CURAVISTAS

An initial certification survey was completed on 1/14/25. No deficiencies were cited.

A change of ownership survey was completed on 1/15/25. A deficiency was cited. Change of ownership occurred on 4/25/24.

Based on observation and interview, the residence failed to notify the department of an intent of change with the administrator of record, affecting 17 current residents. Findings include:On 1/14/25 at approximately 9:30 a.m., a residence business card read the current administrator as different from the one listed with the department database. On 1/14/25 at approximately 9:30 a.m., the administrator said she had been the administrator at the residence since 6/10/24. On 1/15/25 at 7:07 a.m., an electronic message was received from a department representative that read the residence had not notified the department of change in the administrator of record.

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 10/24/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 10/24/23. 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 licensure complaint, prompted by #CO33735, was completed on 10/24/23. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to update the comprehensive assessment when a resident's condition changed from baseline status, affecting one sample resident (#9). Findings include:1. Residence Policy and AgreementThe residence's Fall Response Procedures policy, dated 10/1/22, read in part: The residence conducted an assessment when a resident experienced a fall with injury or required medical intervention/treatment, repeat falls, and when a change in condition occurred. The residence's Residence and Care Agreement, dated 8/25/23, read in part: Residence staff conducted reassessments regularly to determine the resident's needs. 2. Resident #9 was admitted to the residence on 7/1/22 with diagnoses including muscle wasting and atrophy, polyneuropathy, and other unspecified lack of coordination. On 10/24/23 at 9:12 a.m., Resident #9 was ambulating in a wheelchair. Progress notes, dated 5/1-10/16/23, read in part:On 5/1/23, the residence staff found Resident #9 on the floor of her apartment. The floor was saturated with urine and an alcoholic beverage. Staff assisted and evaluated the resident. The resident went to breakfast. On 5/18/23, the resident was intoxicated in her room. On 6/23/23, "(Resident #9) has dementia and is an alcoholic." On 10/4/23, the resident fell in the computer room and refused to go to the hospital. On 10/5/23, the resident fell last evening and reported no injury; however, the resident's ankle was swollen and painful. The resident went to the emergency department via emergency medical services. On 10/16/23, the resident's practitioner contacted the residence to follow up on the resident's sprained ankle. A practitioner's assessment, dated 10/5/23, read in part that the resident sprained her ankle, which could cause more pain and require more time to heal than a fracture. An assessment, dated 7/2/23, read in part: Resident #9 fell in the last three months; however, the residence failed to include the dates and circumstances of the falls. Further, the assessment read that Resident #9 required no assistance from the residence to monitor her alcohol consumption and failed to include the resident's use of a wheelchair. The residence provided no additional assessments of Resident #9 updated with information regarding the two falls she sustained on 5/1/23 and 10/4/23, instances of intoxication related to her falls, or her changed condition post-falls, including her use of a wheelchair. 3. InterviewsOn 10/24/23 at 9:12 a.m., Resident #9 stated she thought she fell recently because she still felt pain in her ankle. She stated she did not know what the residence had done to assist her with avoiding future falls; however, she now utilized a wheelchair all the time to ambulate because of her sprained ankle. On 10/24/23 at 2:49 p.m., the residence care director stated that Resident #9 had two falls, one in May or June of 2023 and one in October 2023. She added that both falls were precipitated by the resident drinking alcohol and becoming intoxicated. She added that she should have updated the assessment to include the resident's increased risk of intoxication-related falls. On 10/24/23 at 4:10 p.m., the administrator stated that he expected the residence to reassess residents when they experienced a change in condition. He stated that he considered falls with injury, a series of falls, and instances of intoxication experienced by Resident #9 as changes to her condition. He added that the residence should have reassessed Resident #9 after she fell and after instances of intoxication. The administrator stated he was unaware that she was not reassessed.

Based on interview and record review, the residence failed to detail in the resident care plans the individualized approach necessary to address fall risk related to deficits, affecting one sample resident (#9) who sustained recent falls. Specifically, on 5/1/23 Resident #9 while intoxicated fell in her room. After her initial fall on 5/1/23, the residence failed to update the care plan to address individualized approaches necessary to address fall risks related to strength, balance, or other deficits. Subsequently, on 10/4/23 Resident #9 was intoxicated and fell which resulted in a sprained ankle. Findings include:1. Residence PolicyThe residence's Fall Response Procedure policy, dated 10/1/22, read in part that the residence's fall reduction program included that each resident's service (care) plan was updated when a resident experienced a first fall, repeated falls, a fall with injury, or a change in condition. 2. Resident #9 was admitted to the residence on 7/1/22 with diagnoses including muscle wasting and atrophy, polyneuropathy, and other unspecified lack of coordination. Progress notes, dated 5/1-10/16/33, read in part:On 5/1/23, the residence staff found Resident #9 on the floor of her apartment. The floor was saturated with urine and an alcoholic beverage. Staff assisted and evaluated the resident. The resident went to breakfast. On 5/18/23, the resident was intoxicated in her room. On 6/23/23, "(Resident #9) has dementia and is an alcoholic." On 10/4/23, the resident fell in the computer room and refused to go to the hospital. On 10/5/23, the resident fell last evening and reported no injury; however, the resident's ankle was swollen and painful. The resident went to the emergency department via emergency medical services. On 10/16/23, the resident's practitioner contacted the residence to follow up on the resident's sprained ankle. A practitioner's assessment, dated 10/5/23, read in part that the resident sprained her ankle, which could cause more pain and a longer recovery than a fracture. An assessment for Resident #9, dated 7/2/23, read in part: The resident was at risk for falls. A care plan, dated 7/2/23, read in part: Resident #9 required staff intervention to decrease the identified fall risk; however, the care plan contained no individualized approaches necessary to address the resident's risk of falls related to strength, balance, or other deficits, including increased risks when the resident ingested alcohol. The residence provided no additional care plans for Resident #9.3. InterviewsOn 10/23/23 at 1:10 p.m., Staff #3 stated that the residence provided no approaches to address the risk of falls for Resident #9. On 10/24/23 at 2:11 p.m., Staff #13 stated she was unaware of any approaches staff should have taken to address the risk of falls for Resident #9. She added that the resident experienced falls due to the resident being intoxicated. On 10/24/23 at 2:49 p.m., the residence care director stated that Resident #9 had two falls, one in May or June of 2023 and one in October 2023. She added that both falls were precipitated by the resident drinking alcohol and becoming intoxicated. She added that she should have updated the care plan to include increased safety checks when staff knew the resident had been drinking alcohol as her risk of falls increased. She added that the staff may not be aware of any approaches as the residence had not added them to the care plan for Resident #9. On 10/24/23 at 4:10 p.m., the administrator stated that he expected the care plan to be updated with new interventions after each fall a resident experienced or a change in condition. He stated that he considered falls with injury, a series of falls, and instances of intoxication experienced by Resident #9 as a change of condition. The administrator added the care plan for Resident #9 should have been updated with individualized approaches to address the resident ' s risk of fall. The administrator added he was unaware that the careplan did not have the required elements.

Based on record review and interview, the residence failed to ensure that only medications that have been ordered by an authorized practitioner were prepared and administered, affecting two of five sample residents (#3, #9). (Cross-reference Q1514)This deficiency was cited previously during a state licensure survey on 4/12/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's Medication Records policy, dated 10/1/22, read in part that a practitioner's order was required for all medications handled, stored, and administered by staff. Written practitioner's orders for all medications were maintained in the resident records in the "Physician Orders" section. 2. Resident #3 was admitted to the residence on 1/16/23 with diagnoses of hypertension and compression fracture. The September 2023 and October 2023 medication administration records (MARs) read the residence administered the following medications in which there was no evidence of a written practitioner's order:Vazalore 81 mg once daily from 9/1-10/12 and 10/14-10/24/23.3. Additionally, the residence administered medication without a signed practitioner ' s order for Resident #9, Paxlovid, three tablets twice daily, for five days. 4. InterviewsOn 10/24/23 at 2:11 p.m., the resident care director (RCD) stated that the residence did not have the practitioner ' s order for Paxlovid for Resident #9. She added she was responsible for getting the order and she was out of the residence during that time. She stated that Resident #9 was administered the medication. On 10/24/23 at 2:02 p.m., the RCD stated Resident #3 had gone out to a skilled nursing facility and came back to the residence and was missing orders. She stated she thought she had all orders but confirmed she was missing orders for the above medications. On 10/24/23 at 4:15 p.m., the administrator stated that the residence was required to have a practitioner ' s order for medication administered to residents. He added he was unaware that there were medications administered without orders by residence staff. He added he was unaware that the residence was previously cited for noncompliance with this requirement.

Based observation, record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of five residents (#1, #3, #7, #9). (Cross reference Q1514)Findings include:1. Residence PolicyThe residence's Medication Services policy, dated 10/1/22, read in part: "The assisted living residence shall be responsible for complying with authorized practitioner orders."2. Resident #3 was admitted to the residence on 1/16/23 with diagnoses including compression fracture and hypertension.a. SennaA written practitioner's order dated 5/2/23 directed the residence to administer senna 8.6 mg twice daily. However, the September through October 2023 medication administration records (MARs) read the medication was not administered on 9/1 through 10/23/23 because the medication was not transcribed on the MAR. During the medication audit senna was found in stock in the medication cart. b. Melatonin A written practitioner's order dated 5/2/23 directed the residence to administer melatonin one mg once daily at bedtime. However, the September through October 2023 MARs read the medication was not administered on 9/1 through 10/23/23 because the medication was not transcribed on the MAR. During the medication audit melatonin 3 mg was found in stock in the medication cart. c. Amlodipine BesylateA written practitioner's order dated 5/2/23 directed the residence to administer amlodipine besylate 5 mg once daily. However, the September through October 2023 MARs read the medication was not administered on 9/29 through 10/24/23 because the medication was discontinued. During the medication audit amlodipine was found in stock in the medication cart. d. Multivitamin with Minerals A written practitioner's order dated 5/2/23 directed the residence to administer multivitamin with minerals one tablet once daily. However, the September through October 2023 MARs read the medication was not administered on 9/1 through 10/23/23 because the medication was not transcribed on the MAR.e. SalonpasA written practitioner's order dated 5/2/23 directed the residence to administer Salonpas once daily. However, the September through October 2023 MARs read the medication was not administered on 9/9 through 10/23/23 because the medication was discontinued. 3. Additionally, the residence failed to comply with authorized practitioner orders associated with medication administration from September through October 2023 for the following residents:Resident #1, for eucerin eczema 1% cream after showers, once a day; Murine ear wax removal system 6.5% drops at bedtime on the 15th of every month; diclofenac sodium 1% gel, 1 gram three times daily; acetaminophen 500 mg three times daily; ARY Nasal gel three times daily 7:30 a.m., 12:00 p.m. and 4:00 p.m. Resident #7, for gabapentin, one tablet daily; levothyroxine one tablet daily, and senexon-s one tablet twice daily. Resident #9, for Lisinopril. one tablet daily, hold if systolic blood pressure is below 110. 4. InterviewsOn 10/24/23 at 2:02 p.m., the resident care director stated she was the person who ensured the MARs were accurate and medications were administered per practitioner's orders. The resident care director further stated she reviewed the MARs monthly for errors; However, she was unaware that the residence failed to comply with practitioners' orders. On 10/24/23 at approximately 4:15 p.m., the administrator stated that the residence was required to administer medications according to the practitioner ' s order. He added he was unaware that the residence failed to comply with practitioners ' orders.

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records, affecting four of five sample residents (#1, #3, #7, #9) whose medications were reviewed. (Cross-reference Q1430, Q1468)Findings include:The residence Medication Records Policy, dated 10/1/22, read in part: "The administrator and the QMAP supervisor shall, quarterly, 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 10/24/23 at approximately 11:30 a.m., the residence provided documents from the preferred pharmacy, titled Consultant Pharmacist Summary, dated 6/22/23 and 9/29/23; a pharmacy signed the documents. The Resident Care Director's (RCD) title was listed on the document but did not contain her signature. There was no evidence that the administrator participated in completing quarterly medication audits. On 10/24/23 at approximately 2:30 p.m., the RCD stated that she did not perform the documented medication audits provided by the residence. She added that the administrator did not participate in the audits. On 10/24/23 at 4:15 p.m., the administrator stated that he had not participated in quarterly medication audits and was unaware that he was required to participate prior to the onsite survey. He added that he was unaware that the residence had not completed the audits as required.

Based on record review and interview, the residence failed to ensure that the Resident's authorized practitioner was promptly notified of a resident's pattern of refusal, affecting one of five sample residents (#1). Findings include:The residence's policy, dated 10/1/22, read in part: the prescribing practitioner was notified of missed or refused medications immediately or in the time frame and according to the parameters as indicated by the practitioner using the refusal of medication notification form. The Resident Care Director re-appraises the resident and contacts the practitioner and responsible party if the resident continually refused medication. Resident #1 was admitted to the residence on 7/1/22 with diagnoses including Osteoarthritis, Bilateral, Cervical Dysphagia and neurogenic dysphagia and Impacted cerumen. A written practitioner's order, dated 5/15/23, directed the residence to administer Diclofenac sodium 1% gel, one gram three times daily. However, the September and October 2023 electronic medication administration records (eMARs) revealed that Resident #1 refused the medication at 7:30 a.m. on: 9/1-9/5, 9/8-9/15, 9/17- 9/19, 9/22-9/26, 9/29, 9/30,10/6 -10/10, 10/13; at 1:00 on: 9/1-9/5, 9/8-9/18, 9/19, 9/22-9/26, 9/29- 9/30, 10/13, 10/14; at 7:00 p.m. on: 9/3, 9/5- 9/6, 9/11-9/12, 9/15- 9/17, 9/19, 9/22, 9/24, 9/28, 10/1, 10/2, 10/19. There was no documentation that the residence notified the Resident's family member or practitioner that Resident #1 routinely refused medication. A written practitioner's order, dated 5/24/23, directed the residence to administer ARY Nasal gel three times daily 7:30 a.m., 12:00 p.m. and 4:00 p.m.. However, the September and October 2023 eMARs revealed that Resident #1 refused the medication 7:30 a.m. on 9/2-9/4, 9/8-9/9, 9/17,9/23,9/30, 10/1, 10/6, 10/7, 10/15, 10/20, 10/21; at 12:00 p.m. on 9/2-9/4, 9/8-9/9, 9/17, 9/23, 9/30, 10/1, 10/2, 10/7, 10/15, 10/20, 10/21;. at 4:00 p.m. on 9/5, 9/8, 9/11-9/12, 9/22, 10/1, 10/2, 10/13, 10/15. There was no documentation that the residence notified the Resident's family member or practitioner that Resident #1 routinely refused medication. On 10/24/23 at 1:53 p.m., Resident #1 stated she did not refuse medication. On 10/24/23 at 2:02 p.m., the resident care director stated she notified the practitioner of a pattern of refusals. She stated she was not aware of the residence's policy on when to notify a practitioner of a refusal . On 10/24/23 at 2:46 p.m., the practitioner for Resident #1 stated they have not been notified of medication refusals; however, she stated it was their policy to be notified.

A licensure revisit was completed on 10/24/23 for all previous deficiencies cited on 4/12/23. Deficiencies were cited.

Based on interviews and record review, the residence failed to comply with conditions imposed by the department on the license, affecting 22 current residents. Findings include:The department completed a re-licensure survey in conjunction with a change of ownership survey on April 12, 2023. Eleven deficiencies were cited. Chapter VII regulations were cited: 540 B, 610 B, 664 B, 732 B, 734 E, 736 B, 910 B, 1430 B, 1468 B, 1514 B, and 2114. One Chapter II regulation was cited 0290. Deficiency 734 was cited at an E level, actual or potential for serious injury or harm for one or more residents, for the residence's failure at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques. Part 3.16 of the Chapter 7 regulations requires the department to impose at least one intermediate restriction or condition for all cases where the deficiency list includes a Level E deficiency. The department imposed a civil fine of $500, payable by 6/14/23. Department records revealed that the residence had not paid the required civil fine on October 24, 2023. On 10/24/23 at approximately 2:30 p.m., the residence care director stated that she was aware of the previous survey and assisted with the plan of correction; however, she was unaware that the residence failed to pay the associated fine. On 10/24/23 at approximately 4:15 p.m., the administrator stated he was unaware that the residence failed to pay the fine associated with the last survey.

Based on interview and record review, the residence failed to include written documentation regarding orientation and training in each personnel file, for one sample staff (#10) affecting 22 current residents. This deficiency was cited previously during a state licensure survey on 4/12/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 10/24/23, the residence provided personnel documents for Staff #10; however, the file did not include any written documentation of orientation or training. On 10/24/23 at 4:15 p.m., the administrator stated the residence did not have documented training or orientation for Staff #10. He added that he learned that the residence did not have documented training for Staff #10 during the onsite survey. He stated that he was aware that the residence was required to have training documentation for each staff member. He added that he was also unaware that the residence had previously been cited for noncompliance with this requirement.

Based on observation, interview, and record review, the residence failed to place in a visible location a list of all staff who have current certification in first aid or cardiopulmonary resuscitation (CPR), affecting 22 current residents. This deficiency was cited previously during a state licensure survey on 4/12/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. The residence's Emergency Training Policy, dated 10/1/22, read in part that the residence placed a list of staff with current CPR and first aid certifications in a visible location so that the information is readily available to staff at all times. On 10/24/23, from approximately 7:30 a.m. to 4:00 p.m., there was no list of staff with current CPR and first aid certifications placed in a visible location. On 10/24/23 at 11:08 a.m., the resident care director stated that there was no list of staff with current certifications in CPR and first aid readily available to staff visibly posted at the residence. She added that she was unaware of the requirement. On 10/24/23 at 4:15 p.m., the administrator stated he was unaware if there was a posting of all staff with current first aid and CPR certification. He added that he was unaware the residence had previously been cited for noncompliance with the requirement. He added that he was unaware of the requirement; however, the requirement made sense to him.

Based on record review and interview, the residence failed to have a roster of current residents readily available, their room assignments, emergency contact information and a facility diagram showing room locations, affecting 22 current residents. This deficiency was cited previously during a state licensure survey on 4/12/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. On 10/24/23 at approximately 7:30 a.m., Staff #5 and #14 could not provide the resident roster. On 10/24/23 at 8:14 a.m., Staff #12 provided a resident roster that included the resident names, the floor they resided on, and their room number. The roster did not include emergency contact information nor a diagram of the residence showing room locations. On 10/24/23 at 4:15 p.m., the administrator stated that he was unaware of the elements required on the resident roster; however, he would have provided the roster from the electronic medical record. He affirmed that the electronic medical record roster failed to include a residence diagram. He added that he was unaware that the residence had previously been cited for noncompliance with this requirement.

Based on record review and interview, the residence failed to ensure that only medications that have been ordered by an authorized practitioner were prepared and administered, affecting two of five sample residents (#3, #9). (Cross-reference Q1514)This deficiency was cited previously during a state licensure survey on 4/12/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's Medication Records policy, dated 10/1/22, read in part that a practitioner's order was required for all medications handled, stored, and administered by staff. Written practitioner's orders for all medications were maintained in the resident records in the "Physician Orders" section. 2. Resident #3 was admitted to the residence on 1/16/23 with diagnoses of hypertension and compression fracture. The September 2023 and October 2023 medication administration records (MARs) read the residence administered the following medications in which there was no evidence of a written practitioner's order:Vazalore 81 mg once daily from 9/1-10/12 and 10/14-10/24/23.3. Additionally, the residence administered medication without a signed practitioner ' s order for Resident #9, Paxlovid, three tablets twice daily, for five days. 4. InterviewsOn 10/24/23 at 2:11 p.m., the resident care director (RCD) stated that the residence did not have the practitioner ' s order for Paxlovid for Resident #9. She added she was responsible for getting the order and she was out of the residence during that time. She stated that Resident #9 was administered the medication. On 10/24/23 at 2:02 p.m., the RCD stated Resident #3 had gone out to a skilled nursing facility and came back to the residence and was missing orders. She stated she thought she had all orders but confirmed she was missing orders for the above medications. On 10/24/23 at 4:15 p.m., the administrator stated that the residence was required to have a practitioner ' s order for medication administered to residents. He added he was unaware that there were medications administered without orders by residence staff. He added he was unaware that the residence was previously cited for noncompliance with this requirement.

Based observation, record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of five residents (#1, #3, #7, #9). (Cross reference Q1514)Findings include:1. Residence PolicyThe residence's Medication Services policy, dated 10/1/22, read in part: "The assisted living residence shall be responsible for complying with authorized practitioner orders."2. Resident #3 was admitted to the residence on 1/16/23 with diagnoses including compression fracture and hypertension.a. SennaA written practitioner's order dated 5/2/23 directed the residence to administer senna 8.6 mg twice daily. However, the September through October 2023 medication administration records (MARs) read the medication was not administered on 9/1 through 10/23/23 because the medication was not transcribed on the MAR. During the medication audit senna was found in stock in the medication cart. b. Melatonin A written practitioner's order dated 5/2/23 directed the residence to administer melatonin one mg once daily at bedtime. However, the September through October 2023 MARs read the medication was not administered on 9/1 through 10/23/23 because the medication was not transcribed on the MAR. During the medication audit melatonin 3 mg was found in stock in the medication cart. c. Amlodipine BesylateA written practitioner's order dated 5/2/23 directed the residence to administer amlodipine besylate 5 mg once daily. However, the September through October 2023 MARs read the medication was not administered on 9/29 through 10/24/23 because the medication was discontinued. During the medication audit amlodipine was found in stock in the medication cart. d. Multivitamin with Minerals A written practitioner's order dated 5/2/23 directed the residence to administer multivitamin with minerals one tablet once daily. However, the September through October 2023 MARs read the medication was not administered on 9/1 through 10/23/23 because the medication was not transcribed on the MAR.e. SalonpasA written practitioner's order dated 5/2/23 directed the residence to administer Salonpas once daily. However, the September through October 2023 MARs read the medication was not administered on 9/9 through 10/23/23 because the medication was discontinued. 3. Additionally, the residence failed to comply with authorized practitioner orders associated with medication administration from September through October 2023 for the following residents:Resident #1, for eucerin eczema 1% cream after showers, once a day; Murine ear wax removal system 6.5% drops at bedtime on the 15th of every month; diclofenac sodium 1% gel, 1 gram three times daily; acetaminophen 500 mg three times daily; ARY Nasal gel three times daily 7:30 a.m., 12:00 p.m. and 4:00 p.m. Resident #7, for gabapentin, one tablet daily; levothyroxine one tablet daily, and senexon-s one tablet twice daily. Resident #9, for Lisinopril. one tablet daily, hold if systolic blood pressure is below 110. 4. InterviewsOn 10/24/23 at 2:02 p.m., the resident care director stated she was the person who ensured the MARs were accurate and medications were administered per practitioner's orders. The resident care director further stated she reviewed the MARs monthly for errors; However, she was unaware that the residence failed to comply with practitioners' orders. On 10/24/23 at approximately 4:15 p.m., the administrator stated that the residence was required to administer medications according to the practitioner ' s order. He added he was unaware that the residence failed to comply with practitioners ' orders.

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records, affecting four of five sample residents (#1, #3, #7, #9) whose medications were reviewed. (Cross-reference Q1430, Q1468)This deficiency was cited previously during a state licensure survey on 4/12/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence Medication Records Policy, dated 10/1/22, read in part: "The administrator and the QMAP supervisor shall, quarterly, 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 10/24/23 at approximately 11:30 a.m., the residence provided documents from the preferred pharmacy, titled Consultant Pharmacist Summary, dated 6/22/23 and 9/29/23; a pharmacy signed the documents. The Resident Care Director's (RCD) title was listed on the document but did not contain her signature. There was no evidence that the administrator participated in completing quarterly medication audits. On 10/24/23 at approximately 2:30 p.m., the RCD stated that she did not perform the documented medication audits provided by the residence. She added that the administrator did not participate in the audits. On 10/24/23 at 4:15 p.m., the administrator stated that he had not participated in quarterly medication audits and was unaware that he was required to participate prior to the onsite survey. He added that he was unaware that the residence had not completed the audits as required.

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 was completed on 4/12/23. Deficiencies were cited. A change of ownership occurred on 9/30/22.

Based on record review and interview, the residence failed to provide to the Department, upon request, access to or copies of residence documents for the performance of its regulatory oversight responsibilities, affecting 49 current residents. Findings include:1. Record ReviewOn 4/12/23 at 8:45 a.m., the residence's policies and COVID-19 ongoing vaccination and treatment plan were requested. On 4/12/23 at 10:37 a.m., the residence's policies and COVID-19 ongoing vaccination and treatment plan were again requested. On 4/12/23 at 10:44 a.m., complete resident records (including assessments) for six sample residents (#1-#6) were requested. On 4/12/23 at 10:50 a.m., current documentation for staff cardiopulmonary and first aid certifications were requested. At 11:52 a.m., the residence's policies and COVID-19 ongoing vaccination and treatment plan were requested for the third time. On 4/12/23 at 12:00 p.m., the residence's policies were provided, approximately three hours and 15 minutes after the original request. On 4/12/23 at 1:02 p.m., assessments for residents #1-#6 were provided, over two hours after the original request. On 4/12/23 at 1:19 p.m., the residence's COVID-19 ongoing vaccination and treatment plan, staff records for staff #1-#3, and current documentation for staff cardiopulmonary and first aid certifications were again requested. On 4/12/23 at 2:12 p.m., current documentation for staff cardiopulmonary and first aid certifications were requested for the third time. On 4/12/23 at approximately 2:45 p.m., the residence's COVID-19 ongoing vaccination and treatment plan was provided, approximately six hours after the original request. On 4/12/23 at 4:51 p.m., current documentation for staff cardiopulmonary and first aid certifications were provided for all applicable staff, six hours after the original request. 2. InterviewOn 4/12/23 at 5:15 p.m., the administrator stated she was aware of the requirement to provide documents to the department upon request. She stated, however, that she was not able to provide requested documents in a timely fashion because the resident care director was not working the day of the on site visit, so she was taking phone calls and handling resident issues which delayed providing documents to the department.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 49 current residents. Findings include:1. ReferencesThe COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/22/23, required residences to:-Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month) and (period two, defined as days 15-31 of each month). Multiple reports within the same reporting period will overwrite previous reporting and does not meet requirements for future reporting periods.-Assign at least one staff member to complete the Colorado RCF Infection Prevention Training using COTRAIN within two weeks of the assignment of duties and each calendar year thereafter. This information must be reported in EMResource and remain updated. 2. EMResourceOn 4/12/23 at 9:00 a.m., a review of the residence's EMResource details revealed the last date the residence reported updated information was on 2/1/23. It read that there were 53 current residents, with 55 residents having received the flu vaccine. EMResource was not updated to reflect the residence's current 49 residents nor the accurate number of residents who had received the flu vaccine. 3. RCF Infection Prevention TrainingOn 4/12/23 at 8:45 a.m. and at 1:19 p.m., documentation of the Colorado RCF Infection Prevention Training using COTRAIN for any staff was requested, but not provided. On 4/12/23 at 9:00 a.m., a review of the residence's EMResource entry, updated 2/1/23, revealed that the resident care director (RCD) was assigned to be the residence's infection prevention and control person. 4. InterviewOn 4/12/23 at 5:15 p.m., the administrator stated she did not complete the Colorado RCF Infection Prevention Training using COTRAIN, adding that she believed that the RCD did. The administrator stated, however, that she did not have the RCD's certificate of completion.

Based on interview and record review, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire, for two of three sample staff (#1, #2), affecting 49 current residents. Staff #2's personnel file revealed a hire date of 10/18/22. There was no evidence in the personnel file that a name-based criminal history report was conducted by the CBI. Staff #1's personnel file revealed a hire date of 3/7/23. There was documentation that a criminal history report was completed on 3/18/23. However, there was no evidence in the personnel file a name-based criminal history report was conducted by the CBI prior to Staff #1's hire date. The residence's staff schedule revealed that Staff #2 had worked on 3/27/23, 4/3/23, and the morning of 4/12/23. The residence's staff schedule revealed that Staff #1 had worked on 3/28-4/1/23, 4/4-4/8/23, and 4/11/23. On 4/12/23 at 5:15 p.m., the administrator stated that the business office director completed background checks for staff prior to hiring them. She acknowledged that the documents she provided did not indicate that a name-based criminal history report was conducted by the CBI for Staff #1 and #2. The administrator stated she could not answer as to why the residence did not have documentation of name-based criminal history reports conducted by the CBI.

Based on interview and record review, the residence failed to include written documentation regarding orientation and training in each personnel file, affecting three sample staff (#1-#3). Findings include:On 4/12/23, personnel documents were provided and revealed Staff #1-#3's files did not include any written documentation of orientation and training. On 4/12/123 at 5:15 p.m., the administrator stated that the residence provided orientation and training to all new staff. She stated however, that they had not implemented a formal process to include documentation of orientation and training. The administrator stated she was aware of the requirement for documenting staff orientation and training, however the residence had not been doing so.

Based on interview and record review, the residence failed to have at least one staff member onsite who had current certification in first aid from a nationally recognized organization, affecting 49 current residents. 1. References and Residence Policya. The residence's undated resident agreement read in part: "In accordance with Colorado law, there is on premises and on duty at all times at least one staff member who is trained in ... first aid."b. The residence's Emergency Training Policy, dated 10/1/22, read in part that the residence had at least one staff member on site at all times with current certification in first aid from a nationally recognized organization. 2. Record ReviewOn 4/12/23, documentation for all staff who had current first aid certifications was requested. However, the residence provided no documentation that Staff #1 and #7-#9 were currently certified in first aid. The residence's staff schedule from 3/26 to 4/11/23 revealed that Staff #1 and #7-#9 were scheduled for 11 overnight shifts: 3/26-4/1, 4/4-4/6, and 4/11/23. No other staff was scheduled. 3. InterviewOn 4/12/23 at 5:15 p.m., the administrator acknowledged the residence failed to ensure at least one staff member was on site at all times with current CPR certification, adding, "It fell through the cracks."

Based on record review and interview, the residence failed to ensure at least one staff member was on site at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization such as the American Red Cross, the American Heart Association, the National Safety Council or the American Safety and Health Institute, affecting 49 current residents. Specifically, the residence failed to have at least one staff member onsite at all times who had current certification in obstructed airway techniques for the following 11 overnight shifts: 3/26-4/1, 4/4-4/6, and 4/11/23. This failure created an immediate jeopardy risk to 49 current residents in the event of an obstructed airway emergency. On 4/12/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Residence Policya. The residence's undated resident agreement read in part: "In accordance with Colorado law, there is on premises and on duty at all times at least one staff member who is trained in CPR ... Staff certified in CPR are required to promptly provide those services in accordance with their training."b. The residence's Emergency Training Policy, dated 10/1/22, read in part that the residence had at least one staff member on site at all times with current certification in CPR and obstructed airway techniques from a nationally recognized organization.c. According to the Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that's useful in many emergencies, such as a heart attack or near drowning, in which someone's breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to both untrained bystanders and first responders." Mayo Clinic (2/12/22) Cardiopulmonary Resuscitation, retrieved from: https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 2. Record ReviewOn 4/12/23, documentation for all staff who had current CPR certifications was requested. However, the residence provided no documentation that Staff #1 and #7-#9 were currently certified in CPR and obstructed airway technique. The residence's staff schedule from 3/26 to 4/11/23 revealed that Staff #1 and #7-#9 were scheduled for 11 overnight shifts: 3/26-4/1, 4/4-4/6, and 4/11/23. No other staff was scheduled. 3. InterviewOn 4/12/23 at 5:15 p.m., the administrator acknowledged the residence failed to ensure at least one staff member was on site at all times with current CPR certification, adding, "It fell through the cracks."4. Immediate Jeopardy Risk- Written Evidence, Immediate CorrectionThe survey established that the findings above placed 49 current residents at immediate jeopardy risk for the failure to ensure at least one staff member was onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 4/12/23 at 4:51 p.m., the administrator submitted written evidence that read in pertinent part that the administrator ensured that at least one staff member was scheduled at all times who had current certification in CPR and obstructed airway techniques from 4/9/23 to 4/22/23. Additionally, it read the administrator would schedule CPR and obstructed airway technique training with a nationally recognized organization, and would check weekly with the business office manager (BOM) to ensure all staff had documented current certification. However, the written evidence did not indicate the risk had been removed because it did not include a scheduled class date and it did not address the correctiveaction to ensure a staff member with the required certification in CPR and obstructed airway techniques from a nationally recognized organization worked each shift from 4/23/23 until the date of the class on 4/27/23. On 4/12/22 at 5:05 p.m., the administrator submitted additional written evidence that read in pertinent part that the administrator scheduled CPR training with a nationally recognized organization on 4/27/23 at 9:00 a.m. However, the written evidence did not indicate the risk had been removed because it did not address the corrective action to ensure a staff member with the required certification in CPR and obstructed airway techniques from a nationally recognized organization worked each shift from 4/23/23 until the date of the class on 4/27/23. On 4/12/23 at 5:15 p.m., the administrator submitted additional written evidence that read in pertinent part that the administrator ensured that at least one staff member was scheduled at all times who had current certification in CPR and obstructed airway techniques from 4/12/23 to 4/27/23.

Based on record review and interview, the residence failed to place in a visible location a list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times, affecting 49 current residents. The residence's Emergency Training Policy, dated 10/1/22, read in part that the residence placed a list of staff who had current certifications in CPR and first aid in a visible location so that the information is readily available to staff at all times. On 4/12/23, from approximately 7:00 a.m. to 6:15 p.m., there was no list of staff with current CPR and first aid certifications placed in a visible location. On 4/12/23 at 11:58 a.m., the resident care coordinator stated that there was no list of staff with current certifications in CPR and first aid readily available to staff at all throughout the residence. On 4/12/23 at 5:15 p.m., the administrator stated she was aware of the requirement to place a visible list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times. She acknowledged, however, that the residence did not meet this requirement and added that she could not reply as to the reason.

Based on record review and interview, the residence failed to have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations, affecting 49 current residents. On 4/12/23 at 10:20 a.m., the resident care coordinator (RCC) provided a resident roster that included the resident names, the floor they resided on, and their room number. The roster did not include emergency contact information nor a diagram of the residence showing room locations. On 4/12/23 at 10:37 a.m., the RCC stated the resident roster she provided was the same roster the residence would provide to emergency responders in the case of an emergency. On 4/12/23 at 5:15 p.m., the administrator stated she was not aware that the residence was required to have a resident roster including the residents' emergency contact information and a diagram of the residence showing room locations.

Based on record review and interview, the residence failed to ensure that only medications that have been ordered by an authorized practitioner were prepared and administered, affecting four of five sample residents (#1-#3, #6). Findings include:1. Residence PolicyThe residence's Medication Records Policy, dated 10/1/22, read in part that a practitioner's order was required for all medications handled, stored, and administered by staff. Written practitioner's orders for all medications were maintained in the resident records in the "Physician Orders" section. 2. Resident #2 was admitted to the residence on 7/1/22 with diagnoses including cerebral infarction, epilepsy, osteoporosis, overactive bladder, vitamin D deficiency, bipolar disorder, and depression. The March and April 2023 medication administration records (MARs) read the residence administered the following medications from 3/1 to 4/11/23:Aspirin 81 mg dailyAtorvastatin 40 mg every eveningCarbamazepine 200 mg at 12:00 p.m. dailyCarbamazepine 400 mg twice dailyLamotrigine 100 mg twice dailyVitamin D3 100 mcg dailyAdditionally, the residence administered the following medications:Citalopram 40 mg daily on 3/1-3/10/23Citalopram 20 mg daily on 3/1, 3/2, 3/11-4/11/23Sumatriptan 25 mg daily on 3/1-4/10/23Myrbetriq 25 mg daily on 3/1-3/10, 3/22-4/11/23Vitamin B12 1000 mcg daily on 3/1-3/9, 3/11-4/10/23However, the residence did not provide written practitioner's orders for the above medications. 3. Resident #1 was admitted to the residence on 7/1/22 with diagnoses including age related physical debility, dysphagia, and vitamin D deficiency. The March and April 2023 MARs read the residence administered the following medications from 3/1 to 4/11/23:Acetaminophen 500 mg twice dailyAmlodipine 5 mg dailyAyr Nasal Gel one gram each nostril three times dailyDiclofenac Sodium 1% gel one gram twice daily to both kneesVitamin B-12 1000 mcg dailyVitamin D3 50 mcg dailyHowever, the residence did not provide written practitioner's orders for the above medications. 4. Resident #6 was admitted to the residence on 7/1/22 with diagnoses including allergic rhinitis. The March and April 2023 MARs read the residence administered the following medications from 3/1 to 4/11/23:Cranberry Concentrate 500 mg dailyFish Oil 1200 mg dailyLoratadine 10 mg dailyTab-A-Vite one tablet dailyVitamin B12 1000 mcg dailyVitamin D3 25 mcg dailyHowever, the residence did not provide written practitioner's orders for the above medications. 5. Resident #3 was admitted to the residence on 1/16/23 with diagnoses including hypertension, depression, anxiety, and pain. The March and April 2023 MARs read the residence administered the following medications:Amlodipine 5 mg daily on 3/7-4/3/232Calcium 600-vitamin D 600 mg daily on 3/28-3/30/23Duloxetine 40 mg daily on 3/11-4/3/23Hydrocodone-acetaminophen 5 mg-325 mg: one dose on 3/8, 3/20, and 4/3/23, two doses on 3/6/23, and four doses on 3/7 and 3/21-4/2/23Polyethylene Glycol 17 grams in liquid daily on 3/26, 3/28, 3/31, and 4/1/23However, the residence did not provide written practitioner's orders for the above medications. 6. InterviewOn 4/12/23 at 5:15 p.m., the administrator stated she was aware of the requirement that the residence have signed practitioner's orders for all medications that are administered by the residence. She stated when there was a change in the residence's ownership, in October 2022, the former owners allowed limited access to the residence's electronic information management system.

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records, affecting five of five sample residents (#1-#4, #6) whose medications were reviewed. (Cross-reference Q1430)Findings include:The residences Medication Records Policy, dated 10/1/22 read in part: "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 4/12/23 at 8:45 a.m., documentation of the residence's quarterly medication audits from the last two quarters was requested. On 4/12/23 at approximately 11:00 a.m., documents from the residences' preferred pharmacy, titled Consultation Report and signed by a pharmacy representative were provided. The Resident Care Director's (RCD) name was listed on the document but did not contain her signature. There was no evidence that the administrator participated in completing quarterly medication audits. On 4/12/23 at 5:15 p.m., the administrator stated it was the responsibility of the RCD and the resident care coordinator. She stated that she herself did not participate in quarterly medication audits, adding she was not aware of the requirement to do so.

Based on record review and interview, the residence failed to implement a method for the integration of records that allowed effective continuity of care, including the effective management for storing and retrieving care and service information, affecting 49 current residents. Findings include:Chapter VII regulations governing assisted living residences, part 18.8, requires that resident records contain the following items:(A) Face Sheet;(B) Practitioner order;(C) Individualized resident care plan;(D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs;(1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them.(E) Medication Administration Record;(F) Documentation of on-going services provided by external service providers including, but not limited to, family members, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants, and caregivers;(G) Advance directives, if applicable, with extra copies; and(H) Final disposition of resident including, if applicable, date, time, and circumstances of a resident ' s death, along with the name of the person to whom the body is released. The residence's Resident Record Policy, dated 10/1/22, read in part that each resident record was maintained in an orderly fashion and may include an electronic record and a physical chart. The residence implemented a policy and procedure for an effective information management system that is either paper-based or electronic. If the ALR maintains both paper-based and electronic records, there shall be a method for integration of those records that allows effective continuity of care. Processes shall include effective management for capturing reporting, processing, storing and retrieving care/service data and information. On 4/12/23 at 10:44 a.m., complete resident records were requested for sample residents #1-#6. The residence was unable to provide documentation of assessments for any of the sample residents. Additionally, the residence was unable to provide written practitioner's orders for Residents #1, #2, and #6's medications. On 4/12/23 at 5:15 p.m., the administrator stated the residence's previous owner did not allow them access to their electronic information management system for several weeks because they did not want the new owners to take something of theirs. She stated the new owners were slow to obtain access to the former owner's information management system, adding that when they did obtain access, it was for a short period of time. The administrator stated this was the reason for not being able to provide assessments for all sample residents and written practitioner's orders for Residents #1, #2, and #6's medications.

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 7.12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following:(A) Providing fall management education and materials to residents and family members;(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;(C) Providing resident engagement activities to improve strength and balance as specified in Part 12.22(C);(D) Routinely inspecting and maintaining a safe exterior and interior environment as specified in Parts 21 and 22; and(E) Providing staff training related to fall prevention as specified in Part 7.8(B)(6). 14.21 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. 14.27 No stock medications shall be stored or administered by qualified medication administration persons. 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. 22.32 The assisted living residence shall ensure that oxygen tanks are secured upright at all times in a manner that prevents tanks from falling over, being dropped, or striking each other.

A recertification survey was completed on 4/12/23. A deficiency was cited. PLEASE NOTE: The facility chose to voluntarily terminate medicaid certification effective 9/23/23. A plan of correction was not submitted or approved and therefore a revisit to determine compliance with the deficiency cited was not completed prior to de-certification.

Based on observations, interviews and record reviews, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with Chapter VII medication administration regulations, affecting five of six sample participants (residents) (#1-#4, #6)Findings include:1. Chapter VII regulations governing assisted living residences, part 14.11, requires residences to prepare and administer only medication that has been ordered by an authorized practitioner.a. Residence PolicyThe residence's Medication Records Policy, dated 10/1/22, read in part that a practitioner's order was required for all medications handled, stored, and administered by staff. Written practitioner's orders for all medications were maintained in the resident records in the "Physician Orders" section.b. Resident #2 was admitted to the residence on 7/1/22 with diagnoses including cerebral infarction, epilepsy, osteoporosis, overactive bladder, vitamin D deficiency, bipolar disorder, and depression. The March and April 2023 medication administration records (MARs) read the residence administered the following medications from 3/1 to 4/11/23:Aspirin 81 mg dailyAtorvastatin 40 mg every eveningCarbamazepine 200 mg at 12:00 p.m. dailyCarbamazepine 400 mg twice dailyLamotrigine 100 mg twice dailyVitamin D3 100 mcg dailyAdditionally, the residence administered the following medications:Citalopram 40 mg daily on 3/1-3/10/23Citalopram 20 mg daily on 3/1, 3/2, 3/11-4/11/23Sumatriptan 25 mg daily on 3/1-4/10/23Myrbetriq 25 mg daily on 3/1-3/10, 3/22-4/11/23Vitamin B12 1000 mcg daily on 3/1-3/9, 3/11-4/10/23However, the residence did not provide written practitioner's orders for the above medications.c. Resident #1 was admitted to the residence on 7/1/22 with diagnoses including age related physical debility, dysphagia, and vitamin D deficiency. The March and April 2023 MARs read the residence administered the following medications from 3/1 to 4/11/23:Acetaminophen 500 mg twice dailyAmlodipine 5 mg dailyAyr Nasal Gel one gram each nostril three times dailyDiclofenac Sodium 1% gel one gram twice daily to both kneesVitamin B-12 1000 mcg dailyVitamin D3 50 mcg dailyHowever, the residence did not provide written practitioner's orders for the above medications.d. Resident #6 was admitted to the residence on 7/1/22 with diagnoses including allergic rhinitis. The March and April 2023 MARs read the residence administered the following medications from 3/1 to 4/11/23:Cranberry Concentrate 500 mg dailyFish Oil 1200 mg dailyLoratadine 10 mg dailyTab-A-Vite one tablet dailyVitamin B12 1000 mcg dailyVitamin D3 25 mcg dailyHowever, the residence did not provide written practitioner's orders for the above medications.e. Resident #3 was admitted to the residence on 1/16/23 with diagnoses including hypertension, depression, anxiety, and pain. The March and April 2023 MARs read the residence administered the following medications:Amlodipine 5 mg daily on 3/7-4/3/232Calcium 600-vitamin D 600 mg daily on 3/28-3/30/23Duloxetine 40 mg daily on 3/11-4/3/23Hydrocodone-acetaminophen 5 mg-325 mg: one dose on 3/8, 3/20, and 4/3/23, two doses on 3/6/23, and four doses on 3/7 and 3/21-4/2/23Polyethylene Glycol 17 grams in liquid daily on 3/26, 3/28, 3/31, and 4/1/23However, the residence did not provide written practitioner's orders for the above medications.f. InterviewOn 4/12/23 at 5:15 p.m., the administrator stated she was aware of the requirement that the residence have signed practitioner's orders for all medications that are administered by the residence. She stated when there was a change in the residence's ownership, in October 2022, the former owners allowed limited access to the residence's electronic information management system. 2. Chapter VII regulations governing assisted living residences, part 14.21, requires residences to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administer. Resident #4 was admitted to the residence on 7/1/22.a. Fish OilA written practitioner's order, dated 3/23/23, directed the residence to administer fish oil omega-3 1000 mg daily. However, the April 2023 MAR revealed the residence failed to administer the medication on 4/8/23 to 4/11/23 because the medication was not available, for a total of four missed doses. On 4/12/23 at approximately 8:00 a.m., Staff #4 dispensed fish oil from a container that read a dosage of 1250 mg into a plastic medication cup. Staff #4 then administered this medication to Resident #4 in her room.b. Vitamin EA written practitioner's order, dated 3/23/23, directed the residence to administer vitamin E 450 mg daily. However, the April 2023 MAR read that the residence failed to administer the medication on 4/8/23 because the medication was not available, for one missed dose. On 4/12/23 at approximately 8:00 a.m., Staff #4 stated that Resident #4 ordered her own over the counter medications via the Internet. Staff #4 stated that either the resident care coordinator or the resident care director usually checked to ensure that the medications were the same dose as ordered by the resident's practitioner. On 4/12/23 at 5:15 p.m., the administrator stated the dosage for medication should match what is written on the practitioner's orders at all times, adding that all resident medications should have been in stock when there was a written practitioner's order to administer them. 3. Chapter VII regulations governing assisted living residences, part 14.31, requires the administrator and the QMAP supervisor 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. 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. The residences Medication Records Policy, dated 10/1/22 read in part: "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 4/12/23 at 8:45 a.m., documentation of the residence's quarterly medication audits from the last two quarters was requested. On 4/12/23 at approximately 11:00 a.m., documents from the residences' preferred pharmacy, titled Consultation Report and signed by a pharmacy representative were provided. The Resident Care Director's (RCD) name was listed on the document but did not contain her signature. There was no evidence that the administrator participated in completing quarterly medication audits. On 4/12/23 at 5:15 p.m., the administrator stated it was the responsibility of the RCD and the resident care coordinator. She stated that she herself did not participate in quarterly medication audits, adding she was not aware of the requirement to do so.