11/10, 11/13-11/17, 11/20-11/24, 11/27-11/30, 12/1, 12/4-12/8, 12/11-12/15, 12/18-12/21/23. The November and December 2023 staff schedules revealed Staff #1 worked from 10:00 p.m. to 6:00 a.m. 33 times as follows: 11/1, 11/2, 11/5, 11/12-11/16, 11/19-11/23, 11/26-11/30, 12/3-12/7, 12/10-12/14 and 12/17-12/21/23.b. Resident RecordsOn 12/21/23, resident records and face sheets for Residents #1-#7 were provided and read as follows:Resident #1 was 73 years old. Resident #2 was 93 years old. Resident #3 was 87 years old. Resident #4 had a diagnosis of dementia. Resident #5 was 78 years old. Resident #6 was 82 years old. Resident #7 was 93 years old. 3. InterviewOn 12/21/23 at 2:36 p.m., the administrator stated she was unable to provide CAPS checks for Staff #1 and #2 since they could not be requested. The administrator stated Staff #1 and #2 had worked with residents since they were hired in August 2023. The administrator stated she was aware of the requirement for CAPS checks and was aware of the risk to residents by having Staff #1 and #2 work with at-risk residents prior to conducting a CAPS check. However, she stated she was unable to request a CAPS check since Staff #2 had documents with no last name and social security required a last name, and Staff #1 had no social security card or number at all. The administrator stated Staff #1 and #2 needed employment and she did not want to wait to have them begin working. The administrator further stated Resident #1-#3 and #5-#7 all were over the age of 70 and had either dementia or Alzheimer's Disease. The administrator stated Resident #4 was in her 60s; however, had early onset dementia.

Based on record review and interviews, the residence failed to request, prior to staff hire, a name-based criminal history record check for each prospective staff member for two of three sample staff (#1, #2), affecting seven current residents. Findings include:1. ReferencesChapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein. Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include written documentation regarding the following items: (E) Results of background checks and follow up, as applicable. 2. Record Review Review of personnel files for Staff #1 and #2 revealed they were hired on 8/30/23 and 8/17/23 respectively. Staff #1 and #2's records did not contain evidence of a name-based criminal background check conducted by the CBI, or any other background check. The November and December 2023 staff schedules were reviewed and revealed Staff #1 and #2 worked at the residence as follows:Staff #2 worked from 10:00 a.m. to 6:00 p.m. 37 times as follows: 11/1-11/3, 11/6-11/10, 11/13-11/17, 11/20-11/24, 11/27-11/30, 12/1, 12/4-12/8, 12/11-12/15, 12/18-12/21/23. Staff #1 worked from 10:00 p.m. to 6:00 a.m. 33 times as follows: 11/1, 11/2, 11/5, 11/12-11/16, 11/19-11/23, 11/26-11/30, 12/3-12/7, 12/10-12/14 and 12/17-12/21/23.3. InterviewOn 12/21/23 at 2:36 p.m., the administrator stated she was aware the personnel files for Staff #1 and #2 did not contain their CBI results. The administrator stated she was aware of the requirement for background checks to be conducted through the CBI prior to hire; however, was unable to request it since Staff #2 had documents with no last name and social security required a last name, and Staff #1 had no social security card or number at all. The administrator stated she aware of the risk to residents for having failed to conduct a background check on Staff #1 and #2; however, did not want to deny them employment.

Based on record review and interview, the residence failed to ensure each personnel file contained written documentation of the required information, for three of three sample staff (#1-#3) affecting seven current residents. Findings include:1. Record Review Review of the personnel files for Staff #1-#3 revealed they were hired 8/30/23, 8/17/23 and 6/30/20 respectively. The following was not included in their files:Staff #3: date duties commenced, first aid and CPR certifications, evidence of CBI results or the results of CAPS background checks. On 12/21/23 at 8:53 a.m., the administrator provided a first aid and CPR certification for Staff #3. However, the administrator had to obtain the certification from Staff #3 since it was not in his personal file. Staff #2: date duties commenced and CPR and first aid certifications. On 12/21/23 at 9:33 a.m., the administrator provided a screenshot on her phone that was sent by Staff #2 of the staff member's first aid and CPR certification. However, the above elements were not in Staff #2's personnel file. Staff #1: date duties commenced, first aid and CPR certification. On 12/21/23 at 11:28 a.m., the administrator provided a screenshot on her phone that was sent by Staff #1 of the staff member's first aid and CPR certification since she was unable to obtain it prior. However, the above elements were not in Staff #1's personnel file and Staff #1 work independently from 10:00 p.m. to 6:00 a.m. at the residence. 3. Interviews On 12/21/23 at 9:04 a.m., the administrator stated she was unaware Staff #3's personnel file did not contain their CBI and CAPS background check result and stated it had been completed; however, was likely at her mother's house and not onsite. The administrator stated she expected Staff #2 and #3's personnel files to include CPR and first aid certification; however, acknowledged the personnel files were not complete. On 12/21/23 at 2:56 p.m., the administrator stated she was aware of the requirements for what needed to be included in personnel files and was aware of the risk to residents of not having CPR and first aid certifications readily available; however, stated, she was very busy and was unable to get the required elements.

Based on record review and interview, the residence failed to retain in employee's personnel files, who were qualified medication administration persons (QMAPs), documentation that the individual's names appeared on the department's list of individuals who had successfully completed the medication administration competency evaluation for two of three staff (#1 and #2) affecting seven current residents. Findings include: Review of the personnel files for Staff #1 and #2 revealed they were hired on 8/30/23 and 8/17/23 as QMAPs. The personnel files for Staff #1 and #2 revealed no documentation that their names appeared on the department's list of individuals who have successfully completed the medication administration competency evaluation. The November and December 2023 staff schedules were reviewed and revealed Staff #1 and #2 worked at the residence as follows:Staff #2 worked from 10:00 a.m. to 6:00 p.m. 37 times as follows: 11/1-11/3, 11/6-11/10, 11/13-11/17, 11/20-11/24, 11/27-11/30, 12/1, 12/4-12/8, 12/11-12/15, 12/18-12/21/23. Staff #1 worked from 10:00 p.m. to 6:00 a.m. 33 times as follows: 11/1, 11/2, 11/5, 11/12-11/16, 11/19-11/23, 11/26-11/30, 12/3-12/7, 12/10-12/14 and 12/17-12/21/23. On 12/21/23 at 9:04 a.m., the administrator stated Staff #2 and #3 were both QMAPs. She further stated she was aware of the requirement for Staff #2 and #3's personnel files to include verification of active QMAP and acknowledged the personnel files were not complete due to her being busy.

Based on observation, record review and interview, the residence failed to not use restraints of any kind for the purposes of care or safety, affecting one of three sample residents (#3) that had been restrained since September 2023. 1. References a. Chapter VII regulations governing assisted living residences, part 2.42, defines "Restraint" as any method or device used to involuntarily limit freedom of movement including, but not limited to, bodily physical force, mechanical devices, chemicals or confinement.b. Chapter VII regulations governing assisted living residences, reads in part 12.14 that a device that facilitates a resident's well-being and/or independence may be used only if all of the following criteria are met:(A) The resident has the functional ability to alter his or her position;(B) The resident is able to remove the device to allow for normal movement;(C) The device improves the resident's physical or emotional state and allows the resident to participate in activities that would otherwise be difficult or impossible; and(D) There is an order from a practitioner for its use.(1) There shall also be interdisciplinary documentation from both the practitioner and a therapist describing the benefits and hazards associated with the device and information on its appropriate use.(2) A resident's continued use of such device shall be re-evaluated by both therapist and practitioner at least annually or whenever the resident experiences a significant change in status.(3) Documentation of compliance with this subpart (D) shall be retained in the resident's care plan.c. According to The National Consumer Voice, "Bed rails are frequently used in homes or long-term care facilities because they are believed to keep people safe. In reality, bed rails can be extremely harmful. Bed rails can cause strangulation or asphyxiation ... severe injury ... " The National Consumer Voice for Quality Long-Term Care (2022), retrieved from: https://theconsumervoice.org/issues/other-issues-and-resources/dangers-of-bed-rails#:~:text=Bed%20rails%20are%20frequently%20used,bed%20rail%20and%20the%20mattress. 2. Resident #3 was admitted to the residence on 2/18/23 with diagnoses including Alzheimer's Disease.a. ObservationOn 12/21/23 at approximately 8:30 a.m., Resident #3's hospital bed had a bed rail on the left side and the right side of Resident #3's bed was pushed against the wall which hindered Resident #3 from being able to move freely. On 12/21/23 at approximately 1:36 p.m., when prompted Resident #3 was unable to get out of bed or move the bed rail himself. b. Record ReviewThe residence's comprehensive assessment for Resident #3, dated 5/24/23, read Resident #3 was independent with all transfers, required two hour safety checks and had no devices for mobility or walking. The residence's care plan, which was also the residence's assessment for Resident #3 dated 9/21/23, read Resident #3 required full hands on and verbal assistance with ambulation needs, used a wheelchair and had a practitioner's order for restraints. However, no evidence of a practitioner's order for restraints was provided. Further, there were no additional falls since 8/24/23 since in September 2023 the bed rail restraint was put in place. c. InterviewsOn 12/21/23 at 8:28 a.m., Resident #3 stated he was unsure as to why his bed rail was up and did not remember how long the bed side rail had been up. On 12/21/23 at 1:36 p.m., the family member for Resident #3 stated the bed rail was put in place so Resident #3 did not fall out of bed and she was happy with it. She further stated the resident was not able to get up out of the bed on his own with the rail up or lower the rail on his own. The family member stated she was informed by Staff #3 that the Resident #3 had attempted to get out of bed the day of the onsite investigation; however, she did not want him getting up since the resident was too weak. On 12/21/23 at approximately 1:37 p.m., the external hospice nurse statedthe bed rail was put in place by hospice on 9/26/23 for Resident #3 due to him having falls, and felt it would be beneficial for his safety. On 12/21/23 at 1:44 p.m., the administrator stated that Resident #3 would be unable to get up out of the bed due to the bed rail and since she tightened it down so he could not get up. The administrator stated tightening the bed rail "did not stop him from trying to get up." She further stated the family member and external hospice nurse put the bed rail in place to keep Resident #3 safe and stop him from falling and stated that the resident had not fallen since the bed rail was put in place. The administrator stated she had no documentation of an order for restraints or any rights modifications; however, was aware of the requirement. On 12/21/23 at approximately 2:36 p.m., the administrator stated bed rails were put in place for Resident #3 as an intervention following his falls, and stated the resident had not fallen since the bed rails were put in place. The administrator further stated she understood the safety risk of bed rails and stated risks she was aware of included Resident #3 getting body parts caught in the bed rail. The administrator stated she was unsure what to do since both Resident #3's family member and external hospice nurse wanted Resident #3 to have a bedrail.

Based on record review and interview, the residence failed to have defined procedures to prevent the spread of influenza from unvaccinated healthcare workers, affecting seven current residents. Findings include: On 12/21/23 at 8:23 a.m., the residence's influenza policy was requested. However, there was no policy or procedure to prevent the spread of influenza from unvaccinated healthcare workers. Personnel files for Staff #1-#3 were reviewed and contained no evidence of influenza vaccinations. On 12/21/23 at 2:36 p.m., the administrator stated she was aware of the requirement to have influenza policy and procedures to prevent the spread of influenza; however, had forgotten to create one during the COVID 2020 pandemic. The administrator stated she had no evidence Staff #1-#3 who worked at the residence had received their influenza vaccination for the current influenza season, as required.

Based on record review and interview, the residence failed to ensure only medication that has been ordered by an authorized practitioner was administered to residents, affecting three of three sample residents (#1-#3). Findings include:1. Residence PolicyThe residence's undated Medication Administration policy, read in part: "all medication orders shall be documented in writing."2. Resident #2 was admitted to the residence on 1/1/21 with a diagnosis of Dementia. The December 2023 electronic medication administration record (eMAR) read the residence administered medications to Resident #2 as follows:Morphine sulfate 20 mg three times daily on 12/1-12/6, in the afternoon on 12/7 and 12/8-12/20/23. Lorazepam 0.25 mg once at bedtime on 12/1-12/20/23. Seroquel 25 mg once daily on 12/1-12/20/23. Thick it solution nectar-honey thick three times daily on 12/1-12/6, 12/8-12/20 and in the morning on 12/21/23. However, the resident record for Resident #2 included no written practitioner's orders for the above administered medications. 3. There was similar deficient practice for Resident #1 and #3.4. InterviewsOn 12/21/23 at approximately 1:33 p.m., the administrator stated she was missing signed orders for Resident #1- Resident #3 for the above medications. The administrator stated Resident #2 was admitted with missing signed practitioner's orders and stated Resident #2's family member who passed away in September 2023, took the resident to her appointments and would not provide documentation which included orders. The administrator stated she was unsure where Resident #1's magnesium order was and was unsure why Resident #3 did not have an albuterol order onsite to administer the medication for three days in December. On 12/21/23 at approximately 3:05 p.m., the administrator stated she was responsible for ensuring practitioner's orders were readily available on site, and acknowledged Resident #1-#3 should have had signed orders for all medications being administered.

Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of three sample residents (#2) was administered a pro re nata (PRN) or "as needed" medication daily. Findings include:On 12/21/23 at 9:00 a.m., the surveyor attempted to ask Resident #2 questions. Resident #2 was unable to respond. A written practitioner's order, dated 4/25/22, directed the residence to administer systane ophthalmic drops in each eye twice daily PRN. However, the December 2023 electronic medication administration record (eMAR) read the residence administered systane PRN and provided no documentation of the reason, on 12/1-12/6 and 12/8-12/21/23 for a total of 20 doses. On 12/21/23 at approximately 3:00 p.m., contrary to what the residence's December eMAR read, the administrator stated she had thought Resident #2 was on a scheduled dose of systane and so she had received systane daily. The administrator stated Resident #2 was incapable of requesting PRN medication due to Dementia. The administrator stated she would expect the medication to have been administered in accordance with the medication order.

Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event was completed for each resident along with each of their signatures and, if used, their initials, affecting three of three sample residents (#1-#3). Findings include:1. Residence PolicyThe residence's undated Medication Administration policy, read in part: "each qualified medication administration person shall accurately document each medication administration or monitoring event at the time it is completed for each resident."2. Record Reviewa. Resident #2 was admitted to the residence on 1/1/21 with a diagnosis of Dementia. AcetaminophenA written practitioner's order dated 3/22/22 directed the residence to administer acetaminophen 500 mg two tablets three times daily. The December 2023 electronic medication administration record (eMAR) had blank spaces for both the morning and afternoon dose on 12/7/23. OmeprazoleA written practitioner's order dated 3/22/22 directed the residence to administer omeprazole 40 mg two tablets once daily. The December 2023 eMAR had a blank space on 12/7/23. MethimazoleA written practitioner's order dated 3/22/22 directed the residence to administer methimazole 5 mg one and a half tablets once daily. The December 2023 eMAR had a blank space on 12/7/23. b. There was similar deficient practice for Residents #1 and #3.3. InterviewOn 12/21/23 at 3:04 p.m., the administrator stated the blank spaces in the eMAR meant that staff did not sign off their initials at the time of administration as required. The administrator stated she was aware of the requirement for staff to initial at the time of administration and would have expected staff to have done so.

Based on interview and record review, the administrator and the qualified medication administration person (QMAP) supervisor failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting seven current residents. Findings include:On 12/21/23 at 8:23 a.m., documentation of medication audits from the previous three quarters was requested but not provided. On 12/21/23 at 11:16 a.m., the administrator stated she was aware of the requirement for medication audits to be completed quarterly; however, stated she had forgotten to do them.

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 VII. 12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: (B) 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. 13.1 The assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items: (A) The right to privacy and confidentiality. 25.5 Before an individual moves in, the assisted living residence shall complete a pre-admission assessment to determine the appropriateness and need for secure environment residency. The pre-admission assessment shall include all the items required for the comprehensive assessment in Part 12.7(A) through (M), plus the following:(A) An evaluation by a licensed practitioner which has occurred within the previous ninety (90) calendar days and which describes the resident ' s medical condition and any cognitive deficits that contribute to wandering, compromised safety awareness, and other types of conduct; and (B) Detailed information from the resident ' s family and/or representative concerning the resident ' s recent relevant history and patterns of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting, and any other known types of conduct.