RESIDENCE AT VILLAGE GREEN LLC, THE

1/13/2026Licensure and Licensure Complaint (Combined) · ID 0NXC114 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey with complaint #CO40547 and #CO41413 was completed on 1/14/26. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0734Stf Req-First Aid 1 Stf Onsite CPRS/S B▼

Findings

Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 60 current residents. Findings include:Staff #4 had a CPR certification, however the certification was not from a nationally recognized organization, as required. The January 2026 staff schedule revealed the following 10:00 p.m. to 6:00 a.m. shifts did not have at least one staff member onsite who had current CPR certification from a nationally recognized organization:1/5, 1/9, 1/11-1/13, and 1/15/26, for a total of six shifts. On 1/14/26 at approximately 2:00 p.m., the administrator acknowledged that Staff #4's CPR certification was not nationally recognized. She added she expected there to be one person on-site on each shift who was certified in CPR from a nationally recognized organization.

Plan of correction · submitted by the facility

Tag 0734: At least one staff member who has the appropriate current CPR certification must be scheduled on every shift daily. It was found that staff member #4, who had a CPR certification, did not have the appropriate certification to count as the approved type designated for shift coverage as per requirement. At the time of the survey, 1/14/2026, it was discussed and explained that the plan already in place was that staff members were already scheduled to participate in CPR training the following week. It was posted and scheduled for 1/21/2026. There were seven staff members in attendance for the approved CPR training on that date, which included Staff #4. As of 1/21/2026, we have 100% of our current staff members properly certified in CPR training. Since currently there is 100% probability that there will be one person on every shift daily with proper CPR certification, the only monitoring would be the responsibility of the administrator upon hiring new staff members. She will verify possession of the proper CPR certification and either place a copy in their personnel file, housed in the business office, or add them to the posted list for the next scheduled CPR training to ensure maintenance of 100% completion. In reference to CPR certification discussion during the monthly QAPI meeting, the discussion and documentation will reflect that the community is at 100% CPR compliance, with the number of any new staff scheduled to attend the next training and the date of that training. This was completed on 1/21/2026 as stated during survey.

1146Res Care Srvs-Comp Res Asmnt Annl/Chng BslnS/S A▼

Findings

Based on interviews and record review, the residence failed to complete a reassessment whenever the resident had a change from baseline status, affecting one of five sample residents (Former Resident #8). Findings include: Findings include:Former Resident #8 was admitted to the residence on 1/2/24 with a diagnosis of stroke. She also has a diagnosis of high blood pressure and dizziness. An assessment in Former Resident #8's record was last completed in January 2024 when admitted. A signed practitioner's order dated 05/11/25, in Former Resident #8's chart read she could self-administer her medications, including lasartan 25mg tablet daily for hypertension (high blood pressure) and meclizine 12.5mg tablet daily as needed for dizziness. On 11/8/25, the incident report read that Former Resident #8's blood pressure was not taken; sent to the emergency department related to sciatica pain. On 11/9/25 at 1:30 p.m. the incident report read that Former Resident #8 ' s blood pressure was 166/97 at 2:50 p.m. it was 181/112. Former Resident #8 stated she was dizzy. Former Resident #8 was sent to emergency department. Upon return Former Resident #8 said she felt better and had not been taking her blood pressure medication. On 11/24/25 at 7:00 p.m. the incident report read that Former Resident #8 ' s blood pressure systolic reading was 190 and then taken a second time with systolic reading 195. Former Resident #8 informed QMAP that she did not take her blood pressure medication. QMAP administered Former Resident #8 ' s blood pressure medication. On 11/25/25 at 6:30 a.m. the incident report read Former Resident #8 was sent to the emergency department related to blood pressure per daughter ' s request. No noted blood pressure reading for this incident. On 11/25/25 read reason for visit was elevated blood pressure. On 11/9/25, the incident report read that a reassessment of medication self-administration should be completed to prevent recurrence. On 11/12/25, the incident report was signed by, the resident care coordinator (RCC) and the administrator. The reassessment of self-administration of medication was not completed. The resident continued to self-administer medication with continued emergency department visits. Review of Former Resident #8's record revealed no evidence that a reassessment was completed when she had a change in condition on 11/9/25. On 1/13/26 at 1:30 p.m., the resident care coordinator (RCC) said she was responsible for completing resident assessments every six months and/or with a change in baseline and updating care plans accordingly. On 1/14/26 at 2:00 p.m. Former Resident #8's clinic nurse said she was aware Former Resident #8 ' s noncompliance with medication and blood pressure diagnosis and she would expect the staff residence to contact the primary care provider to request a reassessment for self-administration of medication. On 1/14/26 at 2:30 p.m., Former Resident #8's practitioner said if Former Resident #8 had a concern with the non-compliance in her self-administration, he would expect the staff at the residence to reassess her. On 1/14/26 at 2:45, the administrator said she thought the reassessment was completed for Former Resident #8's non-compliance with taking her medication, noted on 11/9/25. She expected the RCC to have contacted the primary care provider to set up self-administration of medication re-assessment.

Plan of correction · submitted by the facility

Tag 1146: Resident Care Services and AssessmentFormer resident #8 was relocated to a different facility due to needing an increased level of care. Prior to leaving, she continued to self-administer her medications. At that time, there were concerns with her elevated blood pressure and she was sent out via AMR as needed. During this period, the administrator had a discussion with resident #8 and her daughter regarding our concern and the possibility of re-assessing her for her current ability to continue self-administering her medications. Both resident #8 and her daughter agreed that since the family had actively been deciding on a skilled nursing location, they would prefer not to make any adjustments or changes at that time. Although the administrator had suggested the re-assessment, it did not occur at the request of resident #8 and her daughter. The deficiency was in the lack of documenting the decision and outcome. Resident #8 had the right to refuse our request since she new she was moving very soon and had already chosen her new home. We abided by their request. So this would not occur again and to communicate the importance of complete, accurate, and thorough documentation, this example was used in an in-service facilitated by the RCC, Amy, and the administrator, at the mandatory all-staff meeting held on 1/29/2026. This was accounted for by the attendance sheet and topics made for that meeting. Any change of condition and/or concern with every resident will be addressed by the RCC with urgency. Every incident report and progress note is completed at the time of the incident, placed in the RCC box for review, signed off by the RCC, and passed on to the administrator for final review, questions, and recommendations for any follow-up needed by care staff and/or RCC. This plan increases accuracy and completion, the RCC is aware of any coaching needs or further instruction, and the administrator is aware and ultimately responsible for oversight. Incident reports and progress notes will continue to be discussed during the monthly QAPI meetings. Accuracy and follow-through is discussed in detail at these meetings as well. This procedure was in place already, and will continue per protocol on a daily basis as applicable. Since incident reports and progress notes reflect what happened and what was done about it in detail, this information is documented on the daily Qmap audit forms, which are reviewed and submitted by the RCC to the administrator for final review and sign off for accuracy and completion to maintain compliance.

1600Med/Med Adm-Rcrd Kpng MARS/S B▼

Findings

Based on record review and interviews, the residence failed to document accurate information in the medication administration record, including any medication omissions, refusals, and resident-reported responses to medications affecting five out of six sample residents (#1, #2, #4, #5 and #8). Findings include:Resident #2 was admitted to the residence on 5/23/25 with diagnoses including diabetic ketoacidosis, hypertension, chronic pain syndrome, hyperlipidemia, lactic acidosis, and leukocytosis. A written practitioner's order dated 5/23/25 directed the residence to administer. December 2025 and January 2026 MAR revealed blank spaces indicating undocumented doses for the following medications:Lantus Solostar 100 units/milliliter inject 14 units subcutaneously daily. Carvedilol 3.125mg tablet two times dailyCyclobenzaprine hcl 5mg tablet two times dailyAtrovastatin calcium 40mg one tablet dailyOxycodone 10mg one tablet every 4-6 hoursCephalexin 500mg capsule four times dailyFluticasone propionate 50 mcg/act suspension two sprays in each nostril for 14 days dailyOn 1/13/26 at 8:54 a.m. Staff #2 said she was trained to enter initials on the day/time when the medication was given or initial and circle if medication was not provided to the resident with an explanation on the MAR. She stated there should be no blanks on the MAR. Staff #2 recognized there were areas on resident MARs that were not initialed and did not know if the medication was given. On 1/13/26 at 9:29 a.m., staff #1 stated there should be initials on the MARs that coincide with the physician's order. There should be no blanks. On 1/13/26 at 3:52 p.m., the resident care coordinator (RCC) stated she was responsible to audit MARS monthly for completion. RCC states that blank dates on a MAR are considered a medication error. On 1/14/26 at 2:56 p.m., the administrator said the MARs are to be completed and accurate as required. She said that they wereworking on the accuracy of MARS. "The new resident care coordinator was providing education". Similar deficient practice was found for Residents #1, #4, #5 and Former Resident #8.

Plan of correction · submitted by the facility

Tag 1600: Medication Administration - Open spaces in the MAR,Although staff members understand the regulation expectation and have been trained, there were still blank spaces. To ensure blank spaces will not appear in the MAR, during our recent mandatory all staff meeting on 1/29/2026, we facilitated an in-service to include a reading of the current medication administration policy and proper procedures in documentation in the MAR with accuracy and completion. All staff members were in attendance and signed off on an in-service attendance sheet which was placed in the In-service and Training Binder housed in the business office. Picture available upon request. Plan for monitoring: There is a Daily Audit Form which is completed by the Qmap, on each cart, at the end of each shift daily. The Qmap uses this form to ensure the key items are accounted for on their shift. Completion of this daily audit mandates each Qmap ensures that every space is initialed, medication administered, refusals documented, PRNs given, and all necessary accompanied information is accounted for before they leave their shift. The Resident Care Coordinator (RCC) is responsible for collecting these signed audits daily, and on Monday after days off, to follow up on necessary completion of a Medication Error Form, attached to a Disciplinary Action Form, for medication errors and for coaching opportunities for improvement. Additionally, the RCC compiles the information to place on her monthly audits, which are discussed at length during the monthly QAPI meetings. The administrator then signs off on all MAR and cart audits as completed, The audits are maintained in a binder labeled, "Health Services Audits", which is housed in the Administrator's office. The signed daily, monthly, and quarterly audits are kept in this binder for reference as needed. Any disciplinary action on this topic is signed by the Qmap, RCC, and Administrator and it is placed in their personnel file, housed in the business office. This process addresses overall accountability, any need for additional training, and offers support to ensure nothing is left blank on the MAR. This plan is currently in place and will continue indefinitely.

2512Ext Env HazS/S B▼

Findings

Based on observation and interviews, the residence failed to maintain grounds to protect residents from slopes, holes and other hazards, affecting 60 current residents. Findings include:On 1/14/26 from approximately 1:00 p.m. to 1:15 p.m., an environmental tour revealed a concrete walkway to the courtyard in the middle of the residence. However, the edge of the sidewalk had a drop off of 2.6 inches, which posed a hazard. On 1/13/26 and 1/14/26 residents were observed exiting the dining room doors into the courtyard and walking east into the connecting residence. The west side of the exterior of the residence, the corner edge of the sidewalk had a drop of 3.8 inches. On 1/13/26 and 1/14/26 residents were observed exiting the dining room doors into the courtyard and walking east into the connecting residence. On 1/14/26 at approximately 3:09 p.m. the administrator acknowledged that the edge of the sidewalk was steep and could pose a hazard.

Plan of correction · submitted by the facility

Tag 2512: EnvironmentalAs discussed during the survey walk-around, although the majority of the walkways in the gazebo patio area had been leveled to the walkway height for safety, there was an area near the activity back door and along the patio near that area that needed to be filled in for safety..We immediately purchased additional dirt/mulch to level those areas for safety. On 1/16/2026, the work was completed to bring us up to the expected compliance standards. The management team has agreed to monitor all exterior filled areas to make certain materials remain in place after inclement weather. The room in which the daily management meetings are held overlooks the recently repaired area and the enter patio, making it easy to monitor frequently. Additionally, the maintenance director and administrator walk the grounds weekly to account for all environmental needs. This information is documented in the QAPI notes for discussion on a monthly basis. This correction was completed by the maintenance director on 1/16/2026. Pictures are available upon request.

9999Final ObservationsSurveyor note▼

Findings

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 7.12.10 Each resident care plan shall:(A) Be developed with input from the resident and the resident ' s representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence ' s visitation policy as required by Part 9.2, along with care coordination arrangements; and(F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident ' s personal choices and needs.

Plan of correction

The state did not require a plan of correction for this citation.

1/13/2026State Certification and State Certification Complaint (Combined) · ID IRX9116 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A recertification survey with complaint #CO40549 and #CO41412 were completed on 1/14/26. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0148Ind Rts-Adtl Crit-Prov Own/Ctrl-Res-Lock/Key▼

Findings

Based on observation and interviews, the facility (residence) failed to protect the right to privacy and dignity of members (residents) by failing to provide a lockable bathroom, affecting 60 current residents. Findings include:ObservationOn 1/14/26 at approximately 12:27 p.m., an environmental tour of the residence revealed two of the facility bathrooms in the hallway did not have a lock on the doors to access the bathroom. InterviewOn 1/14/26 at 1:45 p.m. the administrator acknowledged that there was a push button on both of the bathrooms in the hallway. The administrator stated that she was not aware that push button locks were not allowed on the doors.

Plan of correction · submitted by the facility

0148: Although the two hall restroom doors locked from the inside for dignity and privacy, they had push button locks inside with no key entry from the outside. Both of the inappropriate handles were immediately replaced with a turning mechanism in the inside and a key lock on the outside of the door. This ensures both privacy and dignity. There is no additional monitoring required to ensure that any use of the two hall common area restrooms offer full privacy. This deficiency was corrected on 1/15/2026 by a member from our maintenance department. Completion pictures are available upon request.

0850PA Req-Personnel-Trainings▼

Findings

Based on records review and interviews, the facility (residence) failed to maintain a training program that trained staff on the health, safety, and services and supports to be provided related to the specific needs of members (residents) served, affecting 60 current residents. Findings include:Staff #4 had a CPR certification, however the certification was not from a nationally recognized organization, as required. The January 2026 staff schedule revealed the following 10:00 p.m. to 6:00 a.m. shifts did not have at least one staff member onsite who had current CPR certification from a nationally recognized organization:1/5, 1/9, 1/11-1/13, and 1/15/26, for a total of six shifts. On 1/14/26 at approximately 2:00 p.m., the administrator acknowledged that Staff #4's CPR certification was not nationally recognized. She added she expected there to be one person on-site on each shift who was certified in CPR from a nationally recognized organization.

Plan of correction · submitted by the facility

Tag 0850: At least one staff member who has the appropriate current CPR certification must be scheduled on every shift daily. It was found that staff member #4, who had a CPR certification, did not have the appropriate certification to count as the approved type designated for shift coverage as per requirement. At the time of the survey, 1/14/2026, it was discussed and explained that the plan already in place was that staff members were already scheduled to participate in CPR training the following week. It was posted and scheduled for 1/21/2026. There were seven staff members in attendance for the approved CPR training on that date, which included Staff #4. As of 1/21/2026, we have 100% of our current staff members properly certified in CPR training. Since currently there is 100% probability that there will be one person on every shift daily with proper CPR certification, the only monitoring would be the responsibility of the administrator upon hiring new staff members. She will verify possession of the proper CPR certification and either place a copy in their personnel file, housed in the business office, or add them to the posted list for the next scheduled CPR training to ensure maintenance of 100% completion. In reference to CPR certification discussion during the monthly QAPI meeting, the discussion and documentation will reflect that the community is at 100% CPR compliance, with the number of any new staff scheduled to attend the next training and the date of that training.

0920PA Req-Med Admin-Rx/PRN▼

Findings

Based on record review and staff interview, the facility failed to ensure medication administered to or refused by members was documented for five out of six sample members (#1, #2, #4, #5 and #8). Findings include:Resident #2 was admitted to the residence on 5/23/25 with diagnoses including diabetic ketoacidosis, hypertension, chronic pain syndrome, hyperlipidemia, lactic acidosis, and leukocytosis. A written practitioner's order dated 5/23/25 directed the residence to administer. December 2025 and January 2026 MAR revealed blank spaces indicating undocumented doses for the following medications:Lantus Solostar 100 units/milliliter inject 14 units subcutaneously daily. Carvedilol 3.125mg tablet two times dailyCyclobenzaprine hcl 5mg tablet two times dailyAtrovastatin calcium 40mg one tablet dailyOxycodone 10mg one tablet every 4-6 hoursCephalexin 500mg capsule four times dailyFluticasone propionate 50 mcg/act suspension two sprays in each nostril for 14 days dailyOn 1/13/26 at 8:54 a.m. Staff #2 said she was trained to enter initials on the day/time when the medication was given or initial and circle if medication was not provided to the resident with an explanation on the MAR. She stated there should be no blanks on the MAR. Staff #2 recognized there were areas on resident MARs that were not initialed and did not know if the medication was given. On 1/13/26 at 9:29 a.m., staff #1 stated there should be initials on the MARs that coincide with the physician's order. There should be no blanks. On 1/13/26 at 3:52 p.m., the resident care coordinator (RCC) stated she was responsible to audit MARS monthly for completion. RCC states that blank dates on a MAR are considered a medication error. On 1/14/26 at 2:56 p.m., the administrator said the MARs are to be completed and accurate as required. She said that they wereworking on the accuracy of MARS. "The new resident care coordinator was providing education". Similar deficient practice was found for Residents #1, #4, #5 and Former Resident #8.

Plan of correction · submitted by the facility

Tag 0920: Medication Administration - Open spaces in the MAR,Although staff members understand the regulation expectation and have been trained, there were still blank spaces. To ensure blank spaces will not appear in the MAR, during our recent mandatory all staff meeting on 1/29/2026, we facilitated an in-service to include a reading of the current medication administration policy and proper procedures in documentation in the MAR with accuracy and completion. All staff members were in attendance and signed off on an in-service attendance sheet which was placed in the In-service and Training Binder housed in the business office. Picture available upon request. Plan for monitoring: There is a Daily Audit Form which is completed by the Qmap, on each cart, at the end of each shift daily. The Qmap uses this form to ensure the key items are accounted for on their shift. Completion of this daily audit mandates each Qmap ensures that every space is initialed, medication administered, refusals documented, PRNs given, and all necessary accompanied information is accounted for before they leave their shift. The Resident Care Coordinator (RCC) is responsible for collecting these signed audits daily, and on Monday after days off, to follow up on necessary completion of a Medication Error Form, attached to a Disciplinary Action Form, for medication errors and for coaching opportunities for improvement. Additionally, the RCC compiles the information to place on her monthly audits, which are discussed at length during the monthly QAPI meetings. The administrator then signs off on all MAR and cart audits as completed, The audits are maintained in a binder labeled, "Health Services Audits", which is housed in the Administrator's office. The signed daily, monthly, and quarterly audits are kept in this binder for reference as needed. Any disciplinary action on this topic is signed by the Qmap, RCC, and Administrator and it is placed in their personnel file, housed in the business office. This process addresses overall accountability, any need for additional training, and offers support to ensure nothing is left blank on the MAR. This plan is currently in place and will continue indefinitely.

0922PA Req-Med Admin-Independent Admin-Qtrly Rvw▼

Findings

Based on observation, record review and interview, the agency failed to adequately document quarterly monitoring of the member's ability for independent medication administration to determine that the medication was taken correctly for one member (#8) of eight sampled members. Findings include: Record ReviewOn 1/13/26 at 9:00 a.m., there are no self-administration of medication quarterly audits to determine if members can take medications as prescribed. InterviewsOn 1/13/26 at 3:52 p.m., the resident care coordinator (RCC) stated she is responsible to audit MARS monthly for completion. RCC states that blank dates on a MAR are considered a medication error. On 1/14/26 at 2:56 p.m., the administrator said the MARs are to be completed and accurate as required. She said that they are working on the accuracy of MARS. The new resident care coordinator is providing education and is required to do audits weekly and quarterly. QMAPs are to complete daily audits.

Plan of correction · submitted by the facility

Tag 0922: Independent Medication Administration - QuarterlyThe new RCC has been working on collecting the necessary documentation to include a self-administration assessment and a doctor's order for the quarter. As of 2/2/2026, the self-administration assessments are completed and housed in the respective residents chart, locked in the medication room.. Of the ten current residents who independently administer their own medications, all but two doctor's orders have been received and were placed in the charts as well. The two remaining doctor orders are due to be received by 2/11/2026. The system put in place to maintain consistent quarterly completion of re-assessments and doctor orders for self-administration is a spreadsheet with resident names, date completed, and next due date. 2 This spreadsheet system will be monitored and maintained by the RCC on her business computer in her office. She has also set a recurring quarterly reminder on her Outlook calendar. There will be no citations for this when this system is followed. The monitoring system will also include support from the administrator when new residents sign contracts for move-in. The administrator will note if they will be self-administering their medications and pass the information on to the RCC to complete a self-administration assessment and immediately reach out to the doctor, unless it is already part of the documentation submitted. This will ensure that upon move-in, the proper documentation is in place and they are placed on the RCC's Outlook quarterly calendar to remain in compliance. When there are changes and a resident can no longer self-administer their medications, documentation will reflect this in the resident's chart on their personalized care plan. In addition, this is discussed following a list of health service topics during the monthly QAPI meeting. This system is currently in place, maintained on the RCC's computer, and scheduled for recurring quarters on her Outlook calendar, and will continue indefinitely.

1750Ben/Svc Req-ACF-PA-Member Engagement▼

Findings

Based on observations and interviews, the facility (residence) failed to provide members (residents) with social and recreational engagement opportunities in an outside the setting, affecting 3 current residents. Observation: On 1/14/26 at approximately 9:00 a.m. it was observed that a community outing was scheduled to take members to the Dollar Tree store. Several members attended but there were no residents in a motorized chair who participated. Interviews:On 1/14/26 at 1:00 p.m., Member #3 stated he would have liked to go on the outing this morning to the Dollar Tree with the facility, but since the van does not have a lift for his electric wheelchair, he did not feel he had the option to go and was not offered an alternate option. On 1/13/26 at 11:30 a.m. Member #1 stated she would not ask to participate in community outings because they did not have a van with a lift for her electric wheelchair. On 1/14/26 at 2:40 p.m. Administrator said as per the member's contract, the facility did not provide a lift assistance van, and it is the member ' s responsibility to make arrangements. The administrator did state she did buy steps with handrails to help get into the van. Members can utilize family. She had offered to physically lift members into the van.

Plan of correction · submitted by the facility

Tag 1750: Member EngagementEvery resident is aware that their contract states that we do not have a van with a lift. The administrator discusses this with every incoming resident during contract signing making certain they are aware. Those with motorized chairs are also aware that there are alternate methods available to them to empower them in participating in every scheduled outdoor function. Member #3 has been invited numerous times to participate in outings and was offered physical lift assistance into the van, other means of transportation, and we also assisted him in completing the Colorado Metro Mobility paperwork and submitted it for him. When member #3 is offered solutions, he consistently turns us down, but we continue to invite and encourage. Member #1 has shown minimal interest in a few of our outings, but has a family member who graciously offers to drive her to participate as she desires. The current plan in place is having a sign-up sheet for every scheduled outdoor activity posted on a board outside of the activity office, next to the large monthly calendar of events posted in the hallway. This is maintained by the activity director, Demi. This was corrected beginning 2/1/2026. We have added a statement to the top of every outing activity posting which states: "If any resident is unable to join on the community van for any outing, please see Demi for a list of alternative transportation options so you may participate". This statement is also printed at the bottom of the large monthly schedule of events calendar so every resident is aware of their options and the support being offered, per our obligation to them, as stated in their agreement. This is also discussed at our monthly QAPI meetings under "resident support" topics to ensure our obligations are consistently and satisfactorily being met. The February 2026 activity calendar and individual outing flyers have all been posted with the inclusion of the alternate transportation statement as of February 1, 2026 and will continue indefinitely. Pictures available upon request.

1780Ben/Svc Req-ACF-PA-Env Standards▼

Findings

Based on observations and interviews, the facility (residence) failed to provide an outdoor area accessible to members (residents) without staff assistance that is well maintained for 60 current residents. Findings include:On 1/14/26 from approximately 1:00 p.m. to 1:15 p.m., an environmental tour revealed a concrete walkway to the courtyard in the middle of the residence. However, the edge of the sidewalk had a drop off of 2.6 inches, which posed a hazard. On 1/13/26 and 1/14/26 residents were observed exiting the dining room doors into the courtyard and walking east into the connecting residence. The west side of the exterior of the residence, the corner edge of the sidewalk had a drop of 3.8 inches. On 1/13/26 and 1/14/26 residents were observed exiting the dining room doors into the courtyard and walking east into the connecting residence. On 1/14/26 at approximately 3:09 p.m. the administrator acknowledged that the edge of the sidewalk was steep and could pose a hazard.

Plan of correction · submitted by the facility

Tag 01780: EnvironmentalAs discussed during the survey walk-around, although the majority of the walkways in the gazebo patio area had been leveled to the walkway height for safety, there was an area near the activity back door and along the patio near that area that needed to be filled in for safety..We immediately purchased additional dirt/mulch to level those areas for safety. On 1/16/2026, the work was completed to bring us up to the expected compliance standards. The management team has agreed to monitor all exterior filled areas to make certain materials remain in place after inclement weather. The room in which the daily management meetings are held overlooks the recently repaired area and the enter patio, making it easy to monitor frequently. Additionally, the maintenance director and administrator walk the grounds weekly to account for all environmental needs. This information is documented in the QAPI notes for discussion on a monthly basis. Pictures are available upon request.

9999Final ObservationsSurveyor note▼

Findings

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 10 CCR 2505-10 8.7000.8.7410 Rendering services according to the Person-Centered Support PlanA. Provider Agencies shall provide all Provider Agencies identified in the Person-Centered Support Plan (PCSP) a copy of the PCSP. Provider Agencies shall maintain this plan on file and ensure it is accessible to all staff who need it. B. Provider Agencies shall utilize the Person-Centered Support Plan as the basis for completing a Provider Care Plan. Any member of the Member Identified Team should be included in the development of the Provider Care Plan. C. Provider Care Plan 1. All Provider Agencies identified in the Person-Centered Support Plan shall develop a Provider Care Plan for each Member. 2. The Provider Care Plan should, at a minimum, identify the following:a. The service and care needs of the Member;b. Provider Care Plan development date;c. Goals or Objectives of the service(s);d. A description of the specific services, supports, methodologies or interventions used to address the identified needs of the Member, written in plain language including;i. information about the Member's preferencesii. relevant medical information from medical and therapy providers (PCP, OT, PT, Speech, etc.)g. Duration: Describes how long the service will be delivered, with the duration of the service corresponding to the abilities of the Member and is reflective of the billing unit identified by service; and h. Frequency: Identifies how often the service or support will be offered to the Member, according to their needs and preferences. 3. The Provider Care Plan shall assure the protection of the rights of Members as defined by the Department under applicable programs, including but not limited to Section 8.7001, et seq. 4. Provider Agencies shall follow specific service or care plan regulations for each covered benefit they render to a Member. Provider Care Plans may vary by name depending on the covered benefit, but will describe the information outlined above. 5. The Provider Care Plan shall be reviewed at least two times a year. as needed, to determine:a. The results achieved;b. If the needs of the Member are accurately reflected in the Provider Care Plan;c. Whether the services and supports identified in the Provider Care Plan are appropriate to meet the Member's needs as assessed in the Person-Centered Support Plan; andd. What actions are necessary for the Provider Care Plan to be successfully implemented. D. Members receiving services shall be included in developing the Provider Care Plan and have the freedom to choose from willing Provider Agencies. E. Provider Agencies shall coordinate with other Provider Agencies, when applicable. F. A Provider Agency shall not condition a Member's receipt of any service on the Member's agreement to receive other services from the provider. G. A Provider Agency shall not discontinue or refuse to provide agreed upon services to a Member unless documented efforts have been made to resolve the situation that triggers such discontinuation or refusal to provide services.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Licensure Complaint · ID JJP111No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO39092, was completed on 4/8/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: Licensure and Licensure Complaint (Combined) · ID ZCVZ15No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey and complaint revisit was completed on 4/8/25 for the previous deficiency cited on 1/14/25. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: State Certification and State Certification Complaint (Combined) · ID YD9K18No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A recertification survey and complaint revisit was completed on 4/8/25 for the previous deficiency cited on 1/14/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: Licensure Complaint · ID TE4317No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/8/25, the previous deficiency cited on 1/14/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: Licensure Complaint · ID RHKP16No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/8/25 for the previous deficiency cited on 1/14/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: Licensure Complaint · ID Q1G513No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/8/25 for the previous deficiency cited on 1/14/25. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: Licensure Complaint · ID RWK713No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/8/25 the previous deficiency cited on 1/14/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: Licensure Complaint · ID ELBO16No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/8/25 for the previous deficiency cited on 1/14/25. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: State Certification and State Certification Complaint (Combined) · ID EI5T15No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A recertification survey and complaint revisit was completed on 4/8/25 for the previous deficiency cited on 1/14/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: Licensure Complaint · ID 8XY714No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/8/25 for the previous deficiency cited on 1/14/25. The facility is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: Licensure Complaint · ID 8MXJ14No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/8/25 for the previous deficiency cited on 1/14/25. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Licensure Complaint · ID 5LCF11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A certification complaint, prompted by #CO39093, was completed on 4/8/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

4/8/2025Revisit: Licensure Complaint · ID 4RC413No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/8/25 for the previous deficiency cited on 1/14/25. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

1/14/2025Revisit: Licensure Complaint · ID Q1G5121 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 1/14/25 for all previous deficiencies cited on 3/28/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on observation, interview, and record review the residence failed to comply with authorized practitioner's orders affecting one of two sample residents (#36). This deficiency was cited previously during a complaint investigation concluded on 3/28/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

S156814.21 Med/Med Admin-Orders Cmpy w/OrdThe residence corrected the deficiency, but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same timespan of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middle-man and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply arrived to the facility on 2/2/25. This POC will help to ensure the continued compliance with both medication orders and administration. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described.

1/14/2025Revisit: Licensure and Licensure Complaint (Combined) · ID ZCVZ141 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey and complaint revisit was completed on 1/14/25 for all previous deficiencies cited on 3/28/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on observation, interview, and record review the residence failed to comply with authorized practitioner's orders affecting one of two sample residents (#36). This deficiency was cited previously during a complaint investigation concluded on 3/28/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

S156814.21 Med/Med Admin-Orders Cmpy w/OrdThe residence corrected the deficiency, but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same timespan of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middle-man and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply arrived to the facility on 2/2/25. This POC will help to ensure the continued compliance with both medication orders and administration. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described.

1/14/2025Revisit: State Certification and State Certification Complaint (Combined) · ID YD9K171 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A recertification survey and complaint revisit was completed on 1/14/25 the previous deficiency cited on 3/28/24. A deficiency was cited. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 11/30/24.

Plan of correction

The state did not require a plan of correction for this citation.

0920PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl Rvw▼

Findings

Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription medications, affecting one of two sample residents (#36). This deficiency was cited previously during a complaint investigation concluded on 3/28/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

0920 - GVEBPA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl RvwThe residence corrected the deficiency, but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same timespan of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middle-man and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply arrived to the facility on 2/2/25. This POC will help to ensure the continued compliance with both medication orders and administration. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described.

1/14/2025Revisit: Licensure Complaint · ID TE43161 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 1/14/25 for all previous deficiencies/the previous deficiency cited on 3/28/24. A deficiency was cited. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 11/30/24.

Plan of correction

The state did not require a plan of correction for this citation.

0920PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl Rvw▼

Findings

Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription medications, affecting one of two sample residents (#36). This deficiency was cited previously during a complaint investigation concluded on 3/28/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

0920 - GVEBPA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl RvwThe residence corrected the deficiency, but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same timespan of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middle-man and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply arrived to the facility on 2/2/25. This POC will help to ensure the continued compliance with both medication orders and administration. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described.

1/14/2025Revisit: Licensure Complaint · ID RWK7121 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 1/14/25 for all previous deficiencies. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0920PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl Rvw▼

Findings

Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription medications, affecting one of two sample residents (#36). This deficiency was cited previously during a complaint investigation concluded on 3/28/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

0920 - GVEBPA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl RvwThe residence corrected the deficiency, but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same timespan of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middle-man and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply arrived to the facility on 2/2/25. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described. This POC will help to ensure the continued compliance with both medication orders and administration.

1/14/2025Revisit: Licensure Complaint · ID RHKP151 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 1/14/25 for all previous deficiencies/the previous deficiency cited on 3/28/24. A deficiency was cited. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 11/30/24.

Plan of correction

The state did not require a plan of correction for this citation.

0920PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl Rvw▼

Findings

Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription medications, affecting one of two sample residents (#36). This deficiency was cited previously during a complaint investigation concluded on 3/28/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

0920 - GVEBPA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl RvwThe residence corrected the deficiency, but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same timespan of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middle-man and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply arrived to the facility on 2/2/25. This POC will help to ensure the continued compliance with both medication orders and administration. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described.

1/14/2025Revisit: Licensure Complaint · ID QZPI12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 1/14/25 for all previous deficiencies cited on 11/8/23. The facility is in compliance with all regulations surveyed. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 11/30/24.

Plan of correction

The state did not require a plan of correction for this citation.

1/14/2025Revisit: Licensure Complaint · ID 8MXJ131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 1/14/25 for all previous deficiencies cited on 3/28/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on observation, interview, and record review the residence failed to comply with authorized practitioner's orders affecting one of two sample residents (#36). This deficiency was cited previously during a survey and complaint investigation revisit concluded on 3/28/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

156814.21 Med/Med Admin-Orders Cmpy w/OrdThe residence corrected the deficiency but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same time span of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case, it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middleman and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply has arrived at the facility. This POC will help to ensure the continued compliance with both medication orders and administration. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described.

1/14/2025Licensure Complaint · ID K5BW11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO38914 was completed on 1/14/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1/14/2025Revisit: Licensure Complaint · ID ELBO151 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey and complaint revisit was completed on 1/14/25 for all previous deficiencies cited on 3/28/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on observation, interview, and record review the residence failed to comply with authorized practitioner's orders affecting one of two sample residents (#36). This deficiency was cited previously during a complaint investigation concluded on 3/28/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

S156814.21 Med/Med Admin-Orders Cmpy w/OrdThe residence corrected the deficiency, but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same timespan of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middle-man and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply arrived to the facility onThis POC will help to ensure the continued compliance with both medication orders and administration. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described.

1/14/2025Revisit: State Certification and State Certification Complaint (Combined) · ID EI5T141 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A recertification survey and complaint revisit was completed on 1/14/25 the previous deficiency cited on 3/28/24. A deficiency was cited. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 11/30/24.

Plan of correction

The state did not require a plan of correction for this citation.

0920PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl Rvw▼

Findings

Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription medications, affecting one of two sample residents (#36). This deficiency was cited previously during a complaint investigation concluded on 3/28/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

0920GVEB - PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl RvwThe residence corrected the deficiency, but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same timespan of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middle-man and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son, Kevin Steele. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply arrived to the facility onThis POC will help to ensure the continued compliance with both medication orders and administration. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described.

1/14/2025Revisit: Licensure Complaint · ID ED4912No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 1/14/25 for all previous deficiencies cited on 9/19/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1/14/2025State Certification Complaint · ID 54VO11No deficiencies▼

0000Initial commentsSurveyor note▼

Findings

A certification complaint, prompted by #CO38913 was completed on 1/14/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1/14/2025Revisit: Licensure Complaint · ID 8XY7131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 1/14/25 for all previous deficiencies/the previous deficiency cited on 3/28/24. A deficiency was cited. The regulations governing Home and Community-Based Services were revised and the new regulations were implemented on 11/30/24.

Plan of correction

The state did not require a plan of correction for this citation.

0920PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl Rvw▼

Findings

Based on record review and interview, the facility (residence) failed to provide sufficient support to members (residents) in the use of prescription medications, affecting one of two sample residents (#36). This deficiency was cited previously during a complaint investigation concluded on 3/28/24. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

0920PA Req-Med Admin-Rx/PRN-Wrtn Ordr/Annl RvwThe residence corrected the deficiency but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same time span of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. The facility did not provide sufficient support to ensure #36 received the medication per orders. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case, it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middleman and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son, Kevin Steele. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply arrived at the facility on 2/2/25. This POC will help to ensure the continued compliance with both medication orders and administration. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described.

1/14/2025Revisit: Licensure Complaint · ID 4RC4121 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 1/14/25 for all previous deficiencies cited on 3/28/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on observation, interview, and record review the residence failed to comply with authorized practitioner's orders affecting one of two sample residents (#36). This deficiency was cited previously during a complaint investigation concluded on 3/28/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #36 was admitted to the residence on 6/1/21 with a diagnosis of an enlarged prostate. a. Potassium chloride A written practitioner's order, dated 11/26/24, directed the residence to administer potassium chloride extended-release 24 meq one tablet twice daily. However, the December 2024 medication administration record (MAR) read the medication was not administered from 12/17-12/28/24 as the morning and evening doses were out of stock. A total of 24 doses were missed. b. Oxybutynin chlorideA written practitioner's order, dated 11/26/24, directed the residence to administer oxybutynin chloride 5 mg one tablet daily. However, the January 2025 MAR read the medication was not administered from 1/7-1/14/25 as the medication was out of stock. A total of eight doses were missed. On 1/14/25 at 3:00 p.m., Staff #20 stated she was aware that Resident #36 was still out of oxybutynin. She stated the residence telephoned the pharmacy to receive a refill of the medication; however, the resident's family member was responsible for picking up and delivering the medication to the residence. She stated the residence had notified Resident #36's family member multiple times but he/she had not responded. On 1/14/25 at 5:45 p.m., the licensed practical nurse (LPN) stated she was aware that Resident #36 had been out of his potassium chloride in December 2024 and that he was currently out of his oxybutynin. She stated she notified Resident #36's family member that the resident had run out of oxybutynin; however, the family member had not responded. The LPN stated the residence notified the pharmacy of any refills but the resident's family member picked up the medications and delivered them to the residence. Additionally, she notified the practitioner and requested the oxybutynin to be placed on hold; however, they had not received a hold order as of yet. On 1/14/25 at 5:45 p.m., the administrator stated the residence created a new policy in July 2024 for families who provided medications for the residents. She stated the residence notified the family when the medication was getting low and that they had five days after notification to ensure the medication(s) were delivered to the residence. If the medication(s) were not delivered, the residence would provide the medication, and the family member was required to absorb the cost. However, she could not explain why they had not followed their new policy and why Resident #36 had been out of the above medications.

Plan of correction · submitted by the facility

S156814.21 Med/Med Admin-Orders Cmpy w/OrdThe residence corrected the deficiency but failed to maintain compliance with one resident #36. Although there were extenuating circumstances occurring during the same time span of this situation, including change of pharmacy, lack of follow-through from family delivering medications during the holidays, a change in their insurance company, and one of the medications being discontinued, but inadvertently left on the MAR by pharmacy, it is still the responsibility of the facility to comply with practitioner orders associated with medication administration. POC:1) The administrator wrote a policy in July 2024 to keep out-of-stock situations from occurring. This policy is generally followed, but in this case, it was not entirely followed to completion. 2) Part of this POC is to retrain the Qmaps and nursing department heads, including the LPN, to follow the policy in place until the necessary medications have arrived in the facility with no exceptions to that rule. This training is scheduled to be facilitated by the administrator at the next clinical staff training on 2/27/25. A copy of the attendance sheet and "out-of-stock" policy can be submitted upon completion. This will be monitored closely by the lead Qmaps bi-weekly and will be notated on the medication audit forms, maintained in the health services office. 3) The administrator immediately made an appointment to meet in person with the POA (son of #36) to discuss the solution of omitting him as the medication delivery middleman and instead have the medications delivered directly to the facility to ensure timely receipt moving forward. The meeting included the administrator, the LPN, and #36s son, Kevin Steele. This meeting was held on 1/30/25 at 1:00. The facility took control of receipt and medication administration at that time. 4) POA had a discussion with the new pharmacy about logistics and expectations, whereby obtaining an agreement that the facility would receive 100-day supplies with refills for his medication. This was put into place immediately, and the first supply arrived at the facility on 2/2/25. This POC will help to ensure the continued compliance with both medication orders and administration. ADDENDUM:a) As part of the POC monitoring, the RCC/Nurse will be VISUALLY reviewing the medication cart audit form for both carts and will use a CHECK-OFF method when monitoring the sample set each week.b) The weekly sample of TEN RESIDENTS, who are currently on our medication administration program (current total facility census of 50), will be included in the weekly monitoring plan.c) This monitoring by visually reviewing the medication cart audits on both carts, will occur weekly and be checked off upon completion EVERY WEEK FOR THREE MONTHS allowing time to recycle back through all residents on our medication administration program to ensure consistency.d) The monitoring will be documented on the medication cart audit form which are completed in their entirety per policy. There will be a checkmark beside the sample of ten (those who have been monitored that week).e) The monitoring will begin on Thursday, February 20, 2025, and will continue for three months, ending on Thursday, May 22, 2025.f) This POC monitoring system will be included in the QMP binder, behind "QMP Notes/Agenda Outline" tab, on the Agenda Outline page under "Medication Related" topics. This will be discussed at the QMP monthly meetings during March, April, and May to verify completion of POC as described.

9/18/2024Licensure Complaint · ID ED49111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO37297, was completed on 9/19/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1382Res Rghts-House Rules Violation/InclS/S B▼

Findings

Based on record review, interview and observation, the residence failed to uphold the house rules, affecting 45 current residents. Findings include:1. Record ReviewThe residence's posted house rules, dated February 2024 read in part, "The designated area for residents to smoke is outside in the enclosed area. Smokers are not allowed to use any other outside area for smoking. Residents who smoke are asked to extinguish and discard all smoking materials in ashtrays or smokers ' stations."2. ObservationsOn 9/9/24 at 8:00 a.m., a tour of the residence's external grounds was conducted. Cigarette butts were observed to be near the street, along the sidewalk, in the grass, and in the parking lot; a few were found near the boulders. The boulder area did not appear to be a designated smoking area as it did not have an ashtray or sitting area, nor was it being used by residents. 3. InterviewsOn 9/9/24 at 7:30 a.m., Resident #2 stated that he locked the enclosed smoking area at approximately 8:00 p.m. each night as part of a voluntary role assigned by the administrator. He stated that when the enclosed smoking area was locked at night he smoked by the grass in the parking lot and flicked his cigarette butts in the street or parking lot. On 9/9/24 at 7:30 a.m., Resident #3 stated that when the enclosed smoking area was locked, the ashtrays were locked inside it, and she flicked her cigarette butts in the parking lot or the street, depending on where she was smoking. On 9/9/24 at 7:30 a.m., Resident #5 stated that when the enclosed smoking area was locked at night, he smoked in different places in the parking lot and he put his cigarette butts in the parking lot or the street. On 9/18/24 at 4:02 p.m., the administrator stated she had the enclosed smoking area locked at night because it prevented the unhoused from camping there. She stated that she instructed residents to smoke by the boulders located in the west parking lot when the enclosed smoking area was closed. She stated this was not reflected in the house rules.

Plan of correction · submitted by the facility

The Residence at Village Green LLC, ID #23H136Survey Completion Date: 09/19/2024Plan of Correction Submission Date: 09/30/2024 PLAN OF CORRECTION Deficiency:S1382 13.4 (A)-(H)SS=B 6 CCR 1011-1 Chapter 7 – Assisted Living Residences Part 13 – RESIDENT RIGHTS – House Rules 13.4The house rules shall list all possible actions which may be taken by the assisted living residence if any rule is knowingly violated by a resident. House rules shall not supersede or contradict any regulation herein, or in any way discourage or hinder a resident’s exercise of his or her rights. House rules shall address, at minimum, the following items: (A) Smoking, including the use of electronic cigarettes and vaporizers; (B) Cooking; (C) Protection of valuables on premises; (D) Visitors; (E) Telephone usage, including frequency and duration of calls; (F) Use of common areas and devices, such as television, radio, and computer; (G) Consumption of alcohol and marijuana; (H) Pets. Plan of Correction:The posted HOUSE RULES, Paragraph 1, now states:“The following House Rules and Residents Rights are practiced at The Residence at Village Green. If a resident does not follow the House Rules, there will be a documented “Structure For Success” meeting with the Executive Director to set clear goals that must be remedied timely allowing for correction prior to the Resident being discharged from the Residence”. 13.4 (A) Smoking, including the use of electronic cigarettes and vaporizers Issue: By closing the designated smoking area in the evening to prevent unhoused from entering, it caused the designated smoking area to be unavailable to the eight residents wanting to use the area after dark. Although there were options, they did not supply all the necessary items to be sufficient. Plan of Correction COMPLETED 9/20/2024:#1) Immediately following the survey exit on 9/19/2024, the Executive Director revised the posted HOUSE RULES to make the necessary updates to paragraph 1 and 7. Revisions were placed in the frame in a visible location on the wall, in the resident communication binder in the lobby, in the QMP binder, and in the policy and procedure binder.#2) Additionally, the lock was removed from the designated area allowing for the eight smokers to utilize the fully equipped space 24/7 for their convenience. There are signs posted designating that area, one fire blanket, three ashtrays, a metal covered trash can, and three metal cigarette butt dispensers. The resident volunteer dumps the trash and dispensers for added safety and cleanliness. Now that the designated smoking area is accessible 24/7, the boulders out front were relocated, and a professional lawn sign was placed asking that cigarette butts be placed in the proper receptacles and not on the ground.(a) The Executive Director and Manager on Duty on the weekends will review the proper use of the designated area and visually note the number of butts in the immediate vicinity to be removed. A weekly average total will be documented on an excel spreadsheet and maintained by the Executive Director in her office. (b) The Executive Director and Manager on Duty on the weekends will monitor daily and maintain the weekly averages for documentation purposes in the binder located in the Executive Director’s office.(c) The monitoring is done on the property near and around the designated smoking area on the premises daily by the Executive Director and the Manager of Duty during weekends.(d) The daily visual monitoring of cigarette butts on the ground is minimal to none since the designated smoking section is open and available 24/7. If there is an issue with this, the Executive Director will document and discuss it with the eight smokers to remedy this immediately.(e) The minimum length of time the monitoring will continue is three months to ensure the HOUSE RULES are followed as stated.(f) The Executive Director immediately added to the QMP binder (Agenda Outline) for the monthly meeting to continue with monitoring. This was added in the QMP under Resident Care and Safety: It now states that we will discuss the fact that “Residents have access to the designated smoking area 24/7 and are following the posted HOUSE RULES, paragraph 7.” #3) This deficiency was corrected and in compliance on September 20, 2024. Monitoring will continue daily for the following three months through December 20, 2024. The posted HOUSE RULES, Paragraph 7, now states in part:“The designated area for Residents to smoke is outside in the enclosed area (where the dumpsters were housed). Smokers are not allowed to use any other outside area on the premises. Residents who smoke are asked to extinguish and discard all smoking material in ashtrays or in the smokers’ stations, and not on the ground.” ADDITIONS: 10/10/241) Residents were informed of the two updates to the house rules (paragraph one and seven) on 9/30/24. Flyers were placed throughout the community and on resident/activity bulletin board for communication and awareness. It will be reiterated during the upcoming resident council meeting on 10/23/24.2) Current staff were informed via the same posted flyers, in addition to a posting in their breakroom on the bulletin board on 9/30/24.3) On 9/30/24, the executive director created an excel spreadsheet to document the monitoring and weekly observation of cigarette butts, use of safety containers, which also stated that flyers were posted regarding the two updates to the house rules for increased awareness for both the residents and the staff. 4) Resident agreements were updated with the two re-worded rules for paragraph one and seven with a one-page amendment for the resident signature of understanding and date. These were completed beginning 10/9/2024. The signed amendments to the original agreement were placed in their individual resident file, maintained in the business office.

9/18/2024State Certification Complaint · ID V70Q11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A certification complaint, prompted by #CO37298, was completed on 9/19/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

7/23/2024Licensure Complaint · ID PF6J11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO35983 and #CO36637, was completed on 7/24/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

7/23/2024State Certification Complaint · ID N1CD11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A certification complaint, prompted by #CO35984 and #CO36638, was completed on 7/23/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

3/5/2024Revisit: Licensure Complaint · ID RHKP141 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 3/28/24 for the previous deficiency cited on 9/29/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S D▼

Findings

Based on observation, interview and record review the (facility) residence failed to follow written policies and procedures for the adminstration of medication in accordance with Chapter VII regulations affecting nine of ten sample (participants) residents (#3, #9, #10, #17, #22, #26-#29) and two former residents (#15, #19). This deficiency was cited previously during a certification revisit 9/29/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #19 was prescribed antibiotics for a urinary tract infection on 1/24/24. However, the residence failed to ensure the prescription was filled. On 1/29/24 Former Resident #19 experienced a change in condition, was combative and had altered mental status. The former resident was subsequently transported to the emergency department, diagnosed with sepsis and a urinary tract infection. Former Resident #19 was administered intravenous (IV) antibiotics, fluids and was hospitalized for six days as a result of not receiving her antibiotics. Specifically, Former Resident #15 was prescribed lasix for edema on 2/14/24. However, the residence failed to ensure the prescription was filled and on 2/20/24 an external service provider notified the practitioner that the former resident had experienced swelling and edema. Former Resident #15 was subsequently transported to the emergency department (ED). Former Resident #15 was diagnosed with congestive heart failure and edema. The former resident was hospitalized for 15 days as a result of not receiving her prescribed medication and subsequently discharged to a skilled nursing facility. Findings include:1. Chapter VII regualtions governing assited living residences, requires in part 14.21 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.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: Medication assistance services were provided by the residence by a qualified medication administration person (QMAP) who had completed the QMAP training and competency evaluation program. The medication assistance program consists of providing assistance with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living residences. Additionally, the policy read that the residence communicated with practitioners and pharmacists to ensure accuracy of medications. According to Good RX: "A urinary tract infection (UTI) is a common condition often caused by Escherichia coli bacteria in the urine. Antibiotics are the typical treatment for a UTI. In some cases, a UTI will go away on its own even if untreated. This is most likely to happen in adult women with no other health conditions. An untreated UTI can sometimes lead to serious complications and hospitalization. It ' s always a good idea to let your provider know you have UTI symptoms ... The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria), The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria) ... Sepsis is a life-threatening condition caused by the body ' s response to infection. It happens when the immune system works to fight an infection, but ends up causing too much inflammation throughout the whole body. Each year, about 1.7 million adults in the U.S. get sepsis, and almost 270,000 die from it. UTIs cause up to 30% of cases of sepsis. Risk factors for developing sepsis include: Being over 65 years old, Having diabetes, Having a weakened immune system, Having a history of prior urinary tract procedures Sepsis is a serious condition, and it needs immediate medical attention. Healthcare providers use specific guidelines to diagnose sepsis. Sepsis symptoms include: Low or high body temperature, High heart rate, High breathing rate, Swelling in parts of the body, Change in mental status (such as confusion) ... So while you may get over a UTI on your own, the risks of not treating a UTI can be pretty high. Some untreated UTIs can cause serious health problems that may even require hospitalization. It ' s best to let your provider know if you have symptoms of a UTI. They can find the source of your symptoms and come up with a treatment plan." Reviewed 2024. Retreived https://www.goodrx.com/conditions/urinary-tract-infection/untreated-uti-risks-dangers. According to RXlist: "Lasix (furosemide) is an anthranilic acid derivative that is used as a strong diuretic in adults and children to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome ... Seek medical care or call 911 at once if you have the following serious side effects: Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out." Reviewed 2024. Retrieved https://www.rxlist.com/lasix-drug.htm#description. According to the Cleveland Clinic: "Congestive heart failure is a long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time. Medications and other treatments help manage symptoms like swelling. Congestive heart failure is life-limiting for many ... Congestive heart failure symptoms include: Shortness of breath. Waking up short of breath at night. Chest pain. Heart palpitations. Fatigue when you ' re active. Swelling in your ankles, legs and abdomen. Weight gain ... Reviewed 2024. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failureb. Former Resident #19 was admitted to the residence on 12/1/21 with diagnoses including urinary tract infection, muscle weakness, vitamin deficiency, post polio syndrome and hypertension. AmoxicillinA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 1/24/24 at 8:13 a.m., directed the residence to administer amoxicillin 500 mg potassium clavulanate 125 mg twice daily for seven days. However, the January 2024 medication administration record (MAR) read the medication was never administered. A residence progress note, dated 1/27/24, read in part: Staff brought food to Former Resident #19's room. The former resident was about to leave and was crying. When staff asked Former Resident #19 what was wrong she stated "she was scared as (expletive) and she feels intimidated." The administrator was notified. Hospital discharge orders, dated 1/29 through 2/5/24, read in part: Former Resident #19 was admitted to the hospital on 1/29/24 with symptoms including an altered mental status. Former Resident #19 was combative at the residence and was transported to the emergency department. The former resident tested positive for a urinary tract infection and would be treated with IV antibiotics, IV fluids and pain medication as needed. Former Resident #19 was admitted to the hospital. Vitamin D A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 2000 units once daily. However, the January 2024 MAR read the medication was not administered on 1/8, 1/9, 1/12-1/17 and 1/21-1/26/24 as the medication was out of stock, for a total of 14 missed doses. MultivitaminA written practitioner's order, dated 2/6/23, directed the residence to administer multivitamin once daily on 1/13-1/16,1/21-1/29/24 as the medication was on order, for a total of 13 missed doses. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/16, 1/17, 1/19, 1/21-1/29/24 as the medication was out of stock, for a total 11 missed doses. GabapentinA written practitioner's order, dated 2/6/23, directed the residence to administer gabapentin 100 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/20-1/27/24 as the medication was out of stock, for a total of seven missed doses. Metoprolol A written practitioner's order dated, 2/6/23, directed the residence to administer metoprolol tartrate 12.5 mg twice daily. However, the January 2024 MAR read the medication was not administered on 1/28/24 at 7:00 p.m. as the medication was out of stock and on 1/29/24 at 7:00 a.m., the dose was not administered as the resident was confused, for a total of two missed doses. HydrocodoneA written practitioner's order, dated 2/6/23, directed the residence to administer hydrocodone acetaminophen 7.5-325 mg twice daily. However, the January 2024 MAR read the medication was not administered the morning dose on 1/21/24 as the medication was out of stock. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #19 stated the former resident was prescribed antibiotics for a urinary tract infection on 1/24/24. He stated the residence did not inform him Resident #19 had not received her antibiotics and as a result on 1/29/24 Former Resident #19 had a change in condition from baseline, was transported to the ED, was hospitalized and later required skilled nursing care. Additionally, the practitioner stated that missing gabapentin, even one dose, could cause the resident to experience nerve pain. On 3/28/24 at 11:00 a.m., the administrator stated on 1/24/24 Former Resident #19 had a change in condition. She stated she was not her normal self, did not want to eat and laid in bed sleeping all day. She stated the former resident was transported to the emergency department and subsequently diagnosed with a urinary tract infection. The administrator further stated Former Resident #19, after her hospitalization, was discharged to a skilled nursing facility as she required more care than what the residence was able to provide. Additionally, the administrator stated she thought the former resident was seen by her practitioner for a suspected urinary tract infection; however, the administrator stated she was not aware the practitioner ordered any medication. c. Former Resident #15 was admitted to the residence on 12/16/18 with diagnoses of tachycardia, atrioventricular block, pacemaker and peripheral vascular disease. A written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 2/14/24 at 4:00 p.m. directed the residence to administer furosemide (Lasix) 20 mg take 0.5 tablet once daily for swelling. A residence progress note, dated 2/20/23, read an external service provider notified the residence that Former Resident #15 had not received her prescription for lasix. The residence telephoned the pharmacy and no order was found. The external service provider stated Former Resident #15 had fluids in her legs and was sent to the ED via emergency medical services. An external service provider note, dated 2/20/24, read in part Former Resident #15 had increased edema of her extremities. The external service provider telephoned the practitioner, notified him of the resident's vitals and the practitioner agreed to have the resident receive emergency medical care. A hospitalization record, dated 2/20/24 through 3/6/24, read in part: Former Resident #15 was admitted to the hospital with diagnoses including: malaise, atherosclerotic heart disease, acute congestive heart failure and edema. The resident presented at the emergency department with shortness of breath and weight gain. The record further read Former Resident #15 "was supposed to be prescribed lasix however she never received the prescription ... Apparently in the past month or so (the resident) had 20 pound weight gain. Apparently the patient was consulted by medical staff there in the recent past concern for weight gain and edema and was supposed to be starting diuretic therapy when the provider checked on her today found her to be more edema and learned that she has not been receiving the diuretic and sent her to the emergency room." Resident #15 was swollen throughout the entire lower abdomen and lower extremities. Resident #15 was administered Lasix 60 mg injection upon admission. On 3/6/24, Former Resident #15 was discharged to a skilled nursing home. On 3/26/24 at 3:40 p.m., the January and February 2024 MARs for Former Resident #15 were requested. However, as of 3/28/24 no MARs were provided. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #15 stated on 2/14/24 the resident was prescribed Lasix due to edema. He stated approximately one week later the medication had not started and an external service provider telephoned him and explained the resident's condition had deteriorated and a decision was made to send the resident to the ED for urgent treatment. On 3/28/24 at 11:07 a.m., the administrator stated the external home health provider for Former Resident #15 was at the residence and noticed swelling and edema. She stated at that point the external home health provider went to the administrator's office to check on the prescription for Lasix which had been prescribed approximately one week prior. The administrator stated she checked and could tell the prescription was faxed to the pharmacy. However, she stated when she telephoned the pharmacy they reported not receiving the prescription. The administrator confirmed the former resident did not receive her medication and stated she should have followed up on the prescription. The administrator further added "it was probably one of the emails that I did not get to timely."d. Resident #3 was admitted to the residence on 2/24/20 with a diagnosis of gastroesophageal reflux disorder. Diclofenac A written practitioner's order, dated 1/31/24, directed the residence to administer diclofenac 1% topical gel 2 gm apply twice daily to neck and knees. However, the February through March 2024 MAR read the medication was not administered twice daily from 2/1-3/25/24 as it was labeled on the MAR as "as needed" medication for a total of 108 missed doses. LisinoprilA written practitioner's order, dated 1/3/24, directed the residence to discontinue omeprazole 40 mg and replace with pantoprazole 40 mg delayed release once daily. However, the February through March 2024 MARs read omeprazole was not discontinued and was administered in conjunction with pantoprazole from 2/1 and 2/4-2/29/24 for a total of 27 days. Vitamin B-12A written practitioner's order, dated 1/31/24, directed the residence to administer vitamin B-12 1000 mcg once daily. However, the March 2024 MAR read the medication was not administered from 3/15-3/26/24 as the medication was out of stock for a total of 11 missed doses. Meclizine HydrochlorideA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg once daily at noon. However, the February 2024 MAR read the medication was not administered on 2/1/24 as the resident was out of the residence for a total of one missed dose. On 3/28/24 at 11:00 a.m., the administrator stated she was not aware of the error with the pantoprazole. She stated the residence had difficulties obtaining prescriptions from the practitioner's and in addition, she stated the residence was also changing pharmacies. The administrator stated she had started her position at the residence in July 2023; however, the administrator stated she had not read the past deficiencies and was not sure why they had not been corrected.e. Additional deficient practice was identified with Residents #9, #10 and #17. 2. Chapter VII regulations governing assisted living residences, requires in part 14.28 that the assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. During morning medication administration on 3/26/24 at 7:52 a.m., the following was observed:Staff #13 donned gloves and began to prepare medications for Resident #26. Staff #13 while preparing the medications grasped her sweatshirt wiping her nose. Staff #13 subsequently spilled the medications for Resident #26 on the medication cart and picked them up with her gloved hand placing them back into the medication cup, Staff #13 then administered the medication, returned to the medication cart, doffed her gloves, opened the medication cart and documented on the medication administration record (MAR). Staff #13 touched her nose with her hand and stated she needed to obtain a tissue. The staff then wiped her nose and began to prepare medication for Resident #27 popping the medication out of the blister package and placing it in the medication cup. Staff #13 then took out a cup and poured water from a pitcher for the resident. Staff #13 then handed Resident #27 her medications and began to cough. She then took out a tissue and blew her nose and sanitized her hands. Staff #13 donned gloves and prepared medication for Resident #10. The staff took out the resident's insulin pen from the medication cart and handed the resident the insulin to self administer. Staff #13 came back to the medication cart, did not remove her gloves or sanitize her hands. She subsequently prepared and administered medications for Resident #9, applied hydrocortisone cream to the resident's neck. Staff #13 doffed her gloves and without washing or sanitizing her hands administered medications to Resident #17,#22, #28 and #29 in a similar unsanitary manner. On 3/28/24 at 11:07 a.m., the administrator stated she had discussed proper infection control when administering medications to residents. The administrator further stated the improper infection control by Staff #13 surprised her. 3. Chapter VII regulations governing assisted living residences, in part 14.29 requires that All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: The residence would maintain current files on all medications. b. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including gastroesophageal reflux disorder, hypertension. FluticasoneA written practitioner's order, dated 1/31/23, directed the residence to administer fluticasone propionate/salmeterol 500-50 mcg one puff twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 evening dose, 2/1-2/3 all doses, 2/7 evening dose, 2/17 evening., 2/24 and 2/27 evening doses, 2/29 morning dose, 3/9 morning dose and 3/21/24 evening dose. LisinoprilA written practitioner's order, dated 1/31/24, directed the residence to administer lisinopril 5 mg once daily. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/1-2/3 and 3/23/24. Gabapentin A written practitioner's order, dated 1/31/24, directed the residence to administer gabapentin 600 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 at bedtime, 2/2- 2/3 all doses and on 3/2/24 at noon. MeclizineA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg tablet at noon. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/2, 2/3 and 3/2/24. IpratropiumA written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium 0.5 mg albuterol 3 mg four times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2 at noon and 3/21/24 at the evening dose and bedtime dose. SertralineA written practitioner's order, dated 1/31/24, directed the residence to administer sertraline 100 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/2 and 2/3/24. PantoprazoleA written practitioner's order, dated 1/31/24, directed the residence to administer pantoprazole sodium 40 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 and 2/2/24. SpirivaA written practitioner's order, dated 1/31/24, directed the residence to administer Spariva handihaler 18 mcg one puff by mouth once daily. However the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/9/24.c. Resident #14 was admitted to the residence on an unknown date. PantoprazoleA written practitioner's order, dated 1/25/24, directed the residence to administer pantoprazole sodium 40 mg twice daily. However, the March 2023 MAR revealed no evidence of documentation at the time of administration on 3/7, 3/11 morningdoses, 3/19, 3/20 evening doses and 3/24/24 morning dose. RosuvastatinA written practitioner's order, dated 2/29/24, directed the residence to administer rosuvastatin calcium 10 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/5/24. SertralineA written practitioner's order, dated 1/25/24, directed the residence to administer sertraline 50 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24. Docusate SodiumA written practitioner's order, dated 1/25/24, directed the residence to administer docusate sodium 100 mg twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24 evening dose. MontelukastA written practitioner's order, dated 1/25/24, directed the residence to administer montelukast sodium 10 mg at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/1/24. BuspironeA written practitioner's order, dated 1/25/24, directed the residence to administer buspirone 10 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/8 and 3/11/24 at 6:00 a.m. ClopidogrelA written practitioner's order, dated 1/25/24, directed the residence to administer clopidogrel 75 mg once daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2/24. d. Additional deficient practice was identified for Resident #10. On 3/28/24 at 11:00 a.m., the administrator stated she expected qualified medication administration persons to administer medications and document on the MAR. She stated she has done training with staff in the past regarding documentation on the MAR; however, the administrator stated there were no consequences put in place to prevent a recurrence. 4. Chapter VII regualtions governing assisted living residences, requires in part 14.31 that 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. Medication Cart/Medication Administration Record Audits completed from December 2023 to present revealed the form focused on three areas of the medication program: Medication administered as ordered, medication signed out appropriately, follow-up completed on any out of stock medications with both the practitioner and pharmacy and follow-up completed on any medication refusal not given. A second audit tool utilized in January 2024 read the residence only audited the medication cart and a list of staff names who signed the MAR. The audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. On 3/26/24 at approximately 11:00 a.m., the residence's contracted consultant stated that neither she or the administrator had done a full audit of the resident records in relation to the practitioner's orders, MARs and medication cart. The consultant further stated there was a corporate nurse scheduled to assist with the audits on 3/27/24. On 3/28/24 at 11:07 a.m., the administrator stated she had been the administrator since July 2023. She stated she had not completed an audit to ensure the accuracy and completeness of the MARs. The administrator further stated the residence had been short staffed and she had not had time to look at the records for the residents. 5. Chapter VII regulations governing assisted living residences, requires in part 14.33 that the assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of: (A) A decline from a resident's baseline status; (B) A resident's pattern of refusal.a. The residence's Medication Services Policy, dated January 2024, read in part: The residence would communicate with practitioners to ensure accuracy of medications. b. Former Resident #19 was admitted to the residence on 12/1/21 with a diagnosis of constipation. A written practitioner's order, dated 7/5/23, directed the residence to administer Senna 8.6 mg once daily. However, the January 2024 MAR read the medication was not administered as the resident refused on 1/4, 1/5, 1/11-1/13, 1/19-1/22 and 1/25-1/27/24 for a total of 12 refused doses. c. Resident #3 was admitted to the residence on 12/24/20. A written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium bromide sulfate 0.5-2.5 mg four times daily. However, the March 2024 MAR read the resident refused the medication on 3/14, 3/19, 3/20 at noon, 3/24, 3/25 and 3/26/24 morning and noon for a total of seven refused doses. On 3/27/24 at 10:12 a.m., the practitioner for Resident #3 stated he had not been notified of any medication refusals. On 3/28/24 at 11:07 a.m., the administrator stated the residence did not have a formal process in place for notifying the practitioner of a pattern of refusals. She stated currently the qualified medication administration person who attempted to administer the medication was responsible for notifying the practitioner of all refusals.

Plan of correction · submitted by the facility

Resident #15 & 19: No longer reside at facilityResident #3: Diclofenac (changed to PRN 4/1), Lisinopril (omeprazole no longer administered after 2/29/24), Vitamin B-12 (D/C’d 4/1/24), Meclizine Hydrochloride (administered as directed starting 2/2/24)Resident #9, 10, 17, 22, 26-29: no specific medication issues cited. Documentation, infection control, and proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served will be addressed through education below. The staff will be retrained on the medication policy and the importance of proper medication administrator in compliance with Chapter 24 regulation, by date of compliance, these areas include proper documentation, infection control with the proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served. The Administrator and RCC have been retrained on the medication policy. RCC and RN or designee will watch 2 Med passes weekly to ensure proper Qmap procedures are followed in all areas of medication administration. Documentation will be included in the monthly review during the QMP meeting. The area will remain as an area of focus for QMP for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

3/5/2024Licensure Complaint · ID 4RC41114 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint investigation prompted by #CO35360, #CO35069 was completed on 4/2/24. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0290LicProc-DeptOvrst-Srvy/Inspct Ensr Cmply-POCS/S B▼

Findings

Based on interview and record review, the residence failed to provide access upon request to individual residence records affecting eight of eight sample residents and one former resident (#3, #9, #10, #14- #18 and Former Resident #19). (Cross-reference S1568)Findings include:Chapter VII regulations governing assisted living residences, part 18.8 require that resident records shall contain, but not be limited to, the following items: (A) Face Sheet; (B) Practitioner order; (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. (E) Medication Administration Record. On 3/20/24 at 1:46 p.m., an email sent to the department, dated 2/14/24 at 2:20 p.m., read the practitioner sent current practitioner's orders to the residence for residents (#3, #10, #14- #17, and former resident #19). On 3/26/24 at 9:32 a.m., a request for full resident records for residents (#3, #9, #10, #14, #15) was given to the administrator. On 3/26/24 at approximately 11:30 a.m., the records for residents (#3, #9, #10, #14, #15) were provided. However, the records were missing recent practitioner's orders. On 3/26/24 at 1:04 p.m., a request was made from the residence's contracted consultant for the practitioner's orders the residence received on 2/14/24. On 3/26/24 at 2:00 p.m., a request for all current practitioners orders for residents (#3, #10, #14) were requested from the administrator. On 3/26/24 at 2:02 p.m., the practitioner's orders requested from the consultant for the sample residents were provided (approximately four and a half hours after the request for resident records was made). On 3/26/24 at 2:59 p.m., the face sheet, progress notes and practitioner's orders for Resident #16 and full resident records for residents (#17, #18 and former resident #19) were requested. On 3/26/24 at 3:00 p.m., additional practitioner's orders were provided for Resident #10 (approximately six and a half hours after requested). On 3/26/24 at 3:40 p.m., the January and February 2024 medication administration records (MARs) for Former Resident #15 were requested. On 3/26/24 at 4:25 p.m., current practitioner's orders for Resident #9 were requested. On 3/26/24 at 4:42 p.m., February 2024 MARs, current practitioner's orders and progress notes were requested for Former Resident #19. On 3/26/24 at 4:53 p.m., progress notes for the sample residents were provided by the residence's contracted consultant approximately seven hours and 20 minutes after the initial request. On 3/26/24 at 5:02 p.m., current practitioner's orders for Resident #9 were provided approximately seven hours and 30 minutes after the initial request. On 3/26/24 at 5:14 p.m., current practitioner's orders for Resident #18 and the January 2024 MAR for Former Resident #19 were requested. On 3/26/24 at 5:21 p.m., the January and February 2024 MARs for Former Resident #19 was provided approximately two hours and 20 minutes after the initial request. On 3/26/24 at 5:39 p.m., additional orders for Resident #9, current orders and face sheet for Resident #16 and Former Resident #19's most recent orders were requested. On 3/26/24 at 10:02 a.m., the remaining orders for residents (#9, #17, #18 and Former Resident #19) were provided. Additionally, the face sheet and practitioners orders for Resident #16 were provided. The January and February 2024 MARs for Former Resident #15 were never provided. On 3/28/24 at 11:08 a.m., the administrator stated documents required to bein resident records were not provided upon request because resident records had not been updated since July 2023. She stated staff had access to practitioner's orders and a lot of the orders were located in the medication room and her office to be filed. She stated she also had prescriptions in her email that had not been filed in the resident records. In a second interview on 3/28/24 at 3:30 p.m., the administrator confirmed documents were not provided by request and stated she was going to get all resident records in order but had other priorities that had come up.

Plan of correction · submitted by the facility

(Cross-reference S1568)The storage of the resident records has been changed and the resident records will be stored in the locked medication room. The Resident Care Coordinator (RCC) and the RN are reviewing each resident record to ensure it is compliant with Part 18 of Chapter 7 regulations and documents are easy to access if needed. This will be completed by the compliance date of the POC The new resident move in process has been revised to ensure each new resident has a compliant file prior to being allowed to move into the facility. A check list will be used to account for all documents. To ensure records remain compliant, a sample of 15% of the population records will be reviewed each month and updated as needed. This documentation will be kept along side the Quality Managment meeting notes and this area of focus will remain in the QMP for 120 days. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

0430Rpt Req-Occ RprtS/S A▼

Findings

Based on document review and an interview, the facility failed to report occurrences to the Department as required by state statute. Specifically, the facility failed to report an occurrence involving neglect of a client, as described in section 26-3.1-101(2.3),(7)(b) C.R.S.Findings include:1. Residence policy and referencesa. The Colorado Reportable Occurrence Procedures read, Reportable occurrences must be reported to HFEMSD by the next business day. Occurrences which may be reportable include physical, sexual or verbal abuse; brain injury; burns; deaths; drug diversion; life-threatening anesthesia complications or blood transfusions errors/reactions; malfunction/misuse of equipment; misappropriation of resident property; missing persons; neglect; and spinal cord injuries.b. According to the departments Occurrence Reporting Manual:, any occurrence involving neglect of a resident or resident as described in Section 26-3.1-101 (2.3), C.R.S." Section 25-1-124(e) C.R.S. One Element Needed: Failure to provide any care or services as provided above resulting in actual harm. C.R.S. Section 25-1-124(2)(e) states any occurrence involving caretaker neglect of a resident or resident, as described in section 26-3.1-101(2.3), C.R.S. is a reportable occurrence. C.R.S Section 26-3.1-101(2.3)(a) describes neglect as follows: ' Caretaker neglect ' means neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, or supervision is not secured for the at-risk adult is not secured for an at-risk adult or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence, or intimidation to create a hostile or fearful environment for an at-risk adult.c. The Occurrence Reporting Manual instructed to report an occurrence of neglect when a failure to provide any care or services as provided above resulting in actual harm. "Caretaker neglect" was defined as neglect that occurred when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, or supervision was not secured for an at-risk adult or was not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise.d. Chapter VII regulations governing assisted living residences, part 2.36 defines medication monitoring as reminding the resident to take medications(s) at the time ordered by the authorized practitioner; handing to a resident a container or package of medication that was lawfully labeled previously by an authorized practitioner for the individual resident, visual observation of the resident to ensure compliance; making a written record of the resident's compliance with regard to each medication, including the time taken; and notifying the authorized practitioner if the resident refuses or is unable to comply with the practitioner's instructions regarding the medication. 2. The residence failed to ensure occurrences were reported to the Department as required by state statute or regulation.a. Resident #10 was admitted to the residence on 2/17/22 with diagnoses including type one diabetes. During morning medication pass on 3/26/24 at 8:07 a.m., Staff #13 retrieved the insulin for Resident #10 from the residence's medication cart, handed the resident the medication and monitored the injection. Written practioner's order dated 6/21/23 and 1/4/24 directed the residence to change from Basaglar KwikPen 100 unit/ml-inject 26 units subcutaneously every morning and 10 units subcutaneously every night at bedtime. The order further read, the resident may self administer the medication. A written practitioner's order dated 11/22/23 directed the residence to administer NovoLOG Flex pen U-100 unit/ml (3ml) subcutaneous inject as per sliding scale subcutaneously before meals. Before breakfast inject four units subcutaneously. Add one unit for every 50 mg/dl above 150 mg, subtract one unit for every 25 mg below 90. The order further read during the evening meal inject four units subcutaneously, add one unit for every 50 mg/dl above 150 mg/dl and subtract 1 unit for every 25 mg/dl below 90. An email provided by the practitioner's medical practice on 3/28/24 read in part: Resident #10 was administered the wrong dose of insulin on 1/2/24 and suffered a severe hypoglycemic event. A progress note dated 1/27/24 at 8:22 a.m. read in part, Resident #10 was prompted to put her units in her insulin pen by the qualified medication administration personnel (QMAP) and was provided the wrong insulin pen. b. Review of the department's occurrence reporting database on 3/26/24 (59 days after Resident #10's event) revealed no occurrences were reported in regards to the neglect of Resident #10.c. An email dated, 3/26/24 from the department's occurrence reporting section read in part: A deviation of practice and blatant disregard for following medication standards of practice leading up to a medication error was required to be reported to the department under the category of neglect.d. InterviewsOn 3/26/24 at 3:15 p.m. the contracted consultant stated that she spoke with the administrator who stated that no occurrences have been reportable in the last eight months. On 3/28/24 at 11:00 a.m., the administrator reviewed the residence's occurrence policy and stated that all occurrences need to be reported within the next business day. The administrator further stated that the department was required to be notified of drug diversions and confirmed that staff giving the resident the wrong insulin was reportable.

Plan of correction · submitted by the facility

Occurrence initial and final report was submitted on 6/5/24, #2423H136002The Administrator and RCC will be retrained on what is considered a reportable occurrence and what is the time frame to report to the Department. The staff will also been retrained on what should be immediately reported to the Administrator and RCC. Training will be completed by compliance date of the POC.To ensure continued compliance, The Administrator and RCC will review progress notes, incident reports and talk with staff to review what is considered a "reportable occurrence" The QMP notes will record if any reportable occurrences happened during the month and this area will be added to the QMP and reviewed monthly for 120 days and ongoing as needed. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

0910Em Pr-Pol/Proc Res RstrS/S B▼

Findings

Based on interview and record review the residence failed to have a roster readily available, affecting 46 current residents. Findings include:On 3/26/24 at 7:30 a.m., upon entrance Staff #9 greeted department surveyors. She stated she did not have access to a resident roster and therefore could not provide it to the department. Staff #9 stated she would telephone the administrator and she would provide the resident roster. On 3/26/24 at 8:33 a.m., a copy of the resident roster with the resident names and room numbers was requested. On 3/26/24 at 9:33 a.m., the administrator provided a copy of a list of residents with their room numbers; however, it failed to include a diagram showing the room locations and emergency contacts. The roster provided was not current and had former residents (#15, #19) listed. On 3/26/24 at 10:20 a.m., an environmental tour of Former Resident #19's room revealed the resident had moved out and was no longer living at the residence. On 3/26/24 at 10:21 a.m., an environmental tour of Resident #15's room revealed no evidence the residence was at the residence. On 3/28/24 at 11:00 a.m., the administrator stated that she was aware of what was required on a resident roster more specifically that resident names, room numbers, and emergency contact information was required. She noted she was not aware of the requirement of a residence diagram showing the room locations.

Plan of correction · submitted by the facility

The residence has a resident roster but the Business Manager could not find it the day of survey, it was provided to the surveyor on day of survey but was not accepted due to it not being readily available. All Staff have been trained on where to locate the Resident roster. The resident roster will be updated as needed with new residents moving in and any residents that have moved out. The Administrator and RCC have been trained that the resident roster includes the resident name, room number, emergency contact information and schematic map showing room locations. This issue will be reviewed at staff meeting monthly so that all staff are aware the roster has been updated and where to locate it when requested. The resident roster will be added to the QMP, reviewed monthly for 120 days to ensure continued compliance. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Based on observation, interview and record review the residence failed to ensure either directly or indirectly through a resident agreement provide protective oversight affecting three of three sample residents #26, #10 and #30. Findings include:1. References and Residence Policya. The residence's resident agreement, read in part: The residence, through its staff, shall regularly observe your health status to identify any changes in your physical, mental, emotional and social functioning and will help you respond to your dietary and health needs and needs for special services. b. Chapter VII regulations governing assisted living residences part 2.36, defines medication monitoring as reminding the resident to take medications(s) at the time ordered by the authorized practitioner; handing to a resident a container or package of medication that was lawfully labeled previously by an authorized practitioner for the individual resident, visual observation of the resident to ensure compliance; making a written record of the resident's compliance with regard to each medication, including the time taken; and notifying the authorized practitioner if the resident refuses or is unable to comply with the practitioner's instructions regarding the medication.c. According to the National Drug and Alcohol Research Centre, "Cleaning injecting sites with an alcohol swab prior to injecting has consistently been shown to reduce the risk of soft tissue infections." National Drug and Alcohol Research Centre (7/2019) SWAB: Safely Wipe Away Bacteria - Findings on Injecting practices from IDRS, retrieved from: https://ndarc.med.unsw.edu.au/blog/swab-safely-wipe-away-bacteria-findings-injecting-practices-idrs#:~:text=Cleaning%20injecting%20sites%20with%20an,risk%20of%20soft%20tissue%20infections 2. During morning medication pass on 3/26/24 from 7:30 a.m. to 7:35 a.m. the following insulin administration was observed:Staff #13 retrieved insulin for Resident #25 from the residence's medication cart. The staff subsequently handed the resident the dial-up insulin syringe. Staff #13 did not provide or prompt the resident to prepare the area with an alcohol swab prior to the resident administering the insulin. Staff #13 subsequently collected the insulin pen and secured it back into the residence's medication cart. Similar findings were observed for Resident #10 and Resident #30. 3. InterviewsOn 3/27/24 at 10:12 a.m., the practitioner stated that skin was covered in bacteria staphylococcus aureus and humans have a symbiotic relationship. He stated this bacteria on the skin should have been wiped with an alcohol wipe as the friction would open the bacteria and sterilize the area. The practitioner further stated if it was not done then there was potential of pushing the bacteria into the skin resulting in infection. On 3/26/24 at 8:36 a.m., Staff #13 stated that she did not provide alcohol wipes as residents normally did not use them and she was not sure where they would obtain the alcohol wipes. She stated she thought that maybe the pharmacy was responsible for providing the alcohol wipes. On 3/27/24 at 1:25 p.m., Staff #15 stated she did not provide alcohol swabs to residents who self injected medications and that she did not know where alcohol swabs would be located. On 3/28/24 at 11:00 a.m. the administrator stated residents should have been provided with the supplies that they require to self administer medications and that the resident should be cleaning the area and letting it dry before injecting insulin. The administrator stated she was surprised staff did not know where the alcohol swabs were located at the residence and that they were unaware the area should have been cleaned prior to administration.

Plan of correction · submitted by the facility

The staff will be trained by date of compliance on providing proper infection control for residents that have a self-administer order for insulin injections. All Qmap staff are aware where the alcohol swabs are located. The RCC and RN will continue to train staff and documentation of such training will be kept in the staff file. To ensure continued compliance, the RN and RCC will review proper procedures while watching staff administer medication pass along with the resident self-administer for insulin. RN and RCC are watching Med Pass twice weekly to ensure compliance with all infection control, proper glove use and other areas of Chapter 24 medication adminstration. All new Qmap employees will review this upon orientation. Proper infection control and providing protective oversight will be will be added to the QMP as an area of focus and reviewed for 120 days. QMP meeting notes will provide documentation of this review. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1320Res Rghts Rts/Rspn-Civ/Rel-Dig-RspctS/S B▼

Findings

Based on observation, interview and record review the residence failed to ensure residents were free from intimidation affecting 46 current residents. (Cross-reference S1350). Findings include: A posting titled, Resident's Rights, dated January 2024 read in part: Residents had the right to civil and religious liberties including the right to be free from intimidation. A written practitioner's order, dated 1/3/24, read in part: Resident #10 stated the administrator stated she was informed that if she "continued to make claims that she received the incorrect insulin she would be kicked out of the facility." Resident #10 demonstrated a labile affect today and had difficulty controlling her emotional state. On 3/26/24 from 7:30 a.m. to 5:30 p.m., interviews were conducted and revealed residents felt intimidated by the administrator and staff as follows:Resident #25 stated s/he would like to speak with the department surveyors. S/he stated they did not feel comfortable speaking in the common areas and requested the department surveyor to visit with them later in the day in their room. Resident #24 stated s/he would like the surveyor to interview other residents as well as make sure that residence staff saw the surveyor in other resident rooms so that s/he would not be singled out later and questioned about what s/he discussed with the surveyor. Resident #24 also stated that s/he was threatened with a 30-day notice by the administrator for questioning the medication administration of a fellow resident as s/he fellow resident was afraid to speak up for fear of intimidation. Resident #24 also stated s/he observed a confrontation between the administrator and a staff member and stated the administrator shamed the staff member and the staff member walked out the same week the survey was completed. Resident #20 stated a former staff member had yelled at her; however, she stated that staff was no longer employed by the residence. The resident further stated s/he was afraid of retaliation by the administrator for talking to the department. An outside agency representative stated that residents had concerns with intimidation from staff at the residence. S/he stated residents were afraid to talk to the ombudsman and were told they had to voice concerns to the administrator. The outside agency representative stated that s/he had made it clear residents had the right to speak with the ombudsman and did not have to go to the administrator first. The residence's contacted consultant stated two weeks prior to the onsite investigation, law enforcement came to the residence because of an altercation between the administrator and Former Staff #16. She stated that a member from the management company had confirmed the administrator had handled the situation incorrectly. On 3/27/24 at 12:44 p.m., Staff #16 stated the administrator on 3/12/24 attempted to get into a physical altercation with another employee in the front common area of the building. S/he stated the administrator got up from her desk and pulled her hair up and proceeded to threaten the staff member. On 3/27/24 at 1:06 p.m., Staff #15 confirmed the administrator threatened another staff member in the common areas. S/he stated the administrator "was very intimidating. She does not hold back anything you can be in the common area and she will check you and address you in front of anyone and everyone." The staff member stated s/he had been confronted by another staff member one week prior to the onsite investigation. S/he stated the staff member started yelling at them in front of all the residents. S/he stated the staff was cursing and screaming at them. Staff #15 stated residents were constantly witnessing intimidating and unprofessional behavior. The staff further stated s/he did not think the residents needed to see and experience yelling in their home. On 3/28/24 at 11:00 a.m., the administrator stated that she and another employee engaged in a verbal altercation whichstarted in the administrator office. The administrator stated that the employee approached her desk in a threatening manner. She stated that was when she (the administrator) stood up and pulled her hair up using a hair tie. The administrator stated the verbal altercation lingered into the common areas of the residence and further stated that both she and the employee had raised voices and used profanity. The administrator further stated to her knowledge residents were not intimidated by her and did not have knowledge of the altercation.

Plan of correction · submitted by the facility

(Cross-reference S1350). The Administrator will complete a training on person centered care and role play scenarios in which residents could feel intimidated. The training will be completed by date of compliance and ongoing as needed. Documentation will be filed in the Administrators record. The right to live free of intimidation will be addressed at the next resident council meeting. To ensure continued compliance the RCC will survey 10% sample of the residents each month to review any issues they would like to discuss. The RN and Consultant will also talk with residents on a monthly basis to ensure they are not feeling intimated. The right to live free of intimidation will be addressed monthly in the QMP and documented for 120 days. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1324Res Rghts Rts/Rspn-Civ/Rel-NeglectS/S C▼

Findings

Based on interview and record review the residence failed to ensure the residents were free from neglect affecting one sample resident (#10). (Cross-reference S0430, S1110)Specifically, Resident #10 was prescribed two different types of insulin, a long acting and a short acting. Although the resident was deemed to be independent with administering the medication, the residence stored the medication and provided medication monitoring to ensure the health safety and wellbeing of the resident. However, on 1/2/24 the residence qualified administration person (QMAP) provided Resident #10 with the fast acting insulin and the resident subsequently injected 26 units (the prescribed amount for the long acting insulin). As a result Resident #10 suffered a severe hypoglycemic event which bottomed out her blood glucose to the point where her blood glucose monitor would not read the blood glucose. Although the residence stated they labeled the insulin pens for Resident #10 more clearly for the staff to read, on 1/27/24 (25 days later) Resident #10 was provided the incorrect insulin pen again and administered the incorrect insulin. Findings include:1. Residence Posting and Referencesa. A posting titled, Resident's Rights, dated January 2024, read in part: Residents had the right to be free from neglect.b. Chapter VII regulations governing assisted living residences, in part 2.12 defines neglect as occurring when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person.'c. Chapter VII regulations governing assisted living residences, in part 2.36 defines medication monitoring as reminding the resident to take medications(s) at the time ordered by the authorized practitioner; handing to a resident a container or package of medication that was lawfully labeled previously by an authorized practitioner for the individual resident, visual observation of the resident to ensure compliance; making a written record of the resident's compliance with regard to each medication, including the time taken; and notifying the authorized practitioner if the resident refuses or is unable to comply with the practitioner's instructions regarding the medication.d. According to Mayo Clinic, "Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than the standard range. Glucose is your body's main energy source. Hypoglycemia is often related to diabetes treatment. But other drugs and a variety of conditions — many rare — can cause low blood sugar in people who don't have diabetes. Hypoglycemia needs immediate treatment. For many people, a fasting blood sugar of 70 milligrams per deciliter (mg/dL), or 3.9 millimoles per liter (mmol/L), or below should serve as an alert for hypoglycemia. But your numbers might be different. Ask your health care provider. Treatment involves quickly getting your blood sugar back to within the standard range either with a high-sugar food or drink or with medication. Long-term treatment requires identifying and treating the cause of hypoglycemia." Mayo Clinic (11/18/23) Hypoglycemia -Symptoms and causes, retrieved from: https://www.mayoclinic.org/diseases-conditions/hypoglycemia/symptoms-causes/syc-20373685 2. Resident #10 was admitted to the residence on 2/17/22 with diagnoses including type one diabetes. During morning medication pass on 3/26/24 at 8:07 a.m., Staff #13 retrieved the insulin for Resident #10 from the residence's medication cart, handed the resident the medication and monitored the injection. Written practioner's order dated 6/21/23 and 1/4/24 directed the residence to change from Basaglar KwikPen 100 unit/ml-inject 26 units subcutaneously every morning and 10 units subcutaneously every night at bedtime. The order further read, the resident may self administer the medication. A written practitioner's order dated 11/22/23 directed the residence to administer NovoLOG Flex pen U-100 unit/ml (3ml) subcutaneous inject as per sliding scale subcutaneously before meals. Before breakfast inject four units subcutaneously. Add one unit for every 50 mg/dl above 150 mg, subtract one unit for every 25 mg below 90. The order further read during the evening meal inject four units subcutaneously, add one unit for every 50 mg/dl above 150 mg/dl and subtract 1 unit for every 25 mg/dl below 90. An email provided by the practitioner's medical practice on 3/28/24 read in part: Resident #10 was administered the wrong dose of insulin on 1/2/24 and suffered a severe hypoglycemic event. Written practitioner's orders, dated 1/3/24, provided by the practitioner's medical practice read in part: A family member for Resident #10 stated the resident "had a low blood sugar of the 40's they gave her peanut butter sandwich and orange juice then turned around and gave 26 units of fast acting insulin she then bottomed out. This was yesterday morning 1/2/24." The order further read when Resident #10 received 26 units of fast acting insulin (NovoLOG) instead of her long acting insulin (Basaglar) her blood glucose went from 250 to less than 60 and would not register on her continuous glucose monitor. The practitioner reviewed the insulin that was in the residence's medication cart and wrote down which one was long acting and short acting. A progress note dated 1/27/24 at 8:22 a.m., read in part: Resident #10 was prompted to put her units in her insulin pen by the QMAP and was provided the wrong insulin pen. A progress note dated 1/27/24 at 8:40 a.m. read in part, vitals were checked and the blood pressure was 168/87, oxygen was 95%, heart rate was 59 beats per minute, and blood glucose was 219. A progress note dated 1/27/24 at 10:40 a.m., read that the resident "was lying down and fine." A progress note dated 1/27/24 at 12:40 p.m., read that the resident was "doing great and (blood glucose) is 129 took insulin and ate lunch."On 3/28/24 at 11:07 a.m., the administrator stated she was aware of one incident of Resident #10 receiving the wrong insulin. She stated after the incident on 1/2/24, the residence used a marker on the pen so staff were clear as to what medication to hand the resident for administration. However, the administrator stated she had not seen the progress note for 1/27/24 and was not aware of the second incident.

Plan of correction · submitted by the facility

(Cross-reference S0430, S1110)IMPOSITION OF INTERMEDIATE CONDITION(s) - Retain a consultant for four months to address corrective measures for all tags. Required to have an RN (Registered Nurse) in the building at least 2 times a week working with the contracted consultant to correct deficiencies for Tags 430 A, 910 A, 1110 B, 1320 B, 1324 C, 1350 C, 1568 D, 1596 B, 1600 B, 1604 B, 1612 A, 2112 B, 2122 B, 290 B.The facility will review and revise their policy for residents who are able to self-administer insulin and request an evaluation from a medical provider on the cognition level of the resident to determine if they have to capacity to administer insulin independently of staff assistance. The staff will be retrained by date of compliance on the importance of a checking the insulin for correct dosage, proper assist for insulin pens, proper documentation, infection control. RN and the RCC will witness 2 med passes weekly including handing residents the correct dose of insulin for self administer order. The issue will be discussed monthly at the QMP meetings and remain an area of focus for 120 days in the QMP.Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1350Res Rghts Rts/Rspn-Choice/Invlv Cr/Svc-ProvS/S C▼

Findings

Based on observation, interview and record review the residence failed to ensure residents had the right of choice in selecting a health care provider, affecting 46 current residents. (Cross-reference S1320, S1568). Specifically, the residence was under enforcement action for a previous event that required a contracted consultant to correct deficiencies. However, from 2/29 to 3/28/24 residents were informed they had to change practitioner's at the residence and were not given a choice. The residence was notified of the deficient practice regarding resident rights. However, the residence failed to observe resident rights in respect to the choice in selecting a healthcare provider. Residents expressed continued pressure by the administrator, emotional anguish and crying as a result of the residences decision to remove a practitioner and refusal to reverse their decision regarding the removal of the practitioner. Findings include: 1. Residence PostingA posting titled, Resident's Rights, dated January 2024, read in part: Residents had the right to freedom selecting a healthcare provider. 2. Prior to the Onsite InvestigationOn 3/5/24 at 12:51 p.m., the consultant stated there was a personality conflict between the administrator and a practitioner who visited the residence. She stated resident's coordination with medications and medical care suffered as a result. The consultant stated she telephoned the owner of the practice on 2/29/24 "and had him (the practitioner) removed." The consultant stated that the practitioner who had been removed cared for 12 residents at the residence. She stated the owner of the practice was scheduled to take over the 12 residents on 3/6/24. The consultant further stated residents had not been spoken to regarding the change in practitioners and residents still had the freedom to choose between the owner of the medical practice and another medical practice. She stated five residents had already switched to the other medical practice the residence offered. The consultant stated they had to change something as the residents had medications that were out of stock and medical care was not coordinated as required. On 3/13/24 at 12:25 p.m., the owner of the medical practice stated he and another practitioner had residents that resided in the residence for several years. He stated they maintained a positive relationship until the administrator was appointed in July 2023. He stated in July of 2023 the practice cared for 36 residents and was now down to 13 residents. The owner of the practice further stated he was telephoned by the residence's consultant who requested the practitioner not come to the residence. The owner stated he complied with the request and took over medical care for the existing residents. He stated he received a call from a family member of a resident at the residence who was told by the residence they needed to switch medical practices. He stated a second resident during his visit at the residence informed him that the administrator told s/he that they needed to switch over to the other medical practice offered by the residence. Email correspondence from the practitioner's office to the residence and the residence's consultant, dated 2/14/24, read the practitioner provided the residence with all of the most recent history and physicals for the residents the practitioner provided medical care for which included a total of 18 residents. Email correspondence from the practitioner to the residence and the residence's consultant, dated 3/6/24, read the practitioner provided medical care to 15 residents. Email correspondence from the department to the residence, dated 3/11/24, read in part: "It has been brought to the department's attention that a practitioner from (a medical practice) has been removed as a practitioner for the residents at your building. I am writing to let you know that this is not allowed by state regulations. It was determined that the residence, nor the contracted consultant, can request a practitioner to not have patients in (in the residence). While I understand the intentions were good, residents have the choice in practitioners. I also understand that while giving the residents an option to stay with (the medical practice) or go to a different company, it was felt residents were getting the option. However, residents have the right to select a healthcare provider ... It is our recommendation that this decision be reversed. I will also be sending an email to (the medical practice) and the consultant with our recommendation. Please feel free to reach out if you have any questions."An email dated, 3/11/24, from the residence's consultant and copied to the residence's administrator read in part: The practitioner served approximately 12 residents of those residents, approximately five have switched over or are in the process of switching medical practices. "I do feel that the facility should provide protective oversight and get the residents the medical care they deserve and if the provider is not responding to care needs, seek out an option." The email further read four residents were consulted regarding the practitioner change. However, the email read only one resident of the four residents stated he wanted a change in practitioners. 3. During the investigation on 3/27/24 through 3/28/24 the following continued deficient practice was revealed:On 3/26/24 from 7:30 a.m. to 5:30 p.m., Resident #20 stated s/he had a practitioner and within the last month s/he was told her practitioner was no longer coming to the residence to provide services. The resident stated she had been asked several times to switch over to a different practitioner's practice altogether and was pressured on multiple occasions to change. The resident stated staff at the residence stated she was out of her medications because the practitioner was at fault. On 3/26/24 from 7:30 a.m. to 5:30 p.m. Resident #22 stated that s/he was so upset as s/he missed the previous practitioner as he was a good practitioner and it was hard for the resident to have the practitioner leave the residence so abruptly. S/he stated s/he was not sure why there were missed medication or missed medication orders and that the administrator spoke to the resident about switching to another medical practice. On 3/26/24 from 7:30 a.m. to 5:30 p.m. Resident #27 stated that s/he had a practitioner who signed for his medications but s/he was not receiving those medications and was told that the insurance was possibly an issue with how the medications were ordered but s/he was also told that the practitioner was not ordering medications by the administrator so s/he switched to a different medical practice. On 3/26/24 from 7:30 a.m. to 5:30 p.m., Resident #28 stated s/he had a practitioner and within the last few couple of weeks he left and s/he was told s/he is now with a new practice. The resident stated the previous practitioner was no longer there and s/he had no idea what happened although s/he was told by the administrator that the original practitioner was not ordering the medications correctly and that the resident assumed that was why the practitioner is no longer at the residence. On 3/26/24 from 7:30 a.m. to 5:30 p.m., Resident #29 stated that s/he had a practitioner and within the past two to three weeks the practitioner was no longer at the residence and that the practitioner's supervisor was now at the residence and had taken over. The resident stated s/he never met the supervisor of the practitioner as that s/he was told that s/he had to choose a different medical practice as the original practitioner was no longer available as an option. On 3/26/24 from 7:30 a.m. to 5:30 p.m., Staff #14 stated recent changes were made regarding a change in practitioners the residence utilized for residents. S/he stated that between problems with a practitioner and a pharmacy "we have been trying to get them (residents) to move over to a different (medical practice)." S/he stated all residents were being transferred over to a different practice. On 3/27/24 at 1:06 p.m., Staff #15 stated the residence was working on getting all of the remaining residents switched out of the current medical practice to a new one. 3/27/24 10:12 a.m., the practitioner stated he had not been notified by the residence or the owner of the medical practice that he was able to return to the residence to provide medical care to residents. On 3/27/24 at 4:06 p.m., the owner of the medical practice stated the residence had not contacted him and let him know the original practitioner could come back to the residence and provide medical care. He further stated the administrator "has made it pretty apparent that she does not want (the original practitioner) back in the building." He further stated the administrator has stated it was the fault of the original practitioner as to why the residence had deficient practice with coordination of care and compliance with medications. On 3/28/24 at 11:00 a.m., the administrator stated she was not on the telephone call when the residence's consultant called the owner of the medical practice and informed him that the rounding practitioner could no longer work at the residence. The administrator stated that she had not instructed any residents to move practices. However, she stated she had not notified the original practitioner he could come back to the residence and stated she simply had another medical practice do a presentation regarding their services at a meeting. 4. Email Correspondence After the Onsite Investigation revealed the followingAn email dated, 3/27/24, from the practitioner's office to the residence and the consultant read in part: One Resident #14, switched to a different medical practice six weeks ago. Of note, this resident "was pretty upset about this change last week and did not seem to understand why she was switched. I am not sure what exactly she was upset about. I saw her waiting for the new practitioner's office transportation. The practitioner further wrote he said hello to Resident #14 when the resident "bubbled out her emotions."An email dated, 3/28/24, read in part: A family member for Resident #30 notified the practitioner's office twice on 3/28/24 and stated they were contacted by a different medical practice stating "they were concerned for the lack of patient care" and the fact their loved one would not get important medications if they stayed with the current medical practice. The email read a second resident ( #31) stated she had been pressured by the administrator specifically to switch medical practices and was told "other residents are upset and I think you should switch." Resident #31 stated s/he wanted to remain anonymous "because (s/he) was afraid of retaliation." The email referenced a third resident (#28), while the practitioner was visiting the resident, the administrator walked into the resident's room and notified the practitioner that Resident (Sanchez) had switched medical practices and their services were no longer needed. The practitioner informed the resident that since s/he switched practices to let the practitioner know if he ever wanted to come back to the practice. Resident #28 "responded with tears and said I'm not sure what I'm supposed to do. I love (the previous practitioner) and just feel terrible."

Plan of correction · submitted by the facility

IMPOSITION OF INTERMEDIATE CONDITION(s) - Retain a consultant for four months to address corrective measures for all tags. Required to have an RN (Registered Nurse) in the building at least 2 times a week working with the contracted consultant to correct deficiencies for Tags 430 A, 910 A, 1110 B, 1320 B, 1324 C, 1350 C, 1568 D, 1596 B, 1600 B, 1604 B, 1612 A, 2112 B, 2122 B, 290 B.(Cross-reference S1320, S1568). The facility will have each resident sign a document by June 30, 2024 stating they understand they have a choice in medical providers and other external service providers, this will be reviewed with new residents or their legal responsible party. In the event the resident would like to switch providers they will be made to feel welcome to do so at their own will. In the event the resident would like to talk to staff about their current provider the staff will encourage the resident to discuss issues directly with the medical provider first. Discussion of the right to choice will be added to the next resident council meeting. This will be reviewed monthly and added to the QMP and reviewed for 120 days and ongoing. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S D▼

Findings

Based on observation, interview and record review the residence failed to comply with authorized practitioner's orders affecting four of five sample residents (#3, #9, #10,#17) and two former residents (#15, #19). (Cross-reference B0290, S1350, S1604)Specifically, Former Resident #19 was prescribed antibiotics for a urinary tract infection on 1/24/24. However, the residence failed to ensure the prescription was filled. On 1/29/24 Former Resident #19 experienced a change in condition, was combative and had altered mental status. The former resident was subsequently transported to the emergency department, diagnosed with sepsis and a urinary tract infection. Former Resident #19 was administered intravenous (IV) antibiotics, fluids and was hospitalized for six days as a result of not receiving her antibiotics. Specifically, Former Resident #15 was prescribed lasix for edema on 2/14/24. However, the residence failed to ensure the prescription was filled and on 2/20/24 an external service provider notified the practitioner that the former resident had experienced swelling and edema. Former Resident #15 was subsequently transported to the emergency department (ED). Former Resident #15 was diagnosed with congestive heart failure and edema. The former resident was hospitalized for 15 days as a result of not receiving her prescribed medication and subsequently discharged to a skilled nursing facility. Findings Include:1. Residence Policya. The residence's Medication Services Policy, dated January 2024, read in part: Medication assistance services were provided by the residence by a qualified medication administration person (QMAP) who had completed the QMAP training and competency evaluation program. The medication assistance program consists of providing assistance with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living residences. Additionally, the policy read that the residence communicated with practitioners and pharmacists to ensure accuracy of medications. b. According to Good RX: "A urinary tract infection (UTI) is a common condition often caused by Escherichia coli bacteria in the urine. Antibiotics are the typical treatment for a UTI. In some cases, a UTI will go away on its own even if untreated. This is most likely to happen in adult women with no other health conditions. An untreated UTI can sometimes lead to serious complications and hospitalization. It ' s always a good idea to let your provider know you have UTI symptoms ... The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria), The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria) ... Sepsis is a life-threatening condition caused by the body ' s response to infection. It happens when the immune system works to fight an infection, but ends up causing too much inflammation throughout the whole body. Each year, about 1.7 million adults in the U.S. get sepsis, and almost 270,000 die from it. UTIs cause up to 30% of cases of sepsis. Risk factors for developing sepsis include: Being over 65 years old, Having diabetes, Having a weakened immune system, Having a history of prior urinary tract procedures Sepsis is a serious condition, and it needs immediate medical attention. Healthcare providers use specific guidelines to diagnose sepsis. Sepsis symptoms include: Low or high body temperature, High heart rate, High breathing rate, Swelling in parts of the body, Change in mental status (such as confusion) ... So while you may get over a UTI on your own, the risks of not treating a UTI can be pretty high. Some untreated UTIs can cause serious health problems that may even require hospitalization. It ' s best to let your provider know if you have symptoms of a UTI. They can find the source of your symptoms and come up with a treatment plan." Reviewed 2024. Retreived https://www.goodrx.com/conditions/urinary-tract-infection/untreated-uti-risks-dangers. c. According to RXlist: "Lasix (furosemide) is an anthranilic acid derivative that is used as a strong diuretic in adults and children to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome ... Seek medical care or call 911 at once if you have the following serious side effects: Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out." Reviewed 2024. Retrieved https://www.rxlist.com/lasix-drug.htm#description. d. According to the Cleveland Clinic: "Congestive heart failure is a long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time. Medications and other treatments help manage symptoms like swelling. Congestive heart failure is life-limiting for many ... Congestive heart failure symptoms include: Shortness of breath. Waking up short of breath at night. Chest pain. Heart palpitations. Fatigue when you ' re active. Swelling in your ankles, legs and abdomen. Weight gain ... Reviewed 2024. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failure 2. Former Resident #19 was admitted to the residence on 12/1/21 with diagnoses including urinary tract infection, muscle weakness, vitamin deficiency, post polio syndrome and hypertension.a. AmoxicillinA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 1/24/24 at 8:13 a.m., directed the residence to administer amoxicillin 500 mg potassium clavulanate 125 mg twice daily for seven days. However, the January 2024 medication administration record (MAR) read the medication was never administered. A residence progress note, dated 1/27/24, read in part: Staff brought food to Former Resident #19's room. The former resident was about to leave and was crying. When staff asked Former Resident #19 what was wrong she stated "she was scared as (expletive) and she feels intimidated." The administrator was notified. Hospital discharge orders, dated 1/29 through 2/5/24, read in part: Former Resident #19 was admitted to the hospital on 1/29/24 with symptoms including an altered mental status. Former Resident #19 was combative at the residence and was transported to the emergency department. The former resident tested positive for a urinary tract infection and would be treated with IV antibiotics, IV fluids and pain medication as needed. Former Resident #19 was admitted to the hospital. b. Vitamin D A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 2000 units once daily. However, the January 2024 MAR read the medication was not administered on 1/8, 1/9, 1/12-1/17 and 1/21-1/26/24 as the medication was out of stock, for a total of 14 missed doses.c. MultivitaminA written practitioner's order, dated 2/6/23, directed the residence to administer multivitamin once daily on 1/13-1/16,1/21-1/29/24 as the medication was on order, for a total of 13 missed doses. d. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/16, 1/17, 1/19, 1/21-1/29/24 as the medication was out of stock, for a total 11 missed doses.e. GabapentinA written practitioner's order, dated 2/6/23, directed the residence to administer gabapentin 100 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/20-1/27/24 as the medication was out of stock, for a total of seven missed doses. f. Metoprolol A written practitioner's order dated, 2/6/23, directed the residence to administer metoprolol tartrate 12.5 mg twice daily. However, the January 2024 MAR read the medication was not administered on 1/28/24 at 7:00 p.m. as the medication was out of stock and on 1/29/24 at 7:00 a.m., the dose was not administered as the resident was confused, for a total of two missed doses. g. HydrocodoneA written practitioner's order, dated 2/6/23, directed the residence to administer hydrocodone acetaminophen 7.5-325 mg twice daily. However, the January 2024 MAR read the medication was not administered the morning dose on 1/21/24 as the medication was out of stock. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #19 stated the former resident was prescribed antibiotics for a urinary tract infection on 1/24/24. He stated the residence did not inform him Resident #19 had not received her antibiotics and as a result on 1/29/24 Former Resident #19 had a change in condition from baseline, was transported to the ED, was hospitalized and later required skilled nursing care. Additionally, the practitioner stated that missing gabapentin, even one dose, could cause the resident to experience nerve pain. On 3/28/24 at 11:00 a.m., the administrator stated on 1/24/24 Former Resident #19 had a change in condition. She stated she was not her normal self, did not want to eat and laid in bed sleeping all day. She stated the former resident was transported to the emergency department and subsequently diagnosed with a urinary tract infection. The administrator further stated Former Resident #19, after her hospitalization, was discharged to a skilled nursing facility as she required more care than what the residence was able to provide. Additionally, the administrator stated she thought the former resident was seen by her practitioner for a suspected urinary tract infection; however, the administrator stated she was not aware the practitioner ordered any medication. 3. Former Resident #15 was admitted to the residence on 12/16/18 with diagnoses of tachycardia, atrioventricular block, pacemaker and peripheral vascular disease. A written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 2/14/24 at 4:00 p.m. directed the residence to administer furosemide (Lasix) 20 mg take 0.5 tablet once daily for swelling. A residence progress note, dated 2/20/23, read an external service provider notified the residence that Former Resident #15 had not received her prescription for lasix. The residence telephoned the pharmacy and no order was found. The external service provider stated Former Resident #15 had fluids in her legs and was sent to the ED via emergency medical services. An external service provider note, dated 2/20/24, read in part Former Resident #15 had increased edema of her extremities. The external service provider telephoned the practitioner, notified him of the resident's vitals and the practitioner agreed to have the resident receive emergency medical care. A hospitalization record, dated 2/20/24 through 3/6/24, read in part: Former Resident #15 was admitted to the hospital with diagnoses including: malaise, atherosclerotic heart disease, acute congestive heart failure and edema. The resident presented at the emergency department with shortness of breath and weight gain. The record further read Former Resident #15 "was supposed to be prescribed lasix however she never received the prescription ... Apparently in the past month or so (the resident) had 20 pound weight gain. Apparently the patient was consulted by medical staff there in the recent past concern forweight gain and edema and was supposed to be starting diuretic therapy when the provider checked on her today found her to be more edema and learned that she has not been receiving the diuretic and sent her to the emergency room." Resident #15 was swollen throughout the entire lower abdomen and lower extremities. Resident #15 was administered Lasix 60 mg injection upon admission. On 3/6/24, Former Resident #15 was discharged to a skilled nursing home. On 3/26/24 at 3:40 p.m., the January and February 2024 MARs for Former Resident #15 were requested. However, as of 3/28/24 no MARs were provided. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #15 stated on 2/14/24 the resident was prescribed Lasix due to edema. He stated approximately one week later the medication had not started and an external service provider telephoned him and explained the resident's condition had deteriorated and a decision was made to send the resident to the ED for urgent treatment. On 3/28/24 at 11:07 a.m., the administrator stated the external home health provider for Former Resident #15 was at the residence and noticed swelling and edema. She stated at that point the external home health provider went to the administrator's office to check on the prescription for Lasix which had been prescribed approximately one week prior. The administrator stated she checked and could tell the prescription was faxed to the pharmacy. However, she stated when she telephoned the pharmacy they reported not receiving the prescription. The administrator confirmed the former resident did not receive her medication and stated she should have followed up on the prescription. The administrator further added "it was probably one of the emails that I did not get to timely."4. Resident #3 was admitted to the residence on 2/24/20 with a diagnosis of gastroesophageal reflux disorder.a. Diclofenac A written practitioner's order, dated 1/31/24, directed the residence to administer diclofenac 1% topical gel 2 gm apply twice daily to neck and knees. However, the February through March 2024 MAR read the medication was not administered twice daily from 2/1-3/25/24 as it was labeled on the MAR as "as needed" medication for a total of 108 missed doses. b. LisinoprilA written practitioner's order, dated 1/3/24, directed the residence to discontinue omeprazole 40 mg and replace with pantoprazole 40 mg delayed release once daily. However, the February through March 2024 MARs read omeprazole was not discontinued and was administered in conjunction with pantoprazole from 2/1 and 2/4-2/29/24 for a total of 27 days. c. Vitamin B-12A written practitioner's order, dated 1/31/24, directed the residence to administer vitamin B-12 1000 mcg once daily. However, the March 2024 MAR read the medication was not administered from 3/15-3/26/24 as the medication was out of stock for a total of 11 missed doses.d. Meclizine HydrochlorideA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg once daily at noon. However, the February 2024 MAR read the medication was not administered on 2/1/24 as the resident was out of the residence for a total of one missed dose. On 3/28/24 at 11:00 a.m., the administrator stated she was not aware of the error with the pantoprazole. She stated the residence had difficulties obtaining prescriptions from the practitioner's and in addition, she stated the residence was also changing pharmacies. 4. Additional deficient practice was identified with Residents #9, #10 and #17.

Plan of correction · submitted by the facility

(Cross-reference B0290, S1350, S1604)Resident #15 & 19: No longer reside at facilityResident #3: Diclofenac (changed to PRN 4/1), Lisinopril (omeprazole no longer administered after 2/29/24), Vitamin B-12 (D/C’d 4/1/24), Meclizine Hydrochloride (administered as directed starting 2/2/24)Resident #9, 10, & 17: no specific medication issues cited. Medication orders not filled:The Facility has a new system in place to ensure that medication orders are filled and residents receive the medications. A Resident Care Coordinator( RCC) has been hired to over see the medications and this position/designee will review all medication orders upon a resident being seen by a medical provider or returned from the hospital to ensure that medications are ordered and delivered to the facility. A “ Medication order only email“ has been established so that medication orders do not get lost among other emails. The Resident Care Coordinator/designee will also review the Hospital log to ensure the medical provider provides new medication orders upon a re-admission. Out of stock issues:To correct missed doses due to out-of-stock issues, the facility has changed pharmacy and the Resident Care Coordinator/designee reviews the MAR sheets to ensure that the pharmacy has delivered all the medicationsTranscription error – a medication was listed as PRN and it was routine. The RCC/designee and the Administrator/Nurse will have a double check system to review any new orders that are transcribed on the MAR. This process will be started immediately to ensure accuracy. The change in process has already been initiated. QMAP’s will be educated, by date of compliance, on medication orders not filled, out of stock medications, and transcription errors. The ensure on going compliance, the medication orders, supply and transcription will be added to the QMP and reviewed for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1596Med/Med Adm-Med Prep/Hnd Tr ICS/S B▼

Findings

Based on observation and interview, the residence failed to ensure that qualified medication administration persons applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications affecting six of six sample residents (#17, #22, #26-29). Findings include:During morning medication administration on 3/26/24 at 7:52 a.m., the following was observed:Staff #13 donned gloves and began to prepare medications for Resident #26. Staff #13 while preparing the medications grasped her sweatshirt wiping her nose. Staff #13 subsequently spilled the medications for Resident #26 on the medication cart and picked them up with her gloved hand placing them back into the medication cup, Staff #13 then administered the medication, returned to the medication cart, doffed her gloves, opened the medication cart and documented on the medication administration record (MAR). Staff #13 touched her nose with her hand and stated she needed to obtain a tissue. The staff then wiped her nose and began to prepare medication for Resident #27 popping the medication out of the blister package and placing it in the medication cup. Staff #13 then took out a cup and poured water from a pitcher for the resident. Staff #13 then handed Resident #27 her medications and began to cough. She then took out a tissue and blew her nose and sanitized her hands. Staff #13 donned gloves and prepared medication for Resident #10. The staff took out the resident's insulin pen from the medication cart and handed the resident the insulin to self administer. Staff #13 came back to the medication cart, did not remove her gloves or sanitize her hands. She subsequently prepared and administered medications for Resident #9, applied hydrocortisone cream to the resident's neck. Staff #13 doffed her gloves and without washing or sanitizing her hands administered medications to Resident #17,#22, #28 and #29 in a similar unsanitary manner. On 3/28/24 at 11:07 a.m., the administrator stated she had discussed proper infection control when administering medications to residents. The administrator further stated the improper infection control by Staff #13 surprised her.

Plan of correction · submitted by the facility

All Qmap staff will be retrained by date of compliance on proper administration of medication including infection control measures while preparing medication. The RCC, RN or designee will provide such training and monitor medication passes twice weekly to ensure proper procedures are being completed and staff are following Qmap guidelines in Chapter 24. This issue will be addressed with new hires through the Qmap verification training document during Qmap inhouse orientation by the RCC or Administrator or RN. To ensure continued compliance this area will be reviewed monthly at QMP meetings and will remain an area of focus for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1600Med/Med Adm-Rcrd Kpng MARS/S B▼

Findings

Based on interview and record review the residence failed to ensure staff documented on the medication administration record (MAR) at the time of medication administration affecting three of five sample residents (#3, #10, #14). (Cross-reference S1604)Findings include: 1. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: The residence would maintain current files on all medications. 2. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including gastroesophageal reflux disorder, hypertension.a. FluticasoneA written practitioner's order, dated 1/31/23, directed the residence to administer fluticasone propionate/salmeterol 500-50 mcg one puff twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 evening dose, 2/1-2/3 all doses, 2/7 evening dose, 2/17 evening., 2/24 and 2/27 evening doses, 2/29 morning dose, 3/9 morning dose and 3/21/24 evening dose. b. LisinoprilA written practitioner's order, dated 1/31/24, directed the residence to administer lisinopril 5 mg once daily. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/1-2/3 and 3/23/24. c. Gabapentin A written practitioner's order, dated 1/31/24, directed the residence to administer gabapentin 600 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 at bedtime, 2/2- 2/3 all doses and on 3/2/24 at noon. d. MeclizineA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg tablet at noon. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/2, 2/3 and 3/2/24. e. IpratropiumA written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium 0.5 mg albuterol 3 mg four times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2 at noon and 3/21/24 at the evening dose and bedtime dose. f. SertralineA written practitioner's order, dated 1/31/24, directed the residence to administer sertraline 100 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/2 and 2/3/24.g. PantoprazoleA written practitioner's order, dated 1/31/24, directed the residence to administer pantoprazole sodium 40 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 and 2/2/24. h. SpirivaA written practitioner's order, dated 1/31/24, directed the residence to administer Spariva handihaler 18 mcg one puff by mouth once daily. However the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/9/24.3. Resident #14 was admitted to the residence on an unknown date.a. PantoprazoleA written practitioner's order, dated 1/25/24, directed the residence to administer pantoprazole sodium 40 mg twice daily. However, the March 2023 MAR revealed no evidence of documentation at the time of administration on 3/7, 3/11 morningdoses, 3/19, 3/20 evening doses and 3/24/24 morning dose. b. RosuvastatinA written practitioner's order, dated 2/29/24, directed the residence to administer rosuvastatin calcium 10 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/5/24.c. SertralineA written practitioner's order, dated 1/25/24, directed the residence to administer sertraline 50 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24. d. Docusate SodiumA written practitioner's order, dated 1/25/24, directed the residence to administer docusate sodium 100 mg twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24 evening dose. e. MontelukastA written practitioner's order, dated 1/25/24, directed the residence to administer montelukast sodium 10 mg at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/1/24.f. BuspironeA written practitioner's order, dated 1/25/24, directed the residence to administer buspirone 10 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/8 and 3/11/24 at 6:00 a.m.g. ClopidogrelA written practitioner's order, dated 1/25/24, directed the residence to administer clopidogrel 75 mg once daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2/24. 4. Additional deficient practice was identified for Resident #10. On 3/28/24 at 11:00 a.m., the administrator stated she expected qualified medication administration persons to administer medications and document on the MAR. She stated she has done training with staff in the past regarding documentation on the MAR; however, the administrator stated there were no consequences put in place to prevent a recurrence.

Plan of correction · submitted by the facility

(Cross-reference S1604)Correction: The facility has retained a nurse to review staff serving medication and retrain staff that are not properly documenting when the medication is served. The RCC and nurse or designee will observe medication passes twice weekly to watch for proper documentation, infection control measures, proper glove use and that the mediation administrator is compliant with Chapter 24 guidelines. All Qmap Staff will be retrained by date of compliance for the POC and training documentation will be filed in the staff records. The RCC/designee is reviewing MAR sheets daily during the weekdays to ensure staff are documenting and there are no holes in the MAR that are not properly addressed. Issues found will be addressed with staff as needed. To ensure continued compliance, all records reviewed will be discussed monthly in the QMP meetings and this area will remain an area of focus in the QMP for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based on interview and record review the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis audited the accuracy and completeness of the medication administration records (MARs) affecting five of five sample residents (#3, #9, #10,#17). (Cross-reference S1568, S1600)Findings include:Medication Cart/Medication Administration Record Audits completed from December 2023 to present revealed the form focused on three areas of the medication program: Medication administered as ordered, medication signed out appropriately, follow-up completed on any out of stock medications with both the practitioner and pharmacy and follow-up completed on any medication refusal not given. A second audit tool utilized in January 2024 read the residence only audited the medication cart and a list of staff names who signed the MAR. The audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. On 3/26/24 at approximately 11:00 a.m., the residence's contracted consultant stated that neither she or the administrator had done a full audit of the resident records in relation to the practitioner's orders, MARs and medication cart. The consultant further stated there was a corporate nurse scheduled to assist with the audits on 3/27/24.

Plan of correction · submitted by the facility

(Cross-reference S1568, S1600)The RN, the Administrator and the RCC will on a quarterly basis audit the Medication cart to include the MAR, the medication orders, the controlled substance list, medication error reports and medication disposal records. Any discrepancies will be investigated and resolved. One third of the residents’ records will be reviewed monthly to ensure the accuracy of the MAR with the orders with the medication. All 3 months records will be reviewed at the quarterly medication cart audit. To ensure compliance the medication audit records will be reviewed each month and will remain an area of focus for 120 days. The QMP meetings are held monthly and this topic will be discussed during these meeting with meeting notes as documentation. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1612Med/Med Adm-Rprt Pract/Rep NtfdS/S A▼

Findings

Based on interview and record review the residence failed to ensure the resident's authorized practitioner was notified of a resident's pattern of refusal affecting one sample residents (#3) and one former resident (#19). Findings include:1. The residence's Medication Services Policy, dated January 2024, read in part: The residence would communicate with practitioners to ensure accuracy of medications. 2. Former Resident #19 was admitted to the residence on 12/1/21 with a diagnosis of constipation. A written practitioner's order, dated 7/5/23, directed the residence to administer Senna 8.6 mg once daily. However, the January 2024 medication administration record (MAR) read the medication was not administered as the resident refused on 1/4, 1/5, 1/11-1/13, 1/19-1/22 and 1/25-1/27/24 for a total of 12 refused doses. 3. Resident #3 was admitted to the residence on 12/24/20. A written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium bromide sulfate 0.5-2.5 mg four times daily. However, the March 2024 MAR read the resident refused the medication on 3/14, 3/19, 3/20 at noon, 3/24, 3/25 and 3/26/24 morning and noon for a total of seven refused doses. On 3/27/24 at 10:12 a.m., the practitioner for Resident #3 stated he had not been notified of any medication refusals. On 3/28/24 at 11:07 a.m., the administrator stated the residence did not have a formal process in place for notifying the practitioner of a pattern of refusals. She stated currently the qualified medication administration person who attempted to administer the medication was responsible for notifying the practitioner of all refusals.

Plan of correction · submitted by the facility

The Qmaps will be retrained by the RN, RCC, designee by date of compliance, to report missed dosages due to refusals and to properly document this on the MAR. After 3 refusals the RCC or designee will contact the medical provider and take further instruction. The RCC/designee is also reviewing the MARS daily, on weekdays, to provide oversight to address patterns of refusals. This issue will be added to the Medication Policy by date of compliance. Reporting refusals of medication to the practitioner will be added to the QMP and reviewed monthly for 120 days. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

2112Fd/Din Srvs-M/Dr/Sn M Incld/SubS/S B▼

Findings

Based on observation, interview and record review, the residence failed to ensure foods were nutritionally balanced and appealing substitutes of similar nutritional value were available for residents, affecting 46 current residents. (Cross-reference S2122)Findings include:The residence's undated resident agreement read in part: The residence offered meals and snacks. Three nutritionally well-balanced meals per day were included in the basic rate of the residence. On 3/26/24 at approximately 7:30 a.m., during an environmental tour, there was no residence menu available for review. The menu and alternatives were listed on the menu for lunch and dinner. The same menu items were listed as alternatives for each meal. Lunch alternatives were roast beef and cheese with chips Monday-Sunday. The alternative for dinner was a chicken sandwich with chips being offered Monday-Sunday. On 3/26/24 from 7:30 a.m. to 5:30 p.m.,, Resident #20 stated that alternatives were only offered sometimes. S/he stated the meal alternatives offered were salad. On 3/26/24 at 7:30 a.m. to 5:30 p.m Resident #29 stated s/he only received a menu this week at 2:00 p.m. as there were surveyors present so the residence produced a menu for the residents. Resident #29 stated that on Monday's, residents did not have an alternative choice because the residents have been told that the delivery truck did not always arrive on time per the residence chef. Resident #29 stated residents did not have access to snacks but that residents sometimes received fruit. Resident #29 also stated that the residence would provide better quality meals when the department was present as well as case management agencies. On 3/27/24 at 1:06 p.m., Staff #15 stated the only alternative s/he was aware of were hot dogs. On 3/28/24 at 11:00 a.m. the administrator stated that food options were the biggest complaint the residence was working on and that hotdogs and french fries were not the only alternative and that other options have been made available such as soups.

Plan of correction · submitted by the facility

(Cross-reference S2122)The substitute meals process has been changed and each month the residents will decide on 3 choices of alternate meals that will be posted along side the menu. The Administrator will review the alternate meal choices weekly with dietary to ensure they are respecting resident alternative meal selection. To ensure continued compliance, this area will be added to the QMP, reviewed monthly and will remain an area of focus for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

2122Fd/Din Srvs-Menu Wkly MenuS/S B▼

Findings

Based on observation and interview, the residence failed to have weekly menus readily available for residents and public viewing 24 hours prior to serving, affecting 46 current residents. Findings include:During an environmental tour of the residence at approximately 7:30 a.m., there was no evidence of a menu that was ready for resident review and public viewing. A menu was posted at approximately 12:00 p.m. in time for the lunch time meal and was added to each table for residents to review. On 3/26/24 at 2:21 p.m., Resident #29 stated s/he only received a menu this week at 2:00 p.m. as there were surveyors present so the residence produced a menu for the residents. On 3/28/24 at 11:00 a.m. the administrator stated that menus should be changed weekly and acknowledged that the menu and food options are the biggest complaint. The administrator also stated that menus should have been posed earlier in the week and that she would follow up.

Plan of correction · submitted by the facility

The process for menu posting has been reviewed and revised. The dining supervisor will be trained on the regulation that residents have to have access to a menu 24 hours prior to the meal being served. The training will be by date of compliance. The menu will be posted on the bulletin boards in the dining room as well as the activity bulletin board for residents to review. This issue has been added to the facility check list, an inspection list for the Administrator. To ensure continued compliance this area has been added to the QMP and will be reviewed monthly for 120 days. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

3/5/2024Revisit: Licensure and Licensure Complaint (Combined) · ID ZCVZ134 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 3/28/24 for all previous deficiencies cited on 9/29/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0290LicProc-DeptOvrst-Srvy/Inspct Ensr Cmply-POCS/S B▼

Findings

Based on interview and record review, the residence failed to provide access upon request to individual residence records affecting eight of eight sample residents and one former resident (#3, #9, #10, #14- #18 and Former Resident #19). (Cross-reference S1160, S1568)This deficiency was cited previously during a state licensure survey and complaint investigation on 5/17/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Chapter VII regulations governing assisted living residences, part 18.8 require that resident records shall contain, but not be limited to, the following items: (A) Face Sheet; (B) Practitioner order; (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. (E) Medication Administration Record. On 3/20/24 at 1:46 p.m., an email sent to the department, dated 2/14/24 at 2:20 p.m., read the practitioner sent current practitioner's orders to the residence for residents (#3, #10, #14- #17, and former resident #19). On 3/26/24 at 9:32 a.m., a request for full resident records for residents (#3, #9, #10, #14, #15) was given to the administrator. On 3/26/24 at approximately 11:30 a.m., the records for residents (#3, #9, #10, #14, #15) were provided. However, the records were missing recent practitioner's orders. On 3/26/24 at 1:04 p.m., a request was made from the residence's contracted consultant for the practitioner's orders the residence received on 2/14/24. On 3/26/24 at 2:00 p.m., a request for all current practitioners orders for residents (#3, #10, #14) were requested from the administrator. On 3/26/24 at 2:02 p.m., the practitioner's orders requested from the consultant for the sample residents were provided (approximately four and a half hours after the request for resident records was made). On 3/26/24 at 2:59 p.m., the face sheet, progress notes and practitioner's orders for Resident #16 and full resident records for residents (#17, #18 and former resident #19) were requested. On 3/26/24 at 3:00 p.m., additional practitioner's orders were provided for Resident #10 (approximately six and a half hours after requested). On 3/26/24 at 3:40 p.m., the January and February 2024 medication administration records (MARs) for Former Resident #15 were requested. On 3/26/24 at 4:25 p.m., current practitioner's orders for Resident #9 were requested. On 3/26/24 at 4:42 p.m., February 2024 MARs, current practitioner's orders and progress notes were requested for Former Resident #19. On 3/26/24 at 4:53 p.m., progress notes for the sample residents were provided by the residence's contracted consultant approximately seven hours and 20 minutes after the initial request. On 3/26/24 at 5:02 p.m., current practitioner's orders for Resident #9 were provided approximately seven hours and 30 minutes after the initial request. On 3/26/24 at 5:14 p.m., current practitioner's orders for Resident #18 and the January 2024 MAR for Former Resident #19 were requested. On 3/26/24 at 5:21 p.m., the January and February 2024 MARs for Former Resident #19 was provided approximately two hours and 20 minutes after the initial request. On 3/26/24 at 5:39 p.m., additional orders for Resident #9, current orders and face sheet for Resident #16 and Former Resident #19's most recent orders were requested. On 3/26/24 at 10:02 a.m., the remaining orders for residents (#9, #17, #18 and Former Resident #19) were provided. Additionally, the face sheet and practitioners orders for Resident #16 were provided. The January and February 2024 MARs for Former Resident #15 were never provided. On 3/28/24 at 11:08 a.m., the administrator stated documents required to be in resident records were not provided upon request because resident records had not been updated since July 2023. She stated staff had access to practitioner's orders and a lot of the orders were located in the medication room and her office to be filed. She stated she also had prescriptions in her email that had not been filed in the resident records. In a second interview on 3/28/24 at 3:30 p.m., the administrator confirmed documents were not provided by request and stated she was going to get all resident records in order but had other priorities that had come up.

Plan of correction · submitted by the facility

IMPOSITION OF INTERMEDIATE CONDITION(s) - Retain a consultant for four months to address corrective measures for all tags. Required to have an RN (Registered Nurse) in the building at least 2 times a week working with the contracted consultant to correct deficiencies for Tags 430 A, 910 A, 1110 B, 1320 B, 1324 C, 1350 C, 1568 D, 1596 B, 1600 B, 1604 B, 1612 A, 2112 B, 2122 B, 290 B.The storage of the resident records has been changed and the resident records will be stored in the locked medication room. The Resident Care Coordinator (RCC) and the RN are reviewing each resident record to ensure it is compliant with Part 18 of Chapter 7 regulations and documents are easy to access if needed. This will be completed by the compliance date of July 7, 2024 The new resident move in process has been revised to ensure each new resident has a compliant file prior to being allowed to move into the facility. A check list will be used to account for all documents. To ensure records remain compliant, a sample of 15% of the population records will be reviewed each month and updated as needed. This documentation will be kept along side the Quality Management meeting notes and this area of focus will remain in the QMP for 120 days. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S D▼

Findings

Based on observation, interview and record review the residence failed to comply with authorized practitioner's orders affecting four of five sample residents (#3, #9, #10,#17) and two former residents (#15, #19). (Cross-reference B0290, S1160, S1350, S1604)This deficiency was cited previously during a state licensure complaint revisit 9/29/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #19 was prescribed antibiotics for a urinary tract infection on 1/24/24. However, the residence failed to ensure the prescription was filled. On 1/29/24 Former Resident #19 experienced a change in condition, was combative and had altered mental status. The former resident was subsequently transported to the emergency department, diagnosed with sepsis and a urinary tract infection. Former Resident #19 was administered intravenous (IV) antibiotics, fluids and was hospitalized for six days as a result of not receiving her antibiotics. Specifically, Former Resident #15 was prescribed lasix for edema on 2/14/24. However, the residence failed to ensure the prescription was filled and on 2/20/24 an external service provider notified the practitioner that the former resident had experienced swelling and edema. Former Resident #15 was subsequently transported to the emergency department (ED). Former Resident #15 was diagnosed with congestive heart failure and edema. The former resident was hospitalized for 15 days as a result of not receiving her prescribed medication and subsequently discharged to a skilled nursing facility. Findings Include:1. Residence Policya. The residence's Medication Services Policy, dated January 2024, read in part: Medication assistance services were provided by the residence by a qualified medication administration person (QMAP) who had completed the QMAP training and competency evaluation program. The medication assistance program consists of providing assistance with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living residences. Additionally, the policy read that the residence communicated with practitioners and pharmacists to ensure accuracy of medications. b. According to Good RX: "A urinary tract infection (UTI) is a common condition often caused by Escherichia coli bacteria in the urine. Antibiotics are the typical treatment for a UTI. In some cases, a UTI will go away on its own even if untreated. This is most likely to happen in adult women with no other health conditions. An untreated UTI can sometimes lead to serious complications and hospitalization. It ' s always a good idea to let your provider know you have UTI symptoms ... The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria), The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria) ... Sepsis is a life-threatening condition caused by the body ' s response to infection. It happens when the immune system works to fight an infection, but ends up causing too much inflammation throughout the whole body. Each year, about 1.7 million adults in the U.S. get sepsis, and almost 270,000 die from it. UTIs cause up to 30% of cases of sepsis. Risk factors for developing sepsis include: Being over 65 years old, Having diabetes, Having a weakened immune system, Having a history of prior urinary tract procedures Sepsis is a serious condition, and it needs immediate medical attention. Healthcare providers use specific guidelines to diagnose sepsis. Sepsis symptoms include: Low or high body temperature, High heart rate, High breathing rate, Swelling in parts of the body, Change in mental status (such as confusion) ... So while you may get over a UTI on your own, the risks of not treating a UTI can be pretty high. Some untreated UTIs can cause serious health problems that may even require hospitalization. It ' s best to let your provider know if you have symptoms of a UTI. They can find the source of your symptoms and come up with a treatment plan." Reviewed 2024. Retreived https://www.goodrx.com/conditions/urinary-tract-infection/untreated-uti-risks-dangers. c. According to RXlist: "Lasix (furosemide) is an anthranilic acid derivative that is used as a strong diuretic in adults and children to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome ... Seek medical care or call 911 at once if you have the following serious side effects: Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out." Reviewed 2024. Retrieved https://www.rxlist.com/lasix-drug.htm#description. d. According to the Cleveland Clinic: "Congestive heart failure is a long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time. Medications and other treatments help manage symptoms like swelling. Congestive heart failure is life-limiting for many ... Congestive heart failure symptoms include: Shortness of breath. Waking up short of breath at night. Chest pain. Heart palpitations. Fatigue when you ' re active. Swelling in your ankles, legs and abdomen. Weight gain ... Reviewed 2024. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failure 2. Former Resident #19 was admitted to the residence on 12/1/21 with diagnoses including urinary tract infection, muscle weakness, vitamin deficiency, post polio syndrome and hypertension.a. AmoxicillinA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 1/24/24 at 8:13 a.m., directed the residence to administer amoxicillin 500 mg potassium clavulanate 125 mg twice daily for seven days. However, the January 2024 medication administration record (MAR) read the medication was never administered. A residence progress note, dated 1/27/24, read in part: Staff brought food to Former Resident #19's room. The former resident was about to leave and was crying. When staff asked Former Resident #19 what was wrong she stated "she was scared as (expletive) and she feels intimidated." The administrator was notified. Hospital discharge orders, dated 1/29 through 2/5/24, read in part: Former Resident #19 was admitted to the hospital on 1/29/24 with symptoms including an altered mental status. Former Resident #19 was combative at the residence and was transported to the emergency department. The former resident tested positive for a urinary tract infection and would be treated with IV antibiotics, IV fluids and pain medication as needed. Former Resident #19 was admitted to the hospital. b. Vitamin D A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 2000 units once daily. However, the January 2024 MAR read the medication was not administered on 1/8, 1/9, 1/12-1/17 and 1/21-1/26/24 as the medication was out of stock, for a total of 14 missed doses.c. MultivitaminA written practitioner's order, dated 2/6/23, directed the residence to administer multivitamin once daily on 1/13-1/16,1/21-1/29/24 as the medication was on order, for a total of 13 missed doses. d. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/16, 1/17, 1/19, 1/21-1/29/24 as the medication was out of stock, for a total 11 missed doses. GabapentinA written practitioner's order, dated 2/6/23, directed the residence to administer gabapentin 100 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/20-1/27/24 as the medication was out of stock, for a total of seven missed doses. f. Metoprolol A written practitioner's order dated, 2/6/23, directed the residence to administer metoprolol tartrate 12.5 mg twice daily. However, the January 2024 MAR read the medication was not administered on 1/28/24 at 7:00 p.m. as the medication was out of stock and on 1/29/24 at 7:00 a.m., the dose was not administered as the resident was confused, for a total of two missed doses. g. HydrocodoneA written practitioner's order, dated 2/6/23, directed the residence to administer hydrocodone acetaminophen 7.5-325 mg twice daily. However, the January 2024 MAR read the medication was not administered the morning dose on 1/21/24 as the medication was out of stock. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #19 stated the former resident was prescribed antibiotics for a urinary tract infection on 1/24/24. He stated the residence did not inform him Resident #19 had not received her antibiotics and as a result on 1/29/24 Former Resident #19 had a change in condition from baseline, was transported to the ED, was hospitalized and later required skilled nursing care. Additionally, the practitioner stated that missing gabapentin, even one dose, could cause the resident to experience nerve pain. On 3/28/24 at 11:00 a.m., the administrator stated on 1/24/24 Former Resident #19 had a change in condition. She stated she was not her normal self, did not want to eat and laid in bed sleeping all day. She stated the former resident was transported to the emergency department and subsequently diagnosed with a urinary tract infection. The administrator further stated Former Resident #19, after her hospitalization, was discharged to a skilled nursing facility as she required more care than what the residence was able to provide. Additionally, the administrator stated she thought the former resident was seen by her practitioner for a suspected urinary tract infection; however, the administrator stated she was not aware the practitioner ordered any medication. 3. Former Resident #15 was admitted to the residence on 12/16/18 with diagnoses of tachycardia, atrioventricular block, pacemaker and peripheral vascular disease. A written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 2/14/24 at 4:00 p.m. directed the residence to administer furosemide (Lasix) 20 mg take 0.5 tablet once daily for swelling. A residence progress note, dated 2/20/23, read an external service provider notified the residence that Former Resident #15 had not received her prescription for lasix. The residence telephoned the pharmacy and no order was found. The external service provider stated Former Resident #15 had fluids in her legs and was sent to the ED via emergency medical services. An external service provider note, dated 2/20/24, read in part Former Resident #15 had increased edema of her extremities. The external service provider telephoned the practitioner, notified him of the resident's vitals and the practitioner agreed to have the resident receive emergency medical care. A hospitalization record, dated 2/20/24 through 3/6/24, read in part: Former Resident #15 was admitted to the hospital with diagnoses including: malaise, atherosclerotic heart disease, acute congestive heart failure and edema. The resident presented at the emergency department with shortness of breath and weight gain. The record further read Former Resident #15 "was supposed to be prescribed lasix however she never received the prescription ... Apparently in the past month or so (the resident) had 20 pound weight gain. Apparently the patient was consulted by medical staff there in the recent past concern for weight gain and edema and was supposed to be starting diuretic therapy when the provider checked on her today found her to be more edema and learned that she has not been receiving the diuretic and sent her to the emergency room." Resident #15 was swollen throughout the entire lower abdomen and lower extremities. Resident #15 was administered Lasix 60 mg injection upon admission. On 3/6/24, Former Resident #15 was discharged to a skilled nursing home. On 3/26/24 at 3:40 p.m., the January and February 2024 MARs for Former Resident #15 were requested. However, as of 3/28/24 no MARs were provided. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #15 stated on 2/14/24 the resident was prescribed Lasix due to edema. He stated approximately one week later the medication had not started and an external service provider telephoned him and explained the resident's condition had deteriorated and a decision was made to send the resident to the ED for urgent treatment. On 3/28/24 at 11:07 a.m., the administrator stated the external home health provider for Former Resident #15 was at the residence and noticed swelling and edema. She stated at that point the external home health provider went to the administrator's office to check on the prescription for Lasix which had been prescribed approximately one week prior. The administrator stated she checked and could tell the prescription was faxed to the pharmacy. However, she stated when she telephoned the pharmacy they reported not receiving the prescription. The administrator confirmed the former resident did not receive her medication and stated she should have followed up on the prescription. The administrator further added "it was probably one of the emails that I did not get to timely."4. Resident #3 was admitted to the residence on 2/24/20 with a diagnosis of gastroesophageal reflux disorder.a. Diclofenac A written practitioner's order, dated 1/31/24, directed the residence to administer diclofenac 1% topical gel 2 gm apply twice daily to neck and knees. However, the February through March 2024 MAR read the medication was not administered twice daily from 2/1-3/25/24 as it was labeled on the MAR as "as needed" medication for a total of 108 missed doses. b. LisinoprilA written practitioner's order, dated 1/3/24, directed the residence to discontinue omeprazole 40 mg and replace with pantoprazole 40 mg delayed release once daily. However, the February through March 2024 MARs read omeprazole was not discontinued and was administered in conjunction with pantoprazole from 2/1 and 2/4-2/29/24 for a total of 27 days. c. Vitamin B-12A written practitioner's order, dated 1/31/24, directed the residence to administer vitamin B-12 1000 mcg once daily. However, the March 2024 MAR read the medication was not administered from 3/15-3/26/24 as the medication was out of stock for a total of 11 missed doses.d. Meclizine HydrochlorideA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg once daily at noon. However, the February 2024 MAR read the medication was not administered on 2/1/24 as the resident was out of the residence for a total of one missed dose. On 3/28/24 at 11:00 a.m., the administrator stated she was not aware of the error with the pantoprazole. She stated the residence had difficulties obtaining prescriptions from the practitioner's and in addition, she stated the residence was also changing pharmacies. The administrator stated she had started her position at the residence in July 2023; however, the administrator stated she had not read the past deficiencies and was not sure why they had not been corrected. 4. Additional deficient practice was identified with Residents #9, #10 and #17.

Plan of correction · submitted by the facility

(Cross-reference B0290, S1160, S1350, S1604)Resident #15 & 19: No longer reside at facilityResident #3: Diclofenac (changed to PRN 4/1), Lisinopril (omeprazole no longer administered after 2/29/24), Vitamin B-12 (D/C’d 4/1/24), Meclizine Hydrochloride (administered as directed starting 2/2/24)Resident #9, 10, & 17: no specific medication issues cited. Medication orders not filled:The Facility has a new system in place to ensure that medication orders are filled and residents receive the medications. A Resident Care Coordinator( RCC) has been hired to over see the medications and this position/designee will review all medication orders upon a resident being seen by a medical provider or returned from the hospital to ensure that medications are ordered and delivered to the facility. A “ Medication order only email“ has been established so that medication orders do not get lost among other emails. The Resident Care Coordinator/designee will also review the Hospital log to ensure the medical provider provides new medication orders upon a re-admission. Out of stock issues:To correct missed doses due to out-of-stock issues, the facility has changed pharmacy and the Resident Care Coordinator/designee reviews the MAR sheets to ensure that the pharmacy has delivered all the medicationsTranscription error – a medication was listed as PRN and it was routine. The RCC/designee and the Administrator/Nurse will have a double check system to review any new orders that are transcribed on the MAR. This process will be started immediately to ensure accuracy. The change in process has already been initiated. QMAP’s will be educated, by date of compliance, on medication orders not filled, out of stock medications, and transcription errors. The ensure on going compliance, the medication orders, supply and transcription will be added to the QMP and reviewed for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1600Med/Med Adm-Rcrd Kpng MARS/S B▼

Findings

Based on interview and record review the residence failed to ensure staff documented on the medication administration record (MAR) at the time of medication administration affecting three of five sample residents (#3, #10, #14). (Cross-reference S1604)This deficiency was cited previously during a state licensure complaint revisit 9/29/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: The residence would maintain current files on all medications. 2. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including gastroesophageal reflux disorder, hypertension.a. FluticasoneA written practitioner's order, dated 1/31/23, directed the residence to administer fluticasone propionate/salmeterol 500-50 mcg one puff twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 evening dose, 2/1-2/3 all doses, 2/7 evening dose, 2/17 evening., 2/24 and 2/27 evening doses, 2/29 morning dose, 3/9 morning dose and 3/21/24 evening dose. b. LisinoprilA written practitioner's order, dated 1/31/24, directed the residence to administer lisinopril 5 mg once daily. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/1-2/3 and 3/23/24. c. Gabapentin A written practitioner's order, dated 1/31/24, directed the residence to administer gabapentin 600 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 at bedtime, 2/2- 2/3 all doses and on 3/2/24 at noon. d. MeclizineA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg tablet at noon. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/2, 2/3 and 3/2/24. e. IpratropiumA written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium 0.5 mg albuterol 3 mg four times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2 at noon and 3/21/24 at the evening dose and bedtime dose. f. SertralineA written practitioner's order, dated 1/31/24, directed the residence to administer sertraline 100 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/2 and 2/3/24.g. PantoprazoleA written practitioner's order, dated 1/31/24, directed the residence to administer pantoprazole sodium 40 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 and 2/2/24. h. SpirivaA written practitioner's order, dated 1/31/24, directed the residence to administer Spariva handihaler 18 mcg one puff by mouth once daily. However the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/9/24.3. Resident #14 was admitted to the residence on an unknown date.a. PantoprazoleA written practitioner's order, dated 1/25/24, directed the residence to administer pantoprazole sodium 40 mg twice daily. However, the March 2023 MAR revealed no evidence of documentation at the time of administration on 3/7, 3/11 morningdoses, 3/19, 3/20 evening doses and 3/24/24 morning dose. b. RosuvastatinA written practitioner's order, dated 2/29/24, directed the residence to administer rosuvastatin calcium 10 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/5/24.c. SertralineA written practitioner's order, dated 1/25/24, directed the residence to administer sertraline 50 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24. d. Docusate SodiumA written practitioner's order, dated 1/25/24, directed the residence to administer docusate sodium 100 mg twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24 evening dose. e. MontelukastA written practitioner's order, dated 1/25/24, directed the residence to administer montelukast sodium 10 mg at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/1/24.f. BuspironeA written practitioner's order, dated 1/25/24, directed the residence to administer buspirone 10 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/8 and 3/11/24 at 6:00 a.m.g. ClopidogrelA written practitioner's order, dated 1/25/24, directed the residence to administer clopidogrel 75 mg once daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2/24. 4. Additional deficient practice was identified for Resident #10. On 3/28/24 at 11:00 a.m., the administrator stated she expected qualified medication administration persons to administer medications and document on the MAR. She stated she has done training with staff in the past regarding documentation on the MAR; however, the administrator stated there were no consequences put in place to prevent a recurrence. The administrator further stated she had gone over this deficiency with the residence's contracted consultant and was not sure why it had not been corrected.

Plan of correction · submitted by the facility

(Cross-reference S1604)Correction: The facility has retained a nurse to review staff serving medication and retrain staff that are not properly documenting when the medication is served. The RCC and nurse or designee will observe medication passes twice weekly to watch for proper documentation, infection control measures, proper glove use and that the mediation administrator is compliant with Chapter 24 guidelines. All Qmap Staff will be retrained by July 7, 2024 for the POC and training documentation will be filed in the staff records. The RCC/designee is reviewing MAR sheets daily during the weekdays to ensure staff are documenting and there are no holes in the MAR that are not properly addressed. Issues found will be addressed with staff as needed. To ensure continued compliance, all records reviewed will be discussed monthly in the QMP meetings and this area will remain an area of focus in the QMP for 120 days. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based on interview and record review the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis audited the accuracy and completeness of the medication administration records (MARs) affecting five of five sample residents (#3, #9, #10,#17). (Cross-reference S1568, S1600)Findings include:Medication Cart/Medication Administration Record Audits completed from December 2023 to present revealed the form focused on three areas of the medication program: Medication administered as ordered, medication signed out appropriately, follow-up completed on any out of stock medications with both the practitioner and pharmacy and follow-up completed on any medication refusal not given. A second audit tool utilized in January 2024 read the residence only audited the medication cart and a list of staff names who signed the MAR. The audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. On 3/26/24 at approximately 11:00 a.m., the residence's contracted consultant stated that neither she or the administrator had done a full audit of the resident records in relation to the practitioner's orders, MARs and medication cart. The consultant further stated there was a corporate nurse scheduled to assist with the audits on 3/27/24. On 3/28/24 at 11:07 a.m., the administrator stated she had been the administrator since July 2023. She stated she had not completed an audit to ensure the accuracy and completeness of the MARs. The administrator further stated the residence had been short staffed and she had not had time to look at the records for the residents.

Plan of correction · submitted by the facility

(Cross-reference S1568, S1600)The RN, the Administrator and the RCC will on a quarterly basis audit the Medication cart to include the MAR, the medication orders, the controlled substance list, medication error reports and medication disposal records. Any discrepancies will be investigated and resolved. One third of the residents’ records will be reviewed monthly to ensure the accuracy of the MAR with the orders with the medication. All 3 months records will be reviewed at the quarterly medication cart audit. To ensure compliance the medication audit records will be reviewed each month and will remain an area of focus for 120 days. The QMP meetings are held monthly and this topic will be discussed during these meeting with meeting notes as documentation. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

3/5/2024Revisit: Licensure Complaint · ID TE43151 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 3/28/24 for the previous deficiency cited on 9/29/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S D▼

Findings

Based on observation, interview and record review the facility (residence) failed to follow written policies and procedures for the adminstration of medication in accordance with Chapter VII regulations affecting nine of ten sample participants (residents) (#3, #9, #10, #17, #22, #26-#29) and two former residents (#15, #19). This deficiency was cited previously during a certification revisit 9/29/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #19 was prescribed antibiotics for a urinary tract infection on 1/24/24. However, the residence failed to ensure the prescription was filled. On 1/29/24 Former Resident #19 experienced a change in condition, was combative and had altered mental status. The former resident was subsequently transported to the emergency department, diagnosed with sepsis and a urinary tract infection. Former Resident #19 was administered intravenous (IV) antibiotics, fluids and was hospitalized for six days as a result of not receiving her antibiotics. Specifically, Former Resident #15 was prescribed lasix for edema on 2/14/24. However, the residence failed to ensure the prescription was filled and on 2/20/24 an external service provider notified the practitioner that the former resident had experienced swelling and edema. Former Resident #15 was subsequently transported to the emergency department (ED). Former Resident #15 was diagnosed with congestive heart failure and edema. The former resident was hospitalized for 15 days as a result of not receiving her prescribed medication and subsequently discharged to a skilled nursing facility. Findings include:1. Chapter VII regualtions governing assited living residences, requires in part 14.21 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.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: Medication assistance services were provided by the residence by a qualified medication administration person (QMAP) who had completed the QMAP training and competency evaluation program. The medication assistance program consists of providing assistance with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living residences. Additionally, the policy read that the residence communicated with practitioners and pharmacists to ensure accuracy of medications. According to Good RX: "A urinary tract infection (UTI) is a common condition often caused by Escherichia coli bacteria in the urine. Antibiotics are the typical treatment for a UTI. In some cases, a UTI will go away on its own even if untreated. This is most likely to happen in adult women with no other health conditions. An untreated UTI can sometimes lead to serious complications and hospitalization. It ' s always a good idea to let your provider know you have UTI symptoms ... The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria), The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria) ... Sepsis is a life-threatening condition caused by the body ' s response to infection. It happens when the immune system works to fight an infection, but ends up causing too much inflammation throughout the whole body. Each year, about 1.7 million adults in the U.S. get sepsis, and almost 270,000 die from it. UTIs cause up to 30% of cases of sepsis. Risk factors for developing sepsis include: Being over 65 years old, Having diabetes, Having a weakened immune system, Having a history of prior urinary tract procedures Sepsis is a serious condition, and it needs immediate medical attention. Healthcare providers use specific guidelines to diagnose sepsis. Sepsis symptoms include: Low or high body temperature, High heart rate, High breathing rate, Swelling in parts of the body, Change in mental status (such as confusion) ... So while you may get over a UTI on your own, the risks of not treating a UTI can be pretty high. Some untreated UTIs can cause serious health problems that may even require hospitalization. It ' s best to let your provider know if you have symptoms of a UTI. They can find the source of your symptoms and come up with a treatment plan." Reviewed 2024. Retreived https://www.goodrx.com/conditions/urinary-tract-infection/untreated-uti-risks-dangers. According to RXlist: "Lasix (furosemide) is an anthranilic acid derivative that is used as a strong diuretic in adults and children to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome ... Seek medical care or call 911 at once if you have the following serious side effects: Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out." Reviewed 2024. Retrieved https://www.rxlist.com/lasix-drug.htm#description. According to the Cleveland Clinic: "Congestive heart failure is a long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time. Medications and other treatments help manage symptoms like swelling. Congestive heart failure is life-limiting for many ... Congestive heart failure symptoms include: Shortness of breath. Waking up short of breath at night. Chest pain. Heart palpitations. Fatigue when you ' re active. Swelling in your ankles, legs and abdomen. Weight gain ... Reviewed 2024. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failureb. Former Resident #19 was admitted to the residence on 12/1/21 with diagnoses including urinary tract infection, muscle weakness, vitamin deficiency, post polio syndrome and hypertension. AmoxicillinA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 1/24/24 at 8:13 a.m., directed the residence to administer amoxicillin 500 mg potassium clavulanate 125 mg twice daily for seven days. However, the January 2024 medication administration record (MAR) read the medication was never administered. A residence progress note, dated 1/27/24, read in part: Staff brought food to Former Resident #19's room. The former resident was about to leave and was crying. When staff asked Former Resident #19 what was wrong she stated "she was scared as (expletive) and she feels intimidated." The administrator was notified. Hospital discharge orders, dated 1/29 through 2/5/24, read in part: Former Resident #19 was admitted to the hospital on 1/29/24 with symptoms including an altered mental status. Former Resident #19 was combative at the residence and was transported to the emergency department. The former resident tested positive for a urinary tract infection and would be treated with IV antibiotics, IV fluids and pain medication as needed. Former Resident #19 was admitted to the hospital. Vitamin D A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 2000 units once daily. However, the January 2024 MAR read the medication was not administered on 1/8, 1/9, 1/12-1/17 and 1/21-1/26/24 as the medication was out of stock, for a total of 14 missed doses. MultivitaminA written practitioner's order, dated 2/6/23, directed the residence to administer multivitamin once daily on 1/13-1/16,1/21-1/29/24 as the medication was on order, for a total of 13 missed doses. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/16, 1/17, 1/19, 1/21-1/29/24 as the medication was out of stock, for a total 11 missed doses. GabapentinA written practitioner's order, dated 2/6/23, directed the residence to administer gabapentin 100 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/20-1/27/24 as the medication was out of stock, for a total of seven missed doses. Metoprolol A written practitioner's order dated, 2/6/23, directed the residence to administer metoprolol tartrate 12.5 mg twice daily. However, the January 2024 MAR read the medication was not administered on 1/28/24 at 7:00 p.m. as the medication was out of stock and on 1/29/24 at 7:00 a.m., the dose was not administered as the resident was confused, for a total of two missed doses. HydrocodoneA written practitioner's order, dated 2/6/23, directed the residence to administer hydrocodone acetaminophen 7.5-325 mg twice daily. However, the January 2024 MAR read the medication was not administered the morning dose on 1/21/24 as the medication was out of stock. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #19 stated the former resident was prescribed antibiotics for a urinary tract infection on 1/24/24. He stated the residence did not inform him Resident #19 had not received her antibiotics and as a result on 1/29/24 Former Resident #19 had a change in condition from baseline, was transported to the ED, was hospitalized and later required skilled nursing care. Additionally, the practitioner stated that missing gabapentin, even one dose, could cause the resident to experience nerve pain. On 3/28/24 at 11:00 a.m., the administrator stated on 1/24/24 Former Resident #19 had a change in condition. She stated she was not her normal self, did not want to eat and laid in bed sleeping all day. She stated the former resident was transported to the emergency department and subsequently diagnosed with a urinary tract infection. The administrator further stated Former Resident #19, after her hospitalization, was discharged to a skilled nursing facility as she required more care than what the residence was able to provide. Additionally, the administrator stated she thought the former resident was seen by her practitioner for a suspected urinary tract infection; however, the administrator stated she was not aware the practitioner ordered any medication. c. Former Resident #15 was admitted to the residence on 12/16/18 with diagnoses of tachycardia, atrioventricular block, pacemaker and peripheral vascular disease. A written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 2/14/24 at 4:00 p.m. directed the residence to administer furosemide (Lasix) 20 mg take 0.5 tablet once daily for swelling. A residence progress note, dated 2/20/23, read an external service provider notified the residence that Former Resident #15 had not received her prescription for lasix. The residence telephoned the pharmacy and no order was found. The external service provider stated Former Resident #15 had fluids in her legs and was sent to the ED via emergency medical services. An external service provider note, dated 2/20/24, read in part Former Resident #15 had increased edema of her extremities. The external service provider telephoned the practitioner, notified him of the resident's vitals and the practitioner agreed to have the resident receive emergency medical care. A hospitalization record, dated 2/20/24 through 3/6/24, read in part: Former Resident #15 was admitted to the hospital with diagnoses including: malaise, atherosclerotic heart disease, acute congestive heart failure and edema. The resident presented at the emergency department with shortness of breath and weight gain. The record further read Former Resident #15 "was supposed to be prescribed lasix however she never received the prescription ... Apparently in the past month or so (the resident) had 20 pound weight gain. Apparently the patient was consulted by medical staff there in the recent past concern for weight gain and edema and was supposed to be starting diuretic therapy when the provider checked on her today found her to be more edema and learned that she has not been receiving the diuretic and sent her to the emergency room." Resident #15 was swollen throughout the entire lower abdomen and lower extremities. Resident #15 was administered Lasix 60 mg injection upon admission. On 3/6/24, Former Resident #15 was discharged to a skilled nursing home. On 3/26/24 at 3:40 p.m., the January and February 2024 MARs for Former Resident #15 were requested. However, as of 3/28/24 no MARs were provided. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #15 stated on 2/14/24 the resident was prescribed Lasix due to edema. He stated approximately one week later the medication had not started and an external service provider telephoned him and explained the resident's condition had deteriorated and a decision was made to send the resident to the ED for urgent treatment. On 3/28/24 at 11:07 a.m., the administrator stated the external home health provider for Former Resident #15 was at the residence and noticed swelling and edema. She stated at that point the external home health provider went to the administrator's office to check on the prescription for Lasix which had been prescribed approximately one week prior. The administrator stated she checked and could tell the prescription was faxed to the pharmacy. However, she stated when she telephoned the pharmacy they reported not receiving the prescription. The administrator confirmed the former resident did not receive her medication and stated she should have followed up on the prescription. The administrator further added "it was probably one of the emails that I did not get to timely."d. Resident #3 was admitted to the residence on 2/24/20 with a diagnosis of gastroesophageal reflux disorder. Diclofenac A written practitioner's order, dated 1/31/24, directed the residence to administer diclofenac 1% topical gel 2 gm apply twice daily to neck and knees. However, the February through March 2024 MAR read the medication was not administered twice daily from 2/1-3/25/24 as it was labeled on the MAR as "as needed" medication for a total of 108 missed doses. LisinoprilA written practitioner's order, dated 1/3/24, directed the residence to discontinue omeprazole 40 mg and replace with pantoprazole 40 mg delayed release once daily. However, the February through March 2024 MARs read omeprazole was not discontinued and was administered in conjunction with pantoprazole from 2/1 and 2/4-2/29/24 for a total of 27 days. Vitamin B-12A written practitioner's order, dated 1/31/24, directed the residence to administer vitamin B-12 1000 mcg once daily. However, the March 2024 MAR read the medication was not administered from 3/15-3/26/24 as the medication was out of stock for a total of 11 missed doses. Meclizine HydrochlorideA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg once daily at noon. However, the February 2024 MAR read the medication was not administered on 2/1/24 as the resident was out of the residence for a total of one missed dose. On 3/28/24 at 11:00 a.m., the administrator stated she was not aware of the error with the pantoprazole. She stated the residence had difficulties obtaining prescriptions from the practitioner's and in addition, she stated the residence was also changing pharmacies. The administrator stated she had started her position at the residence in July 2023; however, the administrator stated she had not read the past deficiencies and was not sure why they had not been corrected.e. Additional deficient practice was identified with Residents #9, #10 and #17. 2. Chapter VII regulations governing assisted living residences, requires in part 14.28 that the assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. During morning medication administration on 3/26/24 at 7:52 a.m., the following was observed:Staff #13 donned gloves and began to prepare medications for Resident #26. Staff #13 while preparing the medications grasped her sweatshirt wiping her nose. Staff #13 subsequently spilled the medications for Resident #26 on the medication cart and picked them up with her gloved hand placing them back into the medication cup, Staff #13 then administered the medication, returned to the medication cart, doffed her gloves, opened the medication cart and documented on the medication administration record (MAR). Staff #13 touched her nose with her hand and stated she needed to obtain a tissue. The staff then wiped her nose and began to prepare medication for Resident #27 popping the medication out of the blister package and placing it in the medication cup. Staff #13 then took out a cup and poured water from a pitcher for the resident. Staff #13 then handed Resident #27 her medications and began to cough. She then took out a tissue and blew her nose and sanitized her hands. Staff #13 donned gloves and prepared medication for Resident #10. The staff took out the resident's insulin pen from the medication cart and handed the resident the insulin to self administer. Staff #13 came back to the medication cart, did not remove her gloves or sanitize her hands. She subsequently prepared and administered medications for Resident #9, applied hydrocortisone cream to the resident's neck. Staff #13 doffed her gloves and without washing or sanitizing her hands administered medications to Resident #17,#22, #28 and #29 in a similar unsanitary manner. On 3/28/24 at 11:07 a.m., the administrator stated she had discussed proper infection control when administering medications to residents. The administrator further stated the improper infection control by Staff #13 surprised her. 3. Chapter VII regulations governing assisted living residences, in part 14.29 requires that All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: The residence would maintain current files on all medications. b. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including gastroesophageal reflux disorder, hypertension. FluticasoneA written practitioner's order, dated 1/31/23, directed the residence to administer fluticasone propionate/salmeterol 500-50 mcg one puff twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 evening dose, 2/1-2/3 all doses, 2/7 evening dose, 2/17 evening., 2/24 and 2/27 evening doses, 2/29 morning dose, 3/9 morning dose and 3/21/24 evening dose. LisinoprilA written practitioner's order, dated 1/31/24, directed the residence to administer lisinopril 5 mg once daily. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/1-2/3 and 3/23/24. Gabapentin A written practitioner's order, dated 1/31/24, directed the residence to administer gabapentin 600 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 at bedtime, 2/2- 2/3 all doses and on 3/2/24 at noon. MeclizineA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg tablet at noon. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/2, 2/3 and 3/2/24. IpratropiumA written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium 0.5 mg albuterol 3 mg four times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2 at noon and 3/21/24 at the evening dose and bedtime dose. SertralineA written practitioner's order, dated 1/31/24, directed the residence to administer sertraline 100 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/2 and 2/3/24. PantoprazoleA written practitioner's order, dated 1/31/24, directed the residence to administer pantoprazole sodium 40 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 and 2/2/24. SpirivaA written practitioner's order, dated 1/31/24, directed the residence to administer Spariva handihaler 18 mcg one puff by mouth once daily. However the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/9/24.c. Resident #14 was admitted to the residence on an unknown date. PantoprazoleA written practitioner's order, dated 1/25/24, directed the residence to administer pantoprazole sodium 40 mg twice daily. However, the March 2023 MAR revealed no evidence of documentation at the time of administration on 3/7, 3/11 morningdoses, 3/19, 3/20 evening doses and 3/24/24 morning dose. RosuvastatinA written practitioner's order, dated 2/29/24, directed the residence to administer rosuvastatin calcium 10 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/5/24. SertralineA written practitioner's order, dated 1/25/24, directed the residence to administer sertraline 50 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24. Docusate SodiumA written practitioner's order, dated 1/25/24, directed the residence to administer docusate sodium 100 mg twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24 evening dose. MontelukastA written practitioner's order, dated 1/25/24, directed the residence to administer montelukast sodium 10 mg at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/1/24. BuspironeA written practitioner's order, dated 1/25/24, directed the residence to administer buspirone 10 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/8 and 3/11/24 at 6:00 a.m. ClopidogrelA written practitioner's order, dated 1/25/24, directed the residence to administer clopidogrel 75 mg once daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2/24. d. Additional deficient practice was identified for Resident #10. On 3/28/24 at 11:00 a.m., the administrator stated she expected qualified medication administration persons to administer medications and document on the MAR. She stated she has done training with staff in the past regarding documentation on the MAR; however, the administrator stated there were no consequences put in place to prevent a recurrence. 4. Chapter VII regualtions governing assisted living residences, requires in part 14.31 that 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. Medication Cart/Medication Administration Record Audits completed from December 2023 to present revealed the form focused on three areas of the medication program: Medication administered as ordered, medication signed out appropriately, follow-up completed on any out of stock medications with both the practitioner and pharmacy and follow-up completed on any medication refusal not given. A second audit tool utilized in January 2024 read the residence only audited the medication cart and a list of staff names who signed the MAR. The audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. On 3/26/24 at approximately 11:00 a.m., the residence's contracted consultant stated that neither she or the administrator had done a full audit of the resident records in relation to the practitioner's orders, MARs and medication cart. The consultant further stated there was a corporate nurse scheduled to assist with the audits on 3/27/24. On 3/28/24 at 11:07 a.m., the administrator stated she had been the administrator since July 2023. She stated she had not completed an audit to ensure the accuracy and completeness of the MARs. The administrator further stated the residence had been short staffed and she had not had time to look at the records for the residents. 5. Chapter VII regulations governing assisted living residences, requires in part 14.33 that the assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of: (A) A decline from a resident's baseline status; (B) A resident's pattern of refusal.a. The residence's Medication Services Policy, dated January 2024, read in part: The residence would communicate with practitioners to ensure accuracy of medications. b. Former Resident #19 was admitted to the residence on 12/1/21 with a diagnosis of constipation. A written practitioner's order, dated 7/5/23, directed the residence to administer Senna 8.6 mg once daily. However, the January 2024 MAR read the medication was not administered as the resident refused on 1/4, 1/5, 1/11-1/13, 1/19-1/22 and 1/25-1/27/24 for a total of 12 refused doses. c. Resident #3 was admitted to the residence on 12/24/20. A written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium bromide sulfate 0.5-2.5 mg four times daily. However, the March 2024 MAR read the resident refused the medication on 3/14, 3/19, 3/20 at noon, 3/24, 3/25 and 3/26/24 morning and noon for a total of seven refused doses. On 3/27/24 at 10:12 a.m., the practitioner for Resident #3 stated he had not been notified of any medication refusals. On 3/28/24 at 11:07 a.m., the administrator stated the residence did not have a formal process in place for notifying the practitioner of a pattern of refusals. She stated currently the qualified medication administration person who attempted to administer the medication was responsible for notifying the practitioner of all refusals.

Plan of correction · submitted by the facility

Resident #15 & 19: No longer reside at facilityResident #3: Diclofenac (changed to PRN 4/1), Lisinopril (omeprazole no longer administered after 2/29/24), Vitamin B-12 (D/C’d 4/1/24), Meclizine Hydrochloride (administered as directed starting 2/2/24)Resident #9, 10, 17, 22, 26-29: no specific medication issues cited. Documentation, infection control, and proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served will be addressed through education below. The staff will be retrained on the medication policy and the importance of proper medication administrator in compliance with Chapter 24 regulation, by date of compliance, these areas include proper documentation, infection control with the proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served. The Administrator and RCC have been retrained on the medication policy. RCC and RN or designee will watch 2 Med passes weekly to ensure proper Qmap procedures are followed in all areas of medication administration. Documentation will be included in the monthly review during the QMP meeting. The area will remain as an area of focus for QMP for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

3/5/2024State Certification Complaint · ID RWK7112 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A certification complaint prompted by #CO35359, #CO35361 was completed on 3/28/24. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0628Acf-Prov Role/Resp-Svc Req Protct OvrsghtS/S B▼

Findings

Based on observation, interview and record review the facility (residence) failed to ensure the residence provided protective oversight and alternative care services, affecting three of three sample participants (residents) #26, #10 and #30. Findings include:1. References and Residence Policya. The residence's resident agreement, read in part: The residence, through its staff, shall regularly observe your health status to identify any changes in your physical, mental, emotional and social functioning and will help you respond to your dietary and health needs and needs for special services. b. Chapter VII regulations governing assisted living residences part 2.36, defines medication monitoring as reminding the resident to take medications(s) at the time ordered by the authorized practitioner; handing to a resident a container or package of medication that was lawfully labeled previously by an authorized practitioner for the individual resident, visual observation of the resident to ensure compliance; making a written record of the resident's compliance with regard to each medication, including the time taken; and notifying the authorized practitioner if the resident refuses or is unable to comply with the practitioner's instructions regarding the medication.c. According to the National Drug and Alcohol Research Centre, "Cleaning injecting sites with an alcohol swab prior to injecting has consistently been shown to reduce the risk of soft tissue infections." National Drug and Alcohol Research Centre (7/2019) SWAB: Safely Wipe Away Bacteria - Findings on Injecting practices from IDRS, retrieved from: https://ndarc.med.unsw.edu.au/blog/swab-safely-wipe-away-bacteria-findings-injecting-practices-idrs#:~:text=Cleaning%20injecting%20sites%20with%20an,risk%20of%20soft%20tissue%20infections 2. During morning medication pass on 3/26/24 from 7:30 a.m. to 7:35 a.m. the following insulin administration was observed:Staff #13 retrieved insulin for Resident #25 from the residence's medication cart. The staff subsequently handed the resident the dial-up insulin syringe. Staff #13 did not provide or prompt the resident to prepare the area with an alcohol swab prior to the resident administering the insulin. Staff #13 subsequently collected the insulin pen and secured it back into the residence's medication cart. Similar findings were observed for Resident #10 and Resident #30. 3. InterviewsOn 3/27/24 at 10:12 a.m., the practitioner stated that skin was covered in bacteria staphylococcus aureus and humans have a symbiotic relationship. He stated this bacteria on the skin should have been wiped with an alcohol wipe as the friction would open the bacteria and sterilize the area. The practitioner further stated if it was not done then there was potential of pushing the bacteria into the skin resulting in infection. On 3/26/24 at 8:36 a.m., Staff #13 stated that she did not provide alcohol wipes as residents normally did not use them and she was not sure where they would obtain the alcohol wipes. She stated she thought that maybe the pharmacy was responsible for providing the alcohol wipes. On 3/27/24 at 1:25 p.m., Staff #15 stated she did not provide alcohol swabs to residents who self injected medications and that she did not know where alcohol swabs would be located. On 3/28/24 at 11:00 a.m. the administrator stated residents should have been provided with the supplies that they require to self administer medications and that the resident should be cleaning the area and letting it dry before injecting insulin. The administrator stated she was surprised staff did not know where the alcohol swabs were located at the residence and that they were unaware the area should have been cleaned prior to administration.

Plan of correction · submitted by the facility

Staff #13 has been retrained along with other staff on proper use of alcohol swabs to clean skin prior to an injection. The alcohol wipes are stored on each of the Med Carts for easy access. This training was competed by the RN in early Mary. To ensure continued compliance, the RCC and the RN or designee are watching 2 med passes each week including the residents who have a self administer order for an insulin injection. These viewing are documented and staff are retrain on any areas of deficient medication pass. This will be done for 120 days or ongoing if needed. This topic will be discussed through out the year and by monthly staff meetings. Proper medication administration including infection control measures will continue to be an area of focus for the QMP for 120 days with meetings monthly with documentation. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S D▼

Findings

Based on observation, interview and record review the (facility) residence failed to follow written policies and procedures for the adminstration of medication in accordance with Chapter VII regulations affecting nine of ten sample (participants) residents (#3, #9, #10, #17, #22, #26-#29) and two former residents (#15, #19). Specifically, Former Resident #19 was prescribed antibiotics for a urinary tract infection on 1/24/24. However, the residence failed to ensure the prescription was filled. On 1/29/24 Former Resident #19 experienced a change in condition, was combative and had altered mental status. The former resident was subsequently transported to the emergency department, diagnosed with sepsis and a urinary tract infection. Former Resident #19 was administered intravenous (IV) antibiotics, fluids and was hospitalized for six days as a result of not receiving her antibiotics. Specifically, Former Resident #15 was prescribed lasix for edema on 2/14/24. However, the residence failed to ensure the prescription was filled and on 2/20/24 an external service provider notified the practitioner that the former resident had experienced swelling and edema. Former Resident #15 was subsequently transported to the emergency department (ED). Former Resident #15 was diagnosed with congestive heart failure and edema. The former resident was hospitalized for 15 days as a result of not receiving her prescribed medication and subsequently discharged to a skilled nursing facility. Findings include:1. Chapter VII regualtions governing assited living residences, requires in part 14.21 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.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: Medication assistance services were provided by the residence by a qualified medication administration person (QMAP) who had completed the QMAP training and competency evaluation program. The medication assistance program consists of providing assistance with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living residences. Additionally, the policy read that the residence communicated with practitioners and pharmacists to ensure accuracy of medications. According to Good RX: "A urinary tract infection (UTI) is a common condition often caused by Escherichia coli bacteria in the urine. Antibiotics are the typical treatment for a UTI. In some cases, a UTI will go away on its own even if untreated. This is most likely to happen in adult women with no other health conditions. An untreated UTI can sometimes lead to serious complications and hospitalization. It ' s always a good idea to let your provider know you have UTI symptoms ... The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria), The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria) ... Sepsis is a life-threatening condition caused by the body ' s response to infection. It happens when the immune system works to fight an infection, but ends up causing too much inflammation throughout the whole body. Each year, about 1.7 million adults in the U.S. get sepsis, and almost 270,000 die from it. UTIs cause up to 30% of cases of sepsis. Risk factors for developing sepsis include: Being over 65 years old, Having diabetes, Having a weakened immune system, Having a history of prior urinary tract procedures Sepsis is a serious condition, and it needs immediate medical attention. Healthcare providers use specific guidelines to diagnose sepsis. Sepsis symptoms include: Low or high body temperature, High heart rate, High breathing rate, Swelling in parts of the body, Change in mental status (such as confusion) ... So while you may get over a UTI on your own, the risks of not treating a UTI can be pretty high. Some untreated UTIs can cause serious health problems that may even require hospitalization. It ' s best to let your provider know if you have symptoms of a UTI. They can find the source of your symptoms and come up with a treatment plan." Reviewed 2024. Retreived https://www.goodrx.com/conditions/urinary-tract-infection/untreated-uti-risks-dangers. According to RXlist: "Lasix (furosemide) is an anthranilic acid derivative that is used as a strong diuretic in adults and children to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome ... Seek medical care or call 911 at once if you have the following serious side effects: Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out." Reviewed 2024. Retrieved https://www.rxlist.com/lasix-drug.htm#description. According to the Cleveland Clinic: "Congestive heart failure is a long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time. Medications and other treatments help manage symptoms like swelling. Congestive heart failure is life-limiting for many ... Congestive heart failure symptoms include: Shortness of breath. Waking up short of breath at night. Chest pain. Heart palpitations. Fatigue when you ' re active. Swelling in your ankles, legs and abdomen. Weight gain ... Reviewed 2024. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failureb. Former Resident #19 was admitted to the residence on 12/1/21 with diagnoses including urinary tract infection, muscle weakness, vitamin deficiency, post polio syndrome and hypertension. AmoxicillinA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 1/24/24 at 8:13 a.m., directed the residence to administer amoxicillin 500 mg potassium clavulanate 125 mg twice daily for seven days. However, the January 2024 medication administration record (MAR) read the medication was never administered. A residence progress note, dated 1/27/24, read in part: Staff brought food to Former Resident #19's room. The former resident was about to leave and was crying. When staff asked Former Resident #19 what was wrong she stated "she was scared as (expletive) and she feels intimidated." The administrator was notified. Hospital discharge orders, dated 1/29 through 2/5/24, read in part: Former Resident #19 was admitted to the hospital on 1/29/24 with symptoms including an altered mental status. Former Resident #19 was combative at the residence and was transported to the emergency department. The former resident tested positive for a urinary tract infection and would be treated with IV antibiotics, IV fluids and pain medication as needed. Former Resident #19 was admitted to the hospital. Vitamin D A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 2000 units once daily. However, the January 2024 MAR read the medication was not administered on 1/8, 1/9, 1/12-1/17 and 1/21-1/26/24 as the medication was out of stock, for a total of 14 missed doses. MultivitaminA written practitioner's order, dated 2/6/23, directed the residence to administer multivitamin once daily on 1/13-1/16,1/21-1/29/24 as the medication was on order, for a total of 13 missed doses. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/16, 1/17, 1/19, 1/21-1/29/24 as the medication was out of stock, for a total 11 missed doses. GabapentinA written practitioner's order, dated 2/6/23, directed the residence to administer gabapentin 100 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/20-1/27/24 as the medication was out of stock, for a total of seven missed doses. Metoprolol A written practitioner's order dated, 2/6/23, directed the residence to administer metoprolol tartrate 12.5 mg twice daily. However, the January 2024 MAR read the medication was not administered on 1/28/24 at 7:00 p.m. as the medication was out of stock and on 1/29/24 at 7:00 a.m., the dose was not administered as the resident was confused, for a total of two missed doses. HydrocodoneA written practitioner's order, dated 2/6/23, directed the residence to administer hydrocodone acetaminophen 7.5-325 mg twice daily. However, the January 2024 MAR read the medication was not administered the morning dose on 1/21/24 as the medication was out of stock. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #19 stated the former resident was prescribed antibiotics for a urinary tract infection on 1/24/24. He stated the residence did not inform him Resident #19 had not received her antibiotics and as a result on 1/29/24 Former Resident #19 had a change in condition from baseline, was transported to the ED, was hospitalized and later required skilled nursing care. Additionally, the practitioner stated that missing gabapentin, even one dose, could cause the resident to experience nerve pain. On 3/28/24 at 11:00 a.m., the administrator stated on 1/24/24 Former Resident #19 had a change in condition. She stated she was not her normal self, did not want to eat and laid in bed sleeping all day. She stated the former resident was transported to the emergency department and subsequently diagnosed with a urinary tract infection. The administrator further stated Former Resident #19, after her hospitalization, was discharged to a skilled nursing facility as she required more care than what the residence was able to provide. Additionally, the administrator stated she thought the former resident was seen by her practitioner for a suspected urinary tract infection; however, the administrator stated she was not aware the practitioner ordered any medication. c. Former Resident #15 was admitted to the residence on 12/16/18 with diagnoses of tachycardia, atrioventricular block, pacemaker and peripheral vascular disease. A written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 2/14/24 at 4:00 p.m. directed the residence to administer furosemide (Lasix) 20 mg take 0.5 tablet once daily for swelling. A residence progress note, dated 2/20/23, read an external service provider notified the residence that Former Resident #15 had not received her prescription for lasix. The residence telephoned the pharmacy and no order was found. The external service provider stated Former Resident #15 had fluids in her legs and was sent to the ED via emergency medical services. An external service provider note, dated 2/20/24, read in part Former Resident #15 had increased edema of her extremities. The external service provider telephoned the practitioner, notified him of the resident's vitals and the practitioner agreed to have the resident receive emergency medical care. A hospitalization record, dated 2/20/24 through 3/6/24, read in part: Former Resident #15 was admitted to the hospital with diagnoses including: malaise, atherosclerotic heart disease, acute congestive heart failure and edema. The resident presented at the emergency department withshortness of breath and weight gain. The record further read Former Resident #15 "was supposed to be prescribed lasix however she never received the prescription ... Apparently in the past month or so (the resident) had 20 pound weight gain. Apparently the patient was consulted by medical staff there in the recent past concern for weight gain and edema and was supposed to be starting diuretic therapy when the provider checked on her today found her to be more edema and learned that she has not been receiving the diuretic and sent her to the emergency room." Resident #15 was swollen throughout the entire lower abdomen and lower extremities. Resident #15 was administered Lasix 60 mg injection upon admission. On 3/6/24, Former Resident #15 was discharged to a skilled nursing home. On 3/26/24 at 3:40 p.m., the January and February 2024 MARs for Former Resident #15 were requested. However, as of 3/28/24 no MARs were provided. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #15 stated on 2/14/24 the resident was prescribed Lasix due to edema. He stated approximately one week later the medication had not started and an external service provider telephoned him and explained the resident's condition had deteriorated and a decision was made to send the resident to the ED for urgent treatment. On 3/28/24 at 11:07 a.m., the administrator stated the external home health provider for Former Resident #15 was at the residence and noticed swelling and edema. She stated at that point the external home health provider went to the administrator's office to check on the prescription for Lasix which had been prescribed approximately one week prior. The administrator stated she checked and could tell the prescription was faxed to the pharmacy. However, she stated when she telephoned the pharmacy they reported not receiving the prescription. The administrator confirmed the former resident did not receive her medication and stated she should have followed up on the prescription. The administrator further added "it was probably one of the emails that I did not get to timely."d. Resident #3 was admitted to the residence on 2/24/20 with a diagnosis of gastroesophageal reflux disorder. Diclofenac A written practitioner's order, dated 1/31/24, directed the residence to administer diclofenac 1% topical gel 2 gm apply twice daily to neck and knees. However, the February through March 2024 MAR read the medication was not administered twice daily from 2/1-3/25/24 as it was labeled on the MAR as "as needed" medication for a total of 108 missed doses. LisinoprilA written practitioner's order, dated 1/3/24, directed the residence to discontinue omeprazole 40 mg and replace with pantoprazole 40 mg delayed release once daily. However, the February through March 2024 MARs read omeprazole was not discontinued and was administered in conjunction with pantoprazole from 2/1 and 2/4-2/29/24 for a total of 27 days. Vitamin B-12A written practitioner's order, dated 1/31/24, directed the residence to administer vitamin B-12 1000 mcg once daily. However, the March 2024 MAR read the medication was not administered from 3/15-3/26/24 as the medication was out of stock for a total of 11 missed doses. Meclizine HydrochlorideA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg once daily at noon. However, the February 2024 MAR read the medication was not administered on 2/1/24 as the resident was out of the residence for a total of one missed dose. On 3/28/24 at 11:00 a.m., the administrator stated she was not aware of the error with the pantoprazole. She stated the residence had difficulties obtaining prescriptions from the practitioner's and in addition, she stated the residence was also changing pharmacies. e. Additional deficient practice was identified with Residents #9, #10 and #17. 2. Chapter VII regulations governing assisted living residences, requires in part 14.28 that the assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. During morning medication administration on 3/26/24 at 7:52 a.m., the following was observed:Staff #13 donned gloves and began to prepare medications for Resident #26. Staff #13 while preparing the medications grasped her sweatshirt wiping her nose. Staff #13 subsequently spilled the medications for Resident #26 on the medication cart and picked them up with her gloved hand placing them back into the medication cup, Staff #13 then administered the medication, returned to the medication cart, doffed her gloves, opened the medication cart and documented on the medication administration record (MAR). Staff #13 touched her nose with her hand and stated she needed to obtain a tissue. The staff then wiped her nose and began to prepare medication for Resident #27 popping the medication out of the blister package and placing it in the medication cup. Staff #13 then took out a cup and poured water from a pitcher for the resident. Staff #13 then handed Resident #27 her medications and began to cough. She then took out a tissue and blew her nose and sanitized her hands. Staff #13 donned gloves and prepared medication for Resident #10. The staff took out the resident's insulin pen from the medication cart and handed the resident the insulin to self administer. Staff #13 came back to the medication cart, did not remove her gloves or sanitize her hands. She subsequently prepared and administered medications for Resident #9, applied hydrocortisone cream to the resident's neck. Staff #13 doffed her gloves and without washing or sanitizing her hands administered medications to Resident #17,#22, #28 and #29 in a similar unsanitary manner. On 3/28/24 at 11:07 a.m., the administrator stated she had discussed proper infection control when administering medications to residents. The administrator further stated the improper infection control by Staff #13 surprised her. 3. Chapter VII regulations governing assisted living residences, in part 14.29 requires that All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: The residence would maintain current files on all medications. b. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including gastroesophageal reflux disorder, hypertension. FluticasoneA written practitioner's order, dated 1/31/23, directed the residence to administer fluticasone propionate/salmeterol 500-50 mcg one puff twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 evening dose, 2/1-2/3 all doses, 2/7 evening dose, 2/17 evening., 2/24 and 2/27 evening doses, 2/29 morning dose, 3/9 morning dose and 3/21/24 evening dose. LisinoprilA written practitioner's order, dated 1/31/24, directed the residence to administer lisinopril 5 mg once daily. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/1-2/3 and 3/23/24. Gabapentin A written practitioner's order, dated 1/31/24, directed the residence to administer gabapentin 600 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 at bedtime, 2/2- 2/3 all doses and on 3/2/24 at noon. MeclizineA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg tablet at noon. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/2, 2/3 and 3/2/24. IpratropiumA written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium 0.5 mg albuterol 3 mg four times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2 at noon and 3/21/24 at the evening dose and bedtime dose. SertralineA written practitioner's order, dated 1/31/24, directed the residence to administer sertraline 100 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/2 and 2/3/24. PantoprazoleA written practitioner's order, dated 1/31/24, directed the residence to administer pantoprazole sodium 40 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 and 2/2/24. SpirivaA written practitioner's order, dated 1/31/24, directed the residence to administer Spariva handihaler 18 mcg one puff by mouth once daily. However the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/9/24.c. Resident #14 was admitted to the residence on an unknown date. PantoprazoleA written practitioner's order, dated 1/25/24, directed the residence to administer pantoprazole sodium 40 mg twice daily. However, the March 2023 MAR revealed no evidence of documentation at the time of administration on 3/7, 3/11 morningdoses, 3/19, 3/20 evening doses and 3/24/24 morning dose. RosuvastatinA written practitioner's order, dated 2/29/24, directed the residence to administer rosuvastatin calcium 10 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/5/24. SertralineA written practitioner's order, dated 1/25/24, directed the residence to administer sertraline 50 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24. Docusate SodiumA written practitioner's order, dated 1/25/24, directed the residence to administer docusate sodium 100 mg twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24 evening dose. MontelukastA written practitioner's order, dated 1/25/24, directed the residence to administer montelukast sodium 10 mg at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/1/24. BuspironeA written practitioner's order, dated 1/25/24, directed the residence to administer buspirone 10 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/8 and 3/11/24 at 6:00 a.m. ClopidogrelA written practitioner's order, dated 1/25/24, directed the residence to administer clopidogrel 75 mg once daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2/24. d. Additional deficient practice was identified for Resident #10. On 3/28/24 at 11:00 a.m., the administrator stated she expected qualified medication administration persons to administer medications and document on the MAR. She stated she has done training with staff in the past regarding documentation on the MAR; however, the administrator stated there were no consequences put in place to prevent a recurrence. 4. Chapter VII regualtions governing assisted living residences, requires in part 14.31 that 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. Medication Cart/Medication Administration Record Audits completed from December 2023 to present revealed the form focused on three areas of the medication program: Medication administered as ordered, medication signed out appropriately, follow-up completed on any out of stock medications with both the practitioner and pharmacy and follow-up completed on any medication refusal not given. A second audit tool utilized in January 2024 read the residence only audited the medication cart and a list of staff names who signed the MAR. The audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. On 3/26/24 at approximately 11:00 a.m., the residence's contracted consultant stated that neither she or the administrator had done a full audit of the resident records in relation to the practitioner's orders, MARs and medication cart. The consultant further stated there was a corporate nurse scheduled to assist with the audits on 3/27/24. On 3/28/24 at 11:07 a.m., the administrator stated she had been the administrator since July 2023. She stated she had not completed an audit to ensure the accuracy and completeness of the MARs. The administrator further stated the residence had been short staffed and she had not had time to look at the records for the residents. 5. Chapter VII regulations governing assisted living residences, requires in part 14.33 that the assisted living residence shall ensure that the resident's authorized practitioner and resident ' s legal representative are promptly notified of: (A) A decline from a resident ' s baseline status; (B) A resident ' s pattern of refusal.a. The residence's Medication Services Policy, dated January 2024, read in part: The residence would communicate with practitioners to ensure accuracy of medications. b. Former Resident #19 was admitted to the residence on 12/1/21 with a diagnosis of constipation. A written practitioner's order, dated 7/5/23, directed the residence to administer Senna 8.6 mg once daily. However, the January 2024 MAR read the medication was not administered as the resident refused on 1/4, 1/5, 1/11-1/13, 1/19-1/22 and 1/25-1/27/24 for a total of 12 refused doses. c. Resident #3 was admitted to the residence on 12/24/20. A written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium bromide sulfate 0.5-2.5 mg four times daily. However, the March 2024 MAR read the resident refused the medication on 3/14, 3/19, 3/20 at noon, 3/24, 3/25 and 3/26/24 morning and noon for a total of seven refused doses. On 3/27/24 at 10:12 a.m., the practitioner for Resident #3 stated he had not been notified of any medication refusals. On 3/28/24 at 11:07 a.m., the administrator stated the residence did not have a formal process in place for notifying the practitioner of a pattern of refusals. She stated currently the qualified medication administration person who attempted to administer the medication was responsible for notifying the practitioner of all refusals.

Plan of correction · submitted by the facility

Resident #15 & 19: No longer reside at facilityResident #3: Diclofenac (changed to PRN 4/1), Lisinopril (omeprazole no longer administered after 2/29/24), Vitamin B-12 (D/C’d 4/1/24), Meclizine Hydrochloride (administered as directed starting 2/2/24)Resident #9, 10, 17, 22, 26-29: no specific medication issues cited. Documentation, infection control, and proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served will be addressed through education below. The staff will be retrained on the medication policy and the importance of proper medication administrator in compliance with Chapter 24 regulation, by date of compliance, these areas include proper documentation, infection control with the proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served. The Administrator and RCC have been retrained on the medication policy. RCC and RN or designee will watch 2 Med passes weekly to ensure proper Qmap procedures are followed in all areas of medication administration. Documentation will be included in the monthly review during the QMP meeting. The area will remain as an area of focus for QMP for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

3/5/2024Revisit: State Certification and State Certification Complaint (Combined) · ID YD9K161 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 3/28/24 for the previous deficiency cited on 9/29/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S D▼

Findings

Based on observation, interview and record review the facility (residence) failed to follow written policies and procedures for the adminstration of medication in accordance with Chapter VII regulations affecting nine of ten sample participants (residents) (#3, #9, #10, #17, #22, #26-#29) and two former residents (#15, #19). This deficiency was cited previously during a certification revisit 9/29/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #19 was prescribed antibiotics for a urinary tract infection on 1/24/24. However, the residence failed to ensure the prescription was filled. On 1/29/24 Former Resident #19 experienced a change in condition, was combative and had altered mental status. The former resident was subsequently transported to the emergency department, diagnosed with sepsis and a urinary tract infection. Former Resident #19 was administered intravenous (IV) antibiotics, fluids and was hospitalized for six days as a result of not receiving her antibiotics. Specifically, Former Resident #15 was prescribed lasix for edema on 2/14/24. However, the residence failed to ensure the prescription was filled and on 2/20/24 an external service provider notified the practitioner that the former resident had experienced swelling and edema. Former Resident #15 was subsequently transported to the emergency department (ED). Former Resident #15 was diagnosed with congestive heart failure and edema. The former resident was hospitalized for 15 days as a result of not receiving her prescribed medication and subsequently discharged to a skilled nursing facility. Findings include:1. Chapter VII regualtions governing assited living residences, requires in part 14.21 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.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: Medication assistance services were provided by the residence by a qualified medication administration person (QMAP) who had completed the QMAP training and competency evaluation program. The medication assistance program consists of providing assistance with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living residences. Additionally, the policy read that the residence communicated with practitioners and pharmacists to ensure accuracy of medications. According to Good RX: "A urinary tract infection (UTI) is a common condition often caused by Escherichia coli bacteria in the urine. Antibiotics are the typical treatment for a UTI. In some cases, a UTI will go away on its own even if untreated. This is most likely to happen in adult women with no other health conditions. An untreated UTI can sometimes lead to serious complications and hospitalization. It ' s always a good idea to let your provider know you have UTI symptoms ... The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria), The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria) ... Sepsis is a life-threatening condition caused by the body ' s response to infection. It happens when the immune system works to fight an infection, but ends up causing too much inflammation throughout the whole body. Each year, about 1.7 million adults in the U.S. get sepsis, and almost 270,000 die from it. UTIs cause up to 30% of cases of sepsis. Risk factors for developing sepsis include: Being over 65 years old, Having diabetes, Having a weakened immune system, Having a history of prior urinary tract procedures Sepsis is a serious condition, and it needs immediate medical attention. Healthcare providers use specific guidelines to diagnose sepsis. Sepsis symptoms include: Low or high body temperature, High heart rate, High breathing rate, Swelling in parts of the body, Change in mental status (such as confusion) ... So while you may get over a UTI on your own, the risks of not treating a UTI can be pretty high. Some untreated UTIs can cause serious health problems that may even require hospitalization. It ' s best to let your provider know if you have symptoms of a UTI. They can find the source of your symptoms and come up with a treatment plan." Reviewed 2024. Retreived https://www.goodrx.com/conditions/urinary-tract-infection/untreated-uti-risks-dangers. According to RXlist: "Lasix (furosemide) is an anthranilic acid derivative that is used as a strong diuretic in adults and children to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome ... Seek medical care or call 911 at once if you have the following serious side effects: Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out." Reviewed 2024. Retrieved https://www.rxlist.com/lasix-drug.htm#description. According to the Cleveland Clinic: "Congestive heart failure is a long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time. Medications and other treatments help manage symptoms like swelling. Congestive heart failure is life-limiting for many ... Congestive heart failure symptoms include: Shortness of breath. Waking up short of breath at night. Chest pain. Heart palpitations. Fatigue when you ' re active. Swelling in your ankles, legs and abdomen. Weight gain ... Reviewed 2024. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failureb. Former Resident #19 was admitted to the residence on 12/1/21 with diagnoses including urinary tract infection, muscle weakness, vitamin deficiency, post polio syndrome and hypertension. AmoxicillinA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 1/24/24 at 8:13 a.m., directed the residence to administer amoxicillin 500 mg potassium clavulanate 125 mg twice daily for seven days. However, the January 2024 medication administration record (MAR) read the medication was never administered. A residence progress note, dated 1/27/24, read in part: Staff brought food to Former Resident #19's room. The former resident was about to leave and was crying. When staff asked Former Resident #19 what was wrong she stated "she was scared as (expletive) and she feels intimidated." The administrator was notified. Hospital discharge orders, dated 1/29 through 2/5/24, read in part: Former Resident #19 was admitted to the hospital on 1/29/24 with symptoms including an altered mental status. Former Resident #19 was combative at the residence and was transported to the emergency department. The former resident tested positive for a urinary tract infection and would be treated with IV antibiotics, IV fluids and pain medication as needed. Former Resident #19 was admitted to the hospital. Vitamin D A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 2000 units once daily. However, the January 2024 MAR read the medication was not administered on 1/8, 1/9, 1/12-1/17 and 1/21-1/26/24 as the medication was out of stock, for a total of 14 missed doses. MultivitaminA written practitioner's order, dated 2/6/23, directed the residence to administer multivitamin once daily on 1/13-1/16,1/21-1/29/24 as the medication was on order, for a total of 13 missed doses. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/16, 1/17, 1/19, 1/21-1/29/24 as the medication was out of stock, for a total 11 missed doses. GabapentinA written practitioner's order, dated 2/6/23, directed the residence to administer gabapentin 100 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/20-1/27/24 as the medication was out of stock, for a total of seven missed doses. Metoprolol A written practitioner's order dated, 2/6/23, directed the residence to administer metoprolol tartrate 12.5 mg twice daily. However, the January 2024 MAR read the medication was not administered on 1/28/24 at 7:00 p.m. as the medication was out of stock and on 1/29/24 at 7:00 a.m., the dose was not administered as the resident was confused, for a total of two missed doses. HydrocodoneA written practitioner's order, dated 2/6/23, directed the residence to administer hydrocodone acetaminophen 7.5-325 mg twice daily. However, the January 2024 MAR read the medication was not administered the morning dose on 1/21/24 as the medication was out of stock. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #19 stated the former resident was prescribed antibiotics for a urinary tract infection on 1/24/24. He stated the residence did not inform him Resident #19 had not received her antibiotics and as a result on 1/29/24 Former Resident #19 had a change in condition from baseline, was transported to the ED, was hospitalized and later required skilled nursing care. Additionally, the practitioner stated that missing gabapentin, even one dose, could cause the resident to experience nerve pain. On 3/28/24 at 11:00 a.m., the administrator stated on 1/24/24 Former Resident #19 had a change in condition. She stated she was not her normal self, did not want to eat and laid in bed sleeping all day. She stated the former resident was transported to the emergency department and subsequently diagnosed with a urinary tract infection. The administrator further stated Former Resident #19, after her hospitalization, was discharged to a skilled nursing facility as she required more care than what the residence was able to provide. Additionally, the administrator stated she thought the former resident was seen by her practitioner for a suspected urinary tract infection; however, the administrator stated she was not aware the practitioner ordered any medication. c. Former Resident #15 was admitted to the residence on 12/16/18 with diagnoses of tachycardia, atrioventricular block, pacemaker and peripheral vascular disease. A written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 2/14/24 at 4:00 p.m. directed the residence to administer furosemide (Lasix) 20 mg take 0.5 tablet once daily for swelling. A residence progress note, dated 2/20/23, read an external service provider notified the residence that Former Resident #15 had not received her prescription for lasix. The residence telephoned the pharmacy and no order was found. The external service provider stated Former Resident #15 had fluids in her legs and was sent to the ED via emergency medical services. An external service provider note, dated 2/20/24, read in part Former Resident #15 had increased edema of her extremities. The external service provider telephoned the practitioner, notified him of the resident's vitals and the practitioner agreed to have the resident receive emergency medical care. A hospitalization record, dated 2/20/24 through 3/6/24, read in part: Former Resident #15 was admitted to the hospital with diagnoses including: malaise, atherosclerotic heart disease, acute congestive heart failure and edema. The resident presented at the emergency department with shortness of breath and weight gain. The record further read Former Resident #15 "was supposed to be prescribed lasix however she never received the prescription ... Apparently in the past month or so (the resident) had 20 pound weight gain. Apparently the patient was consulted by medical staff there in the recent past concern for weight gain and edema and was supposed to be starting diuretic therapy when the provider checked on her today found her to be more edema and learned that she has not been receiving the diuretic and sent her to the emergency room." Resident #15 was swollen throughout the entire lower abdomen and lower extremities. Resident #15 was administered Lasix 60 mg injection upon admission. On 3/6/24, Former Resident #15 was discharged to a skilled nursing home. On 3/26/24 at 3:40 p.m., the January and February 2024 MARs for Former Resident #15 were requested. However, as of 3/28/24 no MARs were provided. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #15 stated on 2/14/24 the resident was prescribed Lasix due to edema. He stated approximately one week later the medication had not started and an external service provider telephoned him and explained the resident's condition had deteriorated and a decision was made to send the resident to the ED for urgent treatment. On 3/28/24 at 11:07 a.m., the administrator stated the external home health provider for Former Resident #15 was at the residence and noticed swelling and edema. She stated at that point the external home health provider went to the administrator's office to check on the prescription for Lasix which had been prescribed approximately one week prior. The administrator stated she checked and could tell the prescription was faxed to the pharmacy. However, she stated when she telephoned the pharmacy they reported not receiving the prescription. The administrator confirmed the former resident did not receive her medication and stated she should have followed up on the prescription. The administrator further added "it was probably one of the emails that I did not get to timely."d. Resident #3 was admitted to the residence on 2/24/20 with a diagnosis of gastroesophageal reflux disorder. Diclofenac A written practitioner's order, dated 1/31/24, directed the residence to administer diclofenac 1% topical gel 2 gm apply twice daily to neck and knees. However, the February through March 2024 MAR read the medication was not administered twice daily from 2/1-3/25/24 as it was labeled on the MAR as "as needed" medication for a total of 108 missed doses. LisinoprilA written practitioner's order, dated 1/3/24, directed the residence to discontinue omeprazole 40 mg and replace with pantoprazole 40 mg delayed release once daily. However, the February through March 2024 MARs read omeprazole was not discontinued and was administered in conjunction with pantoprazole from 2/1 and 2/4-2/29/24 for a total of 27 days. Vitamin B-12A written practitioner's order, dated 1/31/24, directed the residence to administer vitamin B-12 1000 mcg once daily. However, the March 2024 MAR read the medication was not administered from 3/15-3/26/24 as the medication was out of stock for a total of 11 missed doses. Meclizine HydrochlorideA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg once daily at noon. However, the February 2024 MAR read the medication was not administered on 2/1/24 as the resident was out of the residence for a total of one missed dose. On 3/28/24 at 11:00 a.m., the administrator stated she was not aware of the error with the pantoprazole. She stated the residence had difficulties obtaining prescriptions from the practitioner's and in addition, she stated the residence was also changing pharmacies. The administrator stated she had started her position at the residence in July 2023; however, the administrator stated she had not read the past deficiencies and was not sure why they had not been corrected.e. Additional deficient practice was identified with Residents #9, #10 and #17. 2. Chapter VII regulations governing assisted living residences, requires in part 14.28 that the assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. During morning medication administration on 3/26/24 at 7:52 a.m., the following was observed:Staff #13 donned gloves and began to prepare medications for Resident #26. Staff #13 while preparing the medications grasped her sweatshirt wiping her nose. Staff #13 subsequently spilled the medications for Resident #26 on the medication cart and picked them up with her gloved hand placing them back into the medication cup, Staff #13 then administered the medication, returned to the medication cart, doffed her gloves, opened the medication cart and documented on the medication administration record (MAR). Staff #13 touched her nose with her hand and stated she needed to obtain a tissue. The staff then wiped her nose and began to prepare medication for Resident #27 popping the medication out of the blister package and placing it in the medication cup. Staff #13 then took out a cup and poured water from a pitcher for the resident. Staff #13 then handed Resident #27 her medications and began to cough. She then took out a tissue and blew her nose and sanitized her hands. Staff #13 donned gloves and prepared medication for Resident #10. The staff took out the resident's insulin pen from the medication cart and handed the resident the insulin to self administer. Staff #13 came back to the medication cart, did not remove her gloves or sanitize her hands. She subsequently prepared and administered medications for Resident #9, applied hydrocortisone cream to the resident's neck. Staff #13 doffed her gloves and without washing or sanitizing her hands administered medications to Resident #17,#22, #28 and #29 in a similar unsanitary manner. On 3/28/24 at 11:07 a.m., the administrator stated she had discussed proper infection control when administering medications to residents. The administrator further stated the improper infection control by Staff #13 surprised her. 3. Chapter VII regulations governing assisted living residences, in part 14.29 requires that All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: The residence would maintain current files on all medications. b. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including gastroesophageal reflux disorder, hypertension. FluticasoneA written practitioner's order, dated 1/31/23, directed the residence to administer fluticasone propionate/salmeterol 500-50 mcg one puff twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 evening dose, 2/1-2/3 all doses, 2/7 evening dose, 2/17 evening., 2/24 and 2/27 evening doses, 2/29 morning dose, 3/9 morning dose and 3/21/24 evening dose. LisinoprilA written practitioner's order, dated 1/31/24, directed the residence to administer lisinopril 5 mg once daily. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/1-2/3 and 3/23/24. Gabapentin A written practitioner's order, dated 1/31/24, directed the residence to administer gabapentin 600 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 at bedtime, 2/2- 2/3 all doses and on 3/2/24 at noon. MeclizineA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg tablet at noon. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/2, 2/3 and 3/2/24. IpratropiumA written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium 0.5 mg albuterol 3 mg four times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2 at noon and 3/21/24 at the evening dose and bedtime dose. SertralineA written practitioner's order, dated 1/31/24, directed the residence to administer sertraline 100 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/2 and 2/3/24. PantoprazoleA written practitioner's order, dated 1/31/24, directed the residence to administer pantoprazole sodium 40 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 and 2/2/24. SpirivaA written practitioner's order, dated 1/31/24, directed the residence to administer Spariva handihaler 18 mcg one puff by mouth once daily. However the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/9/24.c. Resident #14 was admitted to the residence on an unknown date. PantoprazoleA written practitioner's order, dated 1/25/24, directed the residence to administer pantoprazole sodium 40 mg twice daily. However, the March 2023 MAR revealed no evidence of documentation at the time of administration on 3/7, 3/11 morningdoses, 3/19, 3/20 evening doses and 3/24/24 morning dose. RosuvastatinA written practitioner's order, dated 2/29/24, directed the residence to administer rosuvastatin calcium 10 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/5/24. SertralineA written practitioner's order, dated 1/25/24, directed the residence to administer sertraline 50 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24. Docusate SodiumA written practitioner's order, dated 1/25/24, directed the residence to administer docusate sodium 100 mg twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24 evening dose. MontelukastA written practitioner's order, dated 1/25/24, directed the residence to administer montelukast sodium 10 mg at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/1/24. BuspironeA written practitioner's order, dated 1/25/24, directed the residence to administer buspirone 10 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/8 and 3/11/24 at 6:00 a.m. ClopidogrelA written practitioner's order, dated 1/25/24, directed the residence to administer clopidogrel 75 mg once daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2/24. d. Additional deficient practice was identified for Resident #10. On 3/28/24 at 11:00 a.m., the administrator stated she expected qualified medication administration persons to administer medications and document on the MAR. She stated she has done training with staff in the past regarding documentation on the MAR; however, the administrator stated there were no consequences put in place to prevent a recurrence. 4. Chapter VII regualtions governing assisted living residences, requires in part 14.31 that 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. Medication Cart/Medication Administration Record Audits completed from December 2023 to present revealed the form focused on three areas of the medication program: Medication administered as ordered, medication signed out appropriately, follow-up completed on any out of stock medications with both the practitioner and pharmacy and follow-up completed on any medication refusal not given. A second audit tool utilized in January 2024 read the residence only audited the medication cart and a list of staff names who signed the MAR. The audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. On 3/26/24 at approximately 11:00 a.m., the residence's contracted consultant stated that neither she or the administrator had done a full audit of the resident records in relation to the practitioner's orders, MARs and medication cart. The consultant further stated there was a corporate nurse scheduled to assist with the audits on 3/27/24. On 3/28/24 at 11:07 a.m., the administrator stated she had been the administrator since July 2023. She stated she had not completed an audit to ensure the accuracy and completeness of the MARs. The administrator further stated the residence had been short staffed and she had not had time to look at the records for the residents. 5. Chapter VII regulations governing assisted living residences, requires in part 14.33 that the assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of: (A) A decline from a resident's baseline status; (B) A resident's pattern of refusal.a. The residence's Medication Services Policy, dated January 2024, read in part: The residence would communicate with practitioners to ensure accuracy of medications. b. Former Resident #19 was admitted to the residence on 12/1/21 with a diagnosis of constipation. A written practitioner's order, dated 7/5/23, directed the residence to administer Senna 8.6 mg once daily. However, the January 2024 MAR read the medication was not administered as the resident refused on 1/4, 1/5, 1/11-1/13, 1/19-1/22 and 1/25-1/27/24 for a total of 12 refused doses. c. Resident #3 was admitted to the residence on 12/24/20. A written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium bromide sulfate 0.5-2.5 mg four times daily. However, the March 2024 MAR read the resident refused the medication on 3/14, 3/19, 3/20 at noon, 3/24, 3/25 and 3/26/24 morning and noon for a total of seven refused doses. On 3/27/24 at 10:12 a.m., the practitioner for Resident #3 stated he had not been notified of any medication refusals. On 3/28/24 at 11:07 a.m., the administrator stated the residence did not have a formal process in place for notifying the practitioner of a pattern of refusals. She stated currently the qualified medication administration person who attempted to administer the medication was responsible for notifying the practitioner of all refusals.

Plan of correction · submitted by the facility

Resident #15 & 19: No longer reside at facilityResident #3: Diclofenac (changed to PRN 4/1), Lisinopril (omeprazole no longer administered after 2/29/24), Vitamin B-12 (D/C’d 4/1/24), Meclizine Hydrochloride (administered as directed starting 2/2/24)Resident #9, 10, 17, 22, 26-29: no specific medication issues cited. Documentation, infection control, and proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served will be addressed through education below. The staff will be retrained on the medication policy and the importance of proper medication administrator in compliance with Chapter 24 regulation, by date of compliance, these areas include proper documentation, infection control with the proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served. The Administrator and RCC have been retrained on the medication policy. RCC and RN or designee will watch 2 Med passes weekly to ensure proper Qmap procedures are followed in all areas of medication administration. Documentation will be included in the monthly review during the QMP meeting. The area will remain as an area of focus for QMP for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

3/5/2024Revisit: Licensure Complaint · ID ELBO141 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 3/28/24 for the previous deficiency cited on 9/29/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S D▼

Findings

Based on observation, interview and record review the residence failed to comply with authorized practitioner's orders affecting four of five sample residents (#3, #9, #10,#17) and two former residents (#15, #19). (Cross-reference B0290, S1160, S1350, S1604)This deficiency was cited previously during a state licensure complaint revisit 9/29/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #19 was prescribed antibiotics for a urinary tract infection on 1/24/24. However, the residence failed to ensure the prescription was filled. On 1/29/24 Former Resident #19 experienced a change in condition, was combative and had altered mental status. The former resident was subsequently transported to the emergency department, diagnosed with sepsis and a urinary tract infection. Former Resident #19 was administered intravenous (IV) antibiotics, fluids and was hospitalized for six days as a result of not receiving her antibiotics. Specifically, Former Resident #15 was prescribed lasix for edema on 2/14/24. However, the residence failed to ensure the prescription was filled and on 2/20/24 an external service provider notified the practitioner that the former resident had experienced swelling and edema. Former Resident #15 was subsequently transported to the emergency department (ED). Former Resident #15 was diagnosed with congestive heart failure and edema. The former resident was hospitalized for 15 days as a result of not receiving her prescribed medication and subsequently discharged to a skilled nursing facility. Findings Include:1. Residence Policya. The residence's Medication Services Policy, dated January 2024, read in part: Medication assistance services were provided by the residence by a qualified medication administration person (QMAP) who had completed the QMAP training and competency evaluation program. The medication assistance program consists of providing assistance with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living residences. Additionally, the policy read that the residence communicated with practitioners and pharmacists to ensure accuracy of medications. b. According to Good RX: "A urinary tract infection (UTI) is a common condition often caused by Escherichia coli bacteria in the urine. Antibiotics are the typical treatment for a UTI. In some cases, a UTI will go away on its own even if untreated. This is most likely to happen in adult women with no other health conditions. An untreated UTI can sometimes lead to serious complications and hospitalization. It ' s always a good idea to let your provider know you have UTI symptoms ... The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria), The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria) ... Sepsis is a life-threatening condition caused by the body ' s response to infection. It happens when the immune system works to fight an infection, but ends up causing too much inflammation throughout the whole body. Each year, about 1.7 million adults in the U.S. get sepsis, and almost 270,000 die from it. UTIs cause up to 30% of cases of sepsis. Risk factors for developing sepsis include: Being over 65 years old, Having diabetes, Having a weakened immune system, Having a history of prior urinary tract procedures Sepsis is a serious condition, and it needs immediate medical attention. Healthcare providers use specific guidelines to diagnose sepsis. Sepsis symptoms include: Low or high body temperature, High heart rate, High breathing rate, Swelling in parts of the body, Change in mental status (such as confusion) ... So while you may get over a UTI on your own, the risks of not treating a UTI can be pretty high. Some untreated UTIs can cause serious health problems that may even require hospitalization. It ' s best to let your provider know if you have symptoms of a UTI. They can find the source of your symptoms and come up with a treatment plan." Reviewed 2024. Retreived https://www.goodrx.com/conditions/urinary-tract-infection/untreated-uti-risks-dangers. c. According to RXlist: "Lasix (furosemide) is an anthranilic acid derivative that is used as a strong diuretic in adults and children to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome ... Seek medical care or call 911 at once if you have the following serious side effects: Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out." Reviewed 2024. Retrieved https://www.rxlist.com/lasix-drug.htm#description. d. According to the Cleveland Clinic: "Congestive heart failure is a long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time. Medications and other treatments help manage symptoms like swelling. Congestive heart failure is life-limiting for many ... Congestive heart failure symptoms include: Shortness of breath. Waking up short of breath at night. Chest pain. Heart palpitations. Fatigue when you ' re active. Swelling in your ankles, legs and abdomen. Weight gain ... Reviewed 2024. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failure 2. Former Resident #19 was admitted to the residence on 12/1/21 with diagnoses including urinary tract infection, muscle weakness, vitamin deficiency, post polio syndrome and hypertension.a. AmoxicillinA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 1/24/24 at 8:13 a.m., directed the residence to administer amoxicillin 500 mg potassium clavulanate 125 mg twice daily for seven days. However, the January 2024 medication administration record (MAR) read the medication was never administered. A residence progress note, dated 1/27/24, read in part: Staff brought food to Former Resident #19's room. The former resident was about to leave and was crying. When staff asked Former Resident #19 what was wrong she stated "she was scared as (expletive) and she feels intimidated." The administrator was notified. Hospital discharge orders, dated 1/29 through 2/5/24, read in part: Former Resident #19 was admitted to the hospital on 1/29/24 with symptoms including an altered mental status. Former Resident #19 was combative at the residence and was transported to the emergency department. The former resident tested positive for a urinary tract infection and would be treated with IV antibiotics, IV fluids and pain medication as needed. Former Resident #19 was admitted to the hospital. b. Vitamin D A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 2000 units once daily. However, the January 2024 MAR read the medication was not administered on 1/8, 1/9, 1/12-1/17 and 1/21-1/26/24 as the medication was out of stock, for a total of 14 missed doses.c. MultivitaminA written practitioner's order, dated 2/6/23, directed the residence to administer multivitamin once daily on 1/13-1/16,1/21-1/29/24 as the medication was on order, for a total of 13 missed doses. d. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/16, 1/17, 1/19, 1/21-1/29/24 as the medication was out of stock, for a total 11 missed doses. GabapentinA written practitioner's order, dated 2/6/23, directed the residence to administer gabapentin 100 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/20-1/27/24 as the medication was out of stock, for a total of seven missed doses. f. Metoprolol A written practitioner's order dated, 2/6/23, directed the residence to administer metoprolol tartrate 12.5 mg twice daily. However, the January 2024 MAR read the medication was not administered on 1/28/24 at 7:00 p.m. as the medication was out of stock and on 1/29/24 at 7:00 a.m., the dose was not administered as the resident was confused, for a total of two missed doses. g. HydrocodoneA written practitioner's order, dated 2/6/23, directed the residence to administer hydrocodone acetaminophen 7.5-325 mg twice daily. However, the January 2024 MAR read the medication was not administered the morning dose on 1/21/24 as the medication was out of stock. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #19 stated the former resident was prescribed antibiotics for a urinary tract infection on 1/24/24. He stated the residence did not inform him Resident #19 had not received her antibiotics and as a result on 1/29/24 Former Resident #19 had a change in condition from baseline, was transported to the ED, was hospitalized and later required skilled nursing care. Additionally, the practitioner stated that missing gabapentin, even one dose, could cause the resident to experience nerve pain. On 3/28/24 at 11:00 a.m., the administrator stated on 1/24/24 Former Resident #19 had a change in condition. She stated she was not her normal self, did not want to eat and laid in bed sleeping all day. She stated the former resident was transported to the emergency department and subsequently diagnosed with a urinary tract infection. The administrator further stated Former Resident #19, after her hospitalization, was discharged to a skilled nursing facility as she required more care than what the residence was able to provide. Additionally, the administrator stated she thought the former resident was seen by her practitioner for a suspected urinary tract infection; however, the administrator stated she was not aware the practitioner ordered any medication. 3. Former Resident #15 was admitted to the residence on 12/16/18 with diagnoses of tachycardia, atrioventricular block, pacemaker and peripheral vascular disease. A written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 2/14/24 at 4:00 p.m. directed the residence to administer furosemide (Lasix) 20 mg take 0.5 tablet once daily for swelling. A residence progress note, dated 2/20/23, read an external service provider notified the residence that Former Resident #15 had not received her prescription for lasix. The residence telephoned the pharmacy and no order was found. The external service provider stated Former Resident #15 had fluids in her legs and was sent to the ED via emergency medical services. An external service provider note, dated 2/20/24, read in part Former Resident #15 had increased edema of her extremities. The external service provider telephoned the practitioner, notified him of the resident's vitals and the practitioner agreed to have the resident receive emergency medical care. A hospitalization record, dated 2/20/24 through 3/6/24, read in part: Former Resident #15 was admitted to the hospital with diagnoses including: malaise, atherosclerotic heart disease, acute congestive heart failure and edema. The resident presented at the emergency department with shortness of breath and weight gain. The record further read Former Resident #15 "was supposed to be prescribed lasix however she never received the prescription ... Apparently in the past month or so (the resident) had 20 pound weight gain. Apparently the patient was consulted by medical staff there in the recent past concern for weight gain and edema and was supposed to be starting diuretic therapy when the provider checked on her today found her to be more edema and learned that she has not been receiving the diuretic and sent her to the emergency room." Resident #15 was swollen throughout the entire lower abdomen and lower extremities. Resident #15 was administered Lasix 60 mg injection upon admission. On 3/6/24, Former Resident #15 was discharged to a skilled nursing home. On 3/26/24 at 3:40 p.m., the January and February 2024 MARs for Former Resident #15 were requested. However, as of 3/28/24 no MARs were provided. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #15 stated on 2/14/24 the resident was prescribed Lasix due to edema. He stated approximately one week later the medication had not started and an external service provider telephoned him and explained the resident's condition had deteriorated and a decision was made to send the resident to the ED for urgent treatment. On 3/28/24 at 11:07 a.m., the administrator stated the external home health provider for Former Resident #15 was at the residence and noticed swelling and edema. She stated at that point the external home health provider went to the administrator's office to check on the prescription for Lasix which had been prescribed approximately one week prior. The administrator stated she checked and could tell the prescription was faxed to the pharmacy. However, she stated when she telephoned the pharmacy they reported not receiving the prescription. The administrator confirmed the former resident did not receive her medication and stated she should have followed up on the prescription. The administrator further added "it was probably one of the emails that I did not get to timely."4. Resident #3 was admitted to the residence on 2/24/20 with a diagnosis of gastroesophageal reflux disorder.a. Diclofenac A written practitioner's order, dated 1/31/24, directed the residence to administer diclofenac 1% topical gel 2 gm apply twice daily to neck and knees. However, the February through March 2024 MAR read the medication was not administered twice daily from 2/1-3/25/24 as it was labeled on the MAR as "as needed" medication for a total of 108 missed doses. b. LisinoprilA written practitioner's order, dated 1/3/24, directed the residence to discontinue omeprazole 40 mg and replace with pantoprazole 40 mg delayed release once daily. However, the February through March 2024 MARs read omeprazole was not discontinued and was administered in conjunction with pantoprazole from 2/1 and 2/4-2/29/24 for a total of 27 days. c. Vitamin B-12A written practitioner's order, dated 1/31/24, directed the residence to administer vitamin B-12 1000 mcg once daily. However, the March 2024 MAR read the medication was not administered from 3/15-3/26/24 as the medication was out of stock for a total of 11 missed doses.d. Meclizine HydrochlorideA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg once daily at noon. However, the February 2024 MAR read the medication was not administered on 2/1/24 as the resident was out of the residence for a total of one missed dose. On 3/28/24 at 11:00 a.m., the administrator stated she was not aware of the error with the pantoprazole. She stated the residence had difficulties obtaining prescriptions from the practitioner's and in addition, she stated the residence was also changing pharmacies. The administrator stated she had started her position at the residence in July 2023; however, the administrator stated she had not read the past deficiencies and was not sure why they had not been corrected. 4. Additional deficient practice was identified with Residents #9, #10 and #17.

Plan of correction · submitted by the facility

(Cross-reference B0290, S1160, S1350, S1604)Resident #15 & 19: No longer reside at facilityResident #3: Diclofenac (changed to PRN 4/1), Lisinopril (omeprazole no longer administered after 2/29/24), Vitamin B-12 (D/C’d 4/1/24), Meclizine Hydrochloride (administered as directed starting 2/2/24)Resident #9, 10, & 17: no specific medication issues cited. Medication orders not filled:The Facility has a new system in place to ensure that medication orders are filled and residents receive the medications. A Resident Care Coordinator( RCC) has been hired to over see the medications and this position/designee will review all medication orders upon a resident being seen by a medical provider or returned from the hospital to ensure that medications are ordered and delivered to the facility. A “ Medication order only email“ has been established so that medication orders do not get lost among other emails. The Resident Care Coordinator/designee will also review the Hospital log to ensure the medical provider provides new medication orders upon a re-admission. Out of stock issues:To correct missed doses due to out-of-stock issues, the facility has changed pharmacy and the Resident Care Coordinator/designee reviews the MAR sheets to ensure that the pharmacy has delivered all the medicationsTranscription error – a medication was listed as PRN and it was routine. The RCC/designee and the Administrator/Nurse will have a double check system to review any new orders that are transcribed on the MAR. This process will be started immediately to ensure accuracy. The change in process has already been initiated. QMAP’s will be educated, by date of compliance, on medication orders not filled, out of stock medications, and transcription errors. The ensure on going compliance, the medication orders, supply and transcription will be added to the QMP and reviewed for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted..

3/5/2024Revisit: State Certification and State Certification Complaint (Combined) · ID EI5T131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 3/28/24 for the previous deficiency cited on 9/29/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S D▼

Findings

Based on observation, interview and record review the (facility) residence failed to follow written policies and procedures for the adminstration of medication in accordance with Chapter VII regulations affecting nine of ten sample (participants) residents (#3, #9, #10, #17, #22, #26-#29) and two former residents (#15, #19). This deficiency was cited previously during a certification revisit 9/29/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #19 was prescribed antibiotics for a urinary tract infection on 1/24/24. However, the residence failed to ensure the prescription was filled. On 1/29/24 Former Resident #19 experienced a change in condition, was combative and had altered mental status. The former resident was subsequently transported to the emergency department, diagnosed with sepsis and a urinary tract infection. Former Resident #19 was administered intravenous (IV) antibiotics, fluids and was hospitalized for six days as a result of not receiving her antibiotics. Specifically, Former Resident #15 was prescribed lasix for edema on 2/14/24. However, the residence failed to ensure the prescription was filled and on 2/20/24 an external service provider notified the practitioner that the former resident had experienced swelling and edema. Former Resident #15 was subsequently transported to the emergency department (ED). Former Resident #15 was diagnosed with congestive heart failure and edema. The former resident was hospitalized for 15 days as a result of not receiving her prescribed medication and subsequently discharged to a skilled nursing facility. Findings include:1. Chapter VII regualtions governing assited living residences, requires in part 14.21 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.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: Medication assistance services were provided by the residence by a qualified medication administration person (QMAP) who had completed the QMAP training and competency evaluation program. The medication assistance program consists of providing assistance with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living residences. Additionally, the policy read that the residence communicated with practitioners and pharmacists to ensure accuracy of medications. According to Good RX: "A urinary tract infection (UTI) is a common condition often caused by Escherichia coli bacteria in the urine. Antibiotics are the typical treatment for a UTI. In some cases, a UTI will go away on its own even if untreated. This is most likely to happen in adult women with no other health conditions. An untreated UTI can sometimes lead to serious complications and hospitalization. It ' s always a good idea to let your provider know you have UTI symptoms ... The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria), The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria) ... Sepsis is a life-threatening condition caused by the body ' s response to infection. It happens when the immune system works to fight an infection, but ends up causing too much inflammation throughout the whole body. Each year, about 1.7 million adults in the U.S. get sepsis, and almost 270,000 die from it. UTIs cause up to 30% of cases of sepsis. Risk factors for developing sepsis include: Being over 65 years old, Having diabetes, Having a weakened immune system, Having a history of prior urinary tract procedures Sepsis is a serious condition, and it needs immediate medical attention. Healthcare providers use specific guidelines to diagnose sepsis. Sepsis symptoms include: Low or high body temperature, High heart rate, High breathing rate, Swelling in parts of the body, Change in mental status (such as confusion) ... So while you may get over a UTI on your own, the risks of not treating a UTI can be pretty high. Some untreated UTIs can cause serious health problems that may even require hospitalization. It ' s best to let your provider know if you have symptoms of a UTI. They can find the source of your symptoms and come up with a treatment plan." Reviewed 2024. Retreived https://www.goodrx.com/conditions/urinary-tract-infection/untreated-uti-risks-dangers. According to RXlist: "Lasix (furosemide) is an anthranilic acid derivative that is used as a strong diuretic in adults and children to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome ... Seek medical care or call 911 at once if you have the following serious side effects: Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out." Reviewed 2024. Retrieved https://www.rxlist.com/lasix-drug.htm#description. According to the Cleveland Clinic: "Congestive heart failure is a long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time. Medications and other treatments help manage symptoms like swelling. Congestive heart failure is life-limiting for many ... Congestive heart failure symptoms include: Shortness of breath. Waking up short of breath at night. Chest pain. Heart palpitations. Fatigue when you ' re active. Swelling in your ankles, legs and abdomen. Weight gain ... Reviewed 2024. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failureb. Former Resident #19 was admitted to the residence on 12/1/21 with diagnoses including urinary tract infection, muscle weakness, vitamin deficiency, post polio syndrome and hypertension. AmoxicillinA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 1/24/24 at 8:13 a.m., directed the residence to administer amoxicillin 500 mg potassium clavulanate 125 mg twice daily for seven days. However, the January 2024 medication administration record (MAR) read the medication was never administered. A residence progress note, dated 1/27/24, read in part: Staff brought food to Former Resident #19's room. The former resident was about to leave and was crying. When staff asked Former Resident #19 what was wrong she stated "she was scared as (expletive) and she feels intimidated." The administrator was notified. Hospital discharge orders, dated 1/29 through 2/5/24, read in part: Former Resident #19 was admitted to the hospital on 1/29/24 with symptoms including an altered mental status. Former Resident #19 was combative at the residence and was transported to the emergency department. The former resident tested positive for a urinary tract infection and would be treated with IV antibiotics, IV fluids and pain medication as needed. Former Resident #19 was admitted to the hospital. Vitamin D A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 2000 units once daily. However, the January 2024 MAR read the medication was not administered on 1/8, 1/9, 1/12-1/17 and 1/21-1/26/24 as the medication was out of stock, for a total of 14 missed doses. MultivitaminA written practitioner's order, dated 2/6/23, directed the residence to administer multivitamin once daily on 1/13-1/16,1/21-1/29/24 as the medication was on order, for a total of 13 missed doses. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/16, 1/17, 1/19, 1/21-1/29/24 as the medication was out of stock, for a total 11 missed doses. GabapentinA written practitioner's order, dated 2/6/23, directed the residence to administer gabapentin 100 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/20-1/27/24 as the medication was out of stock, for a total of seven missed doses. Metoprolol A written practitioner's order dated, 2/6/23, directed the residence to administer metoprolol tartrate 12.5 mg twice daily. However, the January 2024 MAR read the medication was not administered on 1/28/24 at 7:00 p.m. as the medication was out of stock and on 1/29/24 at 7:00 a.m., the dose was not administered as the resident was confused, for a total of two missed doses. HydrocodoneA written practitioner's order, dated 2/6/23, directed the residence to administer hydrocodone acetaminophen 7.5-325 mg twice daily. However, the January 2024 MAR read the medication was not administered the morning dose on 1/21/24 as the medication was out of stock. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #19 stated the former resident was prescribed antibiotics for a urinary tract infection on 1/24/24. He stated the residence did not inform him Resident #19 had not received her antibiotics and as a result on 1/29/24 Former Resident #19 had a change in condition from baseline, was transported to the ED, was hospitalized and later required skilled nursing care. Additionally, the practitioner stated that missing gabapentin, even one dose, could cause the resident to experience nerve pain. On 3/28/24 at 11:00 a.m., the administrator stated on 1/24/24 Former Resident #19 had a change in condition. She stated she was not her normal self, did not want to eat and laid in bed sleeping all day. She stated the former resident was transported to the emergency department and subsequently diagnosed with a urinary tract infection. The administrator further stated Former Resident #19, after her hospitalization, was discharged to a skilled nursing facility as she required more care than what the residence was able to provide. Additionally, the administrator stated she thought the former resident was seen by her practitioner for a suspected urinary tract infection; however, the administrator stated she was not aware the practitioner ordered any medication. c. Former Resident #15 was admitted to the residence on 12/16/18 with diagnoses of tachycardia, atrioventricular block, pacemaker and peripheral vascular disease. A written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 2/14/24 at 4:00 p.m. directed the residence to administer furosemide (Lasix) 20 mg take 0.5 tablet once daily for swelling. A residence progress note, dated 2/20/23, read an external service provider notified the residence that Former Resident #15 had not received her prescription for lasix. The residence telephoned the pharmacy and no order was found. The external service provider stated Former Resident #15 had fluids in her legs and was sent to the ED via emergency medical services. An external service provider note, dated 2/20/24, read in part Former Resident #15 had increased edema of her extremities. The external service provider telephoned the practitioner, notified him of the resident's vitals and the practitioner agreed to have the resident receive emergency medical care. A hospitalization record, dated 2/20/24 through 3/6/24, read in part: Former Resident #15 was admitted to the hospital with diagnoses including: malaise, atherosclerotic heart disease, acute congestive heart failure and edema. The resident presented at the emergency department with shortness of breath and weight gain. The record further read Former Resident #15 "was supposed to be prescribed lasix however she never received the prescription ... Apparently in the past month or so (the resident) had 20 pound weight gain. Apparently the patient was consulted by medical staff there in the recent past concern for weight gain and edema and was supposed to be starting diuretic therapy when the provider checked on her today found her to be more edema and learned that she has not been receiving the diuretic and sent her to the emergency room." Resident #15 was swollen throughout the entire lower abdomen and lower extremities. Resident #15 was administered Lasix 60 mg injection upon admission. On 3/6/24, Former Resident #15 was discharged to a skilled nursing home. On 3/26/24 at 3:40 p.m., the January and February 2024 MARs for Former Resident #15 were requested. However, as of 3/28/24 no MARs were provided. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #15 stated on 2/14/24 the resident was prescribed Lasix due to edema. He stated approximately one week later the medication had not started and an external service provider telephoned him and explained the resident's condition had deteriorated and a decision was made to send the resident to the ED for urgent treatment. On 3/28/24 at 11:07 a.m., the administrator stated the external home health provider for Former Resident #15 was at the residence and noticed swelling and edema. She stated at that point the external home health provider went to the administrator's office to check on the prescription for Lasix which had been prescribed approximately one week prior. The administrator stated she checked and could tell the prescription was faxed to the pharmacy. However, she stated when she telephoned the pharmacy they reported not receiving the prescription. The administrator confirmed the former resident did not receive her medication and stated she should have followed up on the prescription. The administrator further added "it was probably one of the emails that I did not get to timely."d. Resident #3 was admitted to the residence on 2/24/20 with a diagnosis of gastroesophageal reflux disorder. Diclofenac A written practitioner's order, dated 1/31/24, directed the residence to administer diclofenac 1% topical gel 2 gm apply twice daily to neck and knees. However, the February through March 2024 MAR read the medication was not administered twice daily from 2/1-3/25/24 as it was labeled on the MAR as "as needed" medication for a total of 108 missed doses. LisinoprilA written practitioner's order, dated 1/3/24, directed the residence to discontinue omeprazole 40 mg and replace with pantoprazole 40 mg delayed release once daily. However, the February through March 2024 MARs read omeprazole was not discontinued and was administered in conjunction with pantoprazole from 2/1 and 2/4-2/29/24 for a total of 27 days. Vitamin B-12A written practitioner's order, dated 1/31/24, directed the residence to administer vitamin B-12 1000 mcg once daily. However, the March 2024 MAR read the medication was not administered from 3/15-3/26/24 as the medication was out of stock for a total of 11 missed doses. Meclizine HydrochlorideA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg once daily at noon. However, the February 2024 MAR read the medication was not administered on 2/1/24 as the resident was out of the residence for a total of one missed dose. On 3/28/24 at 11:00 a.m., the administrator stated she was not aware of the error with the pantoprazole. She stated the residence had difficulties obtaining prescriptions from the practitioner's and in addition, she stated the residence was also changing pharmacies. The administrator stated she had started her position at the residence in July 2023; however, the administrator stated she had not read the past deficiencies and was not sure why they had not been corrected.e. Additional deficient practice was identified with Residents #9, #10 and #17. 2. Chapter VII regulations governing assisted living residences, requires in part 14.28 that the assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. During morning medication administration on 3/26/24 at 7:52 a.m., the following was observed:Staff #13 donned gloves and began to prepare medications for Resident #26. Staff #13 while preparing the medications grasped her sweatshirt wiping her nose. Staff #13 subsequently spilled the medications for Resident #26 on the medication cart and picked them up with her gloved hand placing them back into the medication cup, Staff #13 then administered the medication, returned to the medication cart, doffed her gloves, opened the medication cart and documented on the medication administration record (MAR). Staff #13 touched her nose with her hand and stated she needed to obtain a tissue. The staff then wiped her nose and began to prepare medication for Resident #27 popping the medication out of the blister package and placing it in the medication cup. Staff #13 then took out a cup and poured water from a pitcher for the resident. Staff #13 then handed Resident #27 her medications and began to cough. She then took out a tissue and blew her nose and sanitized her hands. Staff #13 donned gloves and prepared medication for Resident #10. The staff took out the resident's insulin pen from the medication cart and handed the resident the insulin to self administer. Staff #13 came back to the medication cart, did not remove her gloves or sanitize her hands. She subsequently prepared and administered medications for Resident #9, applied hydrocortisone cream to the resident's neck. Staff #13 doffed her gloves and without washing or sanitizing her hands administered medications to Resident #17,#22, #28 and #29 in a similar unsanitary manner. On 3/28/24 at 11:07 a.m., the administrator stated she had discussed proper infection control when administering medications to residents. The administrator further stated the improper infection control by Staff #13 surprised her. 3. Chapter VII regulations governing assisted living residences, in part 14.29 requires that All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: The residence would maintain current files on all medications. b. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including gastroesophageal reflux disorder, hypertension. FluticasoneA written practitioner's order, dated 1/31/23, directed the residence to administer fluticasone propionate/salmeterol 500-50 mcg one puff twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 evening dose, 2/1-2/3 all doses, 2/7 evening dose, 2/17 evening., 2/24 and 2/27 evening doses, 2/29 morning dose, 3/9 morning dose and 3/21/24 evening dose. LisinoprilA written practitioner's order, dated 1/31/24, directed the residence to administer lisinopril 5 mg once daily. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/1-2/3 and 3/23/24. Gabapentin A written practitioner's order, dated 1/31/24, directed the residence to administer gabapentin 600 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 at bedtime, 2/2- 2/3 all doses and on 3/2/24 at noon. MeclizineA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg tablet at noon. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/2, 2/3 and 3/2/24. IpratropiumA written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium 0.5 mg albuterol 3 mg four times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2 at noon and 3/21/24 at the evening dose and bedtime dose. SertralineA written practitioner's order, dated 1/31/24, directed the residence to administer sertraline 100 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/2 and 2/3/24. PantoprazoleA written practitioner's order, dated 1/31/24, directed the residence to administer pantoprazole sodium 40 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 and 2/2/24. SpirivaA written practitioner's order, dated 1/31/24, directed the residence to administer Spariva handihaler 18 mcg one puff by mouth once daily. However the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/9/24.c. Resident #14 was admitted to the residence on an unknown date. PantoprazoleA written practitioner's order, dated 1/25/24, directed the residence to administer pantoprazole sodium 40 mg twice daily. However, the March 2023 MAR revealed no evidence of documentation at the time of administration on 3/7, 3/11 morningdoses, 3/19, 3/20 evening doses and 3/24/24 morning dose. RosuvastatinA written practitioner's order, dated 2/29/24, directed the residence to administer rosuvastatin calcium 10 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/5/24. SertralineA written practitioner's order, dated 1/25/24, directed the residence to administer sertraline 50 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24. Docusate SodiumA written practitioner's order, dated 1/25/24, directed the residence to administer docusate sodium 100 mg twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24 evening dose. MontelukastA written practitioner's order, dated 1/25/24, directed the residence to administer montelukast sodium 10 mg at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/1/24. BuspironeA written practitioner's order, dated 1/25/24, directed the residence to administer buspirone 10 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/8 and 3/11/24 at 6:00 a.m. ClopidogrelA written practitioner's order, dated 1/25/24, directed the residence to administer clopidogrel 75 mg once daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2/24. d. Additional deficient practice was identified for Resident #10. On 3/28/24 at 11:00 a.m., the administrator stated she expected qualified medication administration persons to administer medications and document on the MAR. She stated she has done training with staff in the past regarding documentation on the MAR; however, the administrator stated there were no consequences put in place to prevent a recurrence. 4. Chapter VII regualtions governing assisted living residences, requires in part 14.31 that 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. Medication Cart/Medication Administration Record Audits completed from December 2023 to present revealed the form focused on three areas of the medication program: Medication administered as ordered, medication signed out appropriately, follow-up completed on any out of stock medications with both the practitioner and pharmacy and follow-up completed on any medication refusal not given. A second audit tool utilized in January 2024 read the residence only audited the medication cart and a list of staff names who signed the MAR. The audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. On 3/26/24 at approximately 11:00 a.m., the residence's contracted consultant stated that neither she or the administrator had done a full audit of the resident records in relation to the practitioner's orders, MARs and medication cart. The consultant further stated there was a corporate nurse scheduled to assist with the audits on 3/27/24. On 3/28/24 at 11:07 a.m., the administrator stated she had been the administrator since July 2023. She stated she had not completed an audit to ensure the accuracy and completeness of the MARs. The administrator further stated the residence had been short staffed and she had not had time to look at the records for the residents. 5. Chapter VII regulations governing assisted living residences, requires in part 14.33 that the assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of: (A) A decline from a resident's baseline status; (B) A resident's pattern of refusal.a. The residence's Medication Services Policy, dated January 2024, read in part: The residence would communicate with practitioners to ensure accuracy of medications. b. Former Resident #19 was admitted to the residence on 12/1/21 with a diagnosis of constipation. A written practitioner's order, dated 7/5/23, directed the residence to administer Senna 8.6 mg once daily. However, the January 2024 MAR read the medication was not administered as the resident refused on 1/4, 1/5, 1/11-1/13, 1/19-1/22 and 1/25-1/27/24 for a total of 12 refused doses. c. Resident #3 was admitted to the residence on 12/24/20. A written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium bromide sulfate 0.5-2.5 mg four times daily. However, the March 2024 MAR read the resident refused the medication on 3/14, 3/19, 3/20 at noon, 3/24, 3/25 and 3/26/24 morning and noon for a total of seven refused doses. On 3/27/24 at 10:12 a.m., the practitioner for Resident #3 stated he had not been notified of any medication refusals. On 3/28/24 at 11:07 a.m., the administrator stated the residence did not have a formal process in place for notifying the practitioner of a pattern of refusals. She stated currently the qualified medication administration person who attempted to administer the medication was responsible for notifying the practitioner of all refusals.

Plan of correction · submitted by the facility

Resident #15 & 19: No longer reside at facilityResident #3: Diclofenac (changed to PRN 4/1), Lisinopril (omeprazole no longer administered after 2/29/24), Vitamin B-12 (D/C’d 4/1/24), Meclizine Hydrochloride (administered as directed starting 2/2/24)Resident #9, 10, 17, 22, 26-29: no specific medication issues cited. Documentation, infection control, and proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served will be addressed through education below. The staff will be retrained on the medication policy and the importance of proper medication administrator in compliance with Chapter 24 regulation, by date of compliance, these areas include proper documentation, infection control with the proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served. The Administrator and RCC have been retrained on the medication policy. RCC and RN or designee will watch 2 Med passes weekly to ensure proper Qmap procedures are followed in all areas of medication administration. Documentation will be included in the monthly review during the QMP meeting. The area will remain as an area of focus for QMP for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

3/5/2024Revisit: Licensure Complaint · ID 8XY7121 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 3/28/24 for the previous deficiency cited on 9/29/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S D▼

Findings

Based on observation, interview and record review the facility (residence) failed to follow written policies and procedures for the adminstration of medication in accordance with Chapter VII regulations affecting nine of ten sample participants (residents) (#3, #9, #10, #17, #22, #26-#29) and two former residents (#15, #19). This deficiency was cited previously during a certification complaint revisit 9/29/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #19 was prescribed antibiotics for a urinary tract infection on 1/24/24. However, the residence failed to ensure the prescription was filled. On 1/29/24 Former Resident #19 experienced a change in condition, was combative and had altered mental status. The former resident was subsequently transported to the emergency department, diagnosed with sepsis and a urinary tract infection. Former Resident #19 was administered intravenous (IV) antibiotics, fluids and was hospitalized for six days as a result of not receiving her antibiotics. Specifically, Former Resident #15 was prescribed lasix for edema on 2/14/24. However, the residence failed to ensure the prescription was filled and on 2/20/24 an external service provider notified the practitioner that the former resident had experienced swelling and edema. Former Resident #15 was subsequently transported to the emergency department (ED). Former Resident #15 was diagnosed with congestive heart failure and edema. The former resident was hospitalized for 15 days as a result of not receiving her prescribed medication and subsequently discharged to a skilled nursing facility. Findings include:1. Chapter VII regualtions governing assited living residences, requires in part 14.21 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.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: Medication assistance services were provided by the residence by a qualified medication administration person (QMAP) who had completed the QMAP training and competency evaluation program. The medication assistance program consists of providing assistance with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living residences. Additionally, the policy read that the residence communicated with practitioners and pharmacists to ensure accuracy of medications. According to Good RX: "A urinary tract infection (UTI) is a common condition often caused by Escherichia coli bacteria in the urine. Antibiotics are the typical treatment for a UTI. In some cases, a UTI will go away on its own even if untreated. This is most likely to happen in adult women with no other health conditions. An untreated UTI can sometimes lead to serious complications and hospitalization. It ' s always a good idea to let your provider know you have UTI symptoms ... The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria), The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria) ... Sepsis is a life-threatening condition caused by the body ' s response to infection. It happens when the immune system works to fight an infection, but ends up causing too much inflammation throughout the whole body. Each year, about 1.7 million adults in the U.S. get sepsis, and almost 270,000 die from it. UTIs cause up to 30% of cases of sepsis. Risk factors for developing sepsis include: Being over 65 years old, Having diabetes, Having a weakened immune system, Having a history of prior urinary tract procedures Sepsis is a serious condition, and it needs immediate medical attention. Healthcare providers use specific guidelines to diagnose sepsis. Sepsis symptoms include: Low or high body temperature, High heart rate, High breathing rate, Swelling in parts of the body, Change in mental status (such as confusion) ... So while you may get over a UTI on your own, the risks of not treating a UTI can be pretty high. Some untreated UTIs can cause serious health problems that may even require hospitalization. It ' s best to let your provider know if you have symptoms of a UTI. They can find the source of your symptoms and come up with a treatment plan." Reviewed 2024. Retreived https://www.goodrx.com/conditions/urinary-tract-infection/untreated-uti-risks-dangers. According to RXlist: "Lasix (furosemide) is an anthranilic acid derivative that is used as a strong diuretic in adults and children to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome ... Seek medical care or call 911 at once if you have the following serious side effects: Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out." Reviewed 2024. Retrieved https://www.rxlist.com/lasix-drug.htm#description. According to the Cleveland Clinic: "Congestive heart failure is a long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time. Medications and other treatments help manage symptoms like swelling. Congestive heart failure is life-limiting for many ... Congestive heart failure symptoms include: Shortness of breath. Waking up short of breath at night. Chest pain. Heart palpitations. Fatigue when you ' re active. Swelling in your ankles, legs and abdomen. Weight gain ... Reviewed 2024. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failureb. Former Resident #19 was admitted to the residence on 12/1/21 with diagnoses including urinary tract infection, muscle weakness, vitamin deficiency, post polio syndrome and hypertension. AmoxicillinA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 1/24/24 at 8:13 a.m., directed the residence to administer amoxicillin 500 mg potassium clavulanate 125 mg twice daily for seven days. However, the January 2024 medication administration record (MAR) read the medication was never administered. A residence progress note, dated 1/27/24, read in part: Staff brought food to Former Resident #19's room. The former resident was about to leave and was crying. When staff asked Former Resident #19 what was wrong she stated "she was scared as (expletive) and she feels intimidated." The administrator was notified. Hospital discharge orders, dated 1/29 through 2/5/24, read in part: Former Resident #19 was admitted to the hospital on 1/29/24 with symptoms including an altered mental status. Former Resident #19 was combative at the residence and was transported to the emergency department. The former resident tested positive for a urinary tract infection and would be treated with IV antibiotics, IV fluids and pain medication as needed. Former Resident #19 was admitted to the hospital. Vitamin D A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 2000 units once daily. However, the January 2024 MAR read the medication was not administered on 1/8, 1/9, 1/12-1/17 and 1/21-1/26/24 as the medication was out of stock, for a total of 14 missed doses. MultivitaminA written practitioner's order, dated 2/6/23, directed the residence to administer multivitamin once daily on 1/13-1/16,1/21-1/29/24 as the medication was on order, for a total of 13 missed doses. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/16, 1/17, 1/19, 1/21-1/29/24 as the medication was out of stock, for a total 11 missed doses. GabapentinA written practitioner's order, dated 2/6/23, directed the residence to administer gabapentin 100 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/20-1/27/24 as the medication was out of stock, for a total of seven missed doses. Metoprolol A written practitioner's order dated, 2/6/23, directed the residence to administer metoprolol tartrate 12.5 mg twice daily. However, the January 2024 MAR read the medication was not administered on 1/28/24 at 7:00 p.m. as the medication was out of stock and on 1/29/24 at 7:00 a.m., the dose was not administered as the resident was confused, for a total of two missed doses. HydrocodoneA written practitioner's order, dated 2/6/23, directed the residence to administer hydrocodone acetaminophen 7.5-325 mg twice daily. However, the January 2024 MAR read the medication was not administered the morning dose on 1/21/24 as the medication was out of stock. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #19 stated the former resident was prescribed antibiotics for a urinary tract infection on 1/24/24. He stated the residence did not inform him Resident #19 had not received her antibiotics and as a result on 1/29/24 Former Resident #19 had a change in condition from baseline, was transported to the ED, was hospitalized and later required skilled nursing care. Additionally, the practitioner stated that missing gabapentin, even one dose, could cause the resident to experience nerve pain. On 3/28/24 at 11:00 a.m., the administrator stated on 1/24/24 Former Resident #19 had a change in condition. She stated she was not her normal self, did not want to eat and laid in bed sleeping all day. She stated the former resident was transported to the emergency department and subsequently diagnosed with a urinary tract infection. The administrator further stated Former Resident #19, after her hospitalization, was discharged to a skilled nursing facility as she required more care than what the residence was able to provide. Additionally, the administrator stated she thought the former resident was seen by her practitioner for a suspected urinary tract infection; however, the administrator stated she was not aware the practitioner ordered any medication. c. Former Resident #15 was admitted to the residence on 12/16/18 with diagnoses of tachycardia, atrioventricular block, pacemaker and peripheral vascular disease. A written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 2/14/24 at 4:00 p.m. directed the residence to administer furosemide (Lasix) 20 mg take 0.5 tablet once daily for swelling. A residence progress note, dated 2/20/23, read an external service provider notified the residence that Former Resident #15 had not received her prescription for lasix. The residence telephoned the pharmacy and no order was found. The external service provider stated Former Resident #15 had fluids in her legs and was sent to the ED via emergency medical services. An external service provider note, dated 2/20/24, read in part Former Resident #15 had increased edema of her extremities. The external service provider telephoned the practitioner, notified him of the resident's vitals and the practitioner agreed to have the resident receive emergency medical care. A hospitalization record, dated 2/20/24 through 3/6/24, read in part: Former Resident #15 was admitted to the hospital with diagnoses including: malaise, atherosclerotic heart disease, acute congestive heart failure and edema. The resident presented at the emergency department with shortness of breath and weight gain. The record further read Former Resident #15 "was supposed to be prescribed lasix however she never received the prescription ... Apparently in the past month or so (the resident) had 20 pound weight gain. Apparently the patient was consulted by medical staff there in the recent past concern for weight gain and edema and was supposed to be starting diuretic therapy when the provider checked on her today found her to be more edema and learned that she has not been receiving the diuretic and sent her to the emergency room." Resident #15 was swollen throughout the entire lower abdomen and lower extremities. Resident #15 was administered Lasix 60 mg injection upon admission. On 3/6/24, Former Resident #15 was discharged to a skilled nursing home. On 3/26/24 at 3:40 p.m., the January and February 2024 MARs for Former Resident #15 were requested. However, as of 3/28/24 no MARs were provided. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #15 stated on 2/14/24 the resident was prescribed Lasix due to edema. He stated approximately one week later the medication had not started and an external service provider telephoned him and explained the resident's condition had deteriorated and a decision was made to send the resident to the ED for urgent treatment. On 3/28/24 at 11:07 a.m., the administrator stated the external home health provider for Former Resident #15 was at the residence and noticed swelling and edema. She stated at that point the external home health provider went to the administrator's office to check on the prescription for Lasix which had been prescribed approximately one week prior. The administrator stated she checked and could tell the prescription was faxed to the pharmacy. However, she stated when she telephoned the pharmacy they reported not receiving the prescription. The administrator confirmed the former resident did not receive her medication and stated she should have followed up on the prescription. The administrator further added "it was probably one of the emails that I did not get to timely."d. Resident #3 was admitted to the residence on 2/24/20 with a diagnosis of gastroesophageal reflux disorder. Diclofenac A written practitioner's order, dated 1/31/24, directed the residence to administer diclofenac 1% topical gel 2 gm apply twice daily to neck and knees. However, the February through March 2024 MAR read the medication was not administered twice daily from 2/1-3/25/24 as it was labeled on the MAR as "as needed" medication for a total of 108 missed doses. LisinoprilA written practitioner's order, dated 1/3/24, directed the residence to discontinue omeprazole 40 mg and replace with pantoprazole 40 mg delayed release once daily. However, the February through March 2024 MARs read omeprazole was not discontinued and was administered in conjunction with pantoprazole from 2/1 and 2/4-2/29/24 for a total of 27 days. Vitamin B-12A written practitioner's order, dated 1/31/24, directed the residence to administer vitamin B-12 1000 mcg once daily. However, the March 2024 MAR read the medication was not administered from 3/15-3/26/24 as the medication was out of stock for a total of 11 missed doses. Meclizine HydrochlorideA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg once daily at noon. However, the February 2024 MAR read the medication was not administered on 2/1/24 as the resident was out of the residence for a total of one missed dose. On 3/28/24 at 11:00 a.m., the administrator stated she was not aware of the error with the pantoprazole. She stated the residence had difficulties obtaining prescriptions from the practitioner's and in addition, she stated the residence was also changing pharmacies. The administrator stated she had started her position at the residence in July 2023; however, the administrator stated she had not read the past deficiencies and was not sure why they had not been corrected.e. Additional deficient practice was identified with Residents #9, #10 and #17. 2. Chapter VII regulations governing assisted living residences, requires in part 14.28 that the assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. During morning medication administration on 3/26/24 at 7:52 a.m., the following was observed:Staff #13 donned gloves and began to prepare medications for Resident #26. Staff #13 while preparing the medications grasped her sweatshirt wiping her nose. Staff #13 subsequently spilled the medications for Resident #26 on the medication cart and picked them up with her gloved hand placing them back into the medication cup, Staff #13 then administered the medication, returned to the medication cart, doffed her gloves, opened the medication cart and documented on the medication administration record (MAR). Staff #13 touched her nose with her hand and stated she needed to obtain a tissue. The staff then wiped her nose and began to prepare medication for Resident #27 popping the medication out of the blister package and placing it in the medication cup. Staff #13 then took out a cup and poured water from a pitcher for the resident. Staff #13 then handed Resident #27 her medications and began to cough. She then took out a tissue and blew her nose and sanitized her hands. Staff #13 donned gloves and prepared medication for Resident #10. The staff took out the resident's insulin pen from the medication cart and handed the resident the insulin to self administer. Staff #13 came back to the medication cart, did not remove her gloves or sanitize her hands. She subsequently prepared and administered medications for Resident #9, applied hydrocortisone cream to the resident's neck. Staff #13 doffed her gloves and without washing or sanitizing her hands administered medications to Resident #17,#22, #28 and #29 in a similar unsanitary manner. On 3/28/24 at 11:07 a.m., the administrator stated she had discussed proper infection control when administering medications to residents. The administrator further stated the improper infection control by Staff #13 surprised her. 3. Chapter VII regulations governing assisted living residences, in part 14.29 requires that All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.a. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: The residence would maintain current files on all medications. b. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including gastroesophageal reflux disorder, hypertension. FluticasoneA written practitioner's order, dated 1/31/23, directed the residence to administer fluticasone propionate/salmeterol 500-50 mcg one puff twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 evening dose, 2/1-2/3 all doses, 2/7 evening dose, 2/17 evening., 2/24 and 2/27 evening doses, 2/29 morning dose, 3/9 morning dose and 3/21/24 evening dose. LisinoprilA written practitioner's order, dated 1/31/24, directed the residence to administer lisinopril 5 mg once daily. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/1-2/3 and 3/23/24. Gabapentin A written practitioner's order, dated 1/31/24, directed the residence to administer gabapentin 600 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 at bedtime, 2/2- 2/3 all doses and on 3/2/24 at noon. MeclizineA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg tablet at noon. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/2, 2/3 and 3/2/24. IpratropiumA written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium 0.5 mg albuterol 3 mg four times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2 at noon and 3/21/24 at the evening dose and bedtime dose. SertralineA written practitioner's order, dated 1/31/24, directed the residence to administer sertraline 100 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/2 and 2/3/24. PantoprazoleA written practitioner's order, dated 1/31/24, directed the residence to administer pantoprazole sodium 40 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 and 2/2/24. SpirivaA written practitioner's order, dated 1/31/24, directed the residence to administer Spariva handihaler 18 mcg one puff by mouth once daily. However the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/9/24.c. Resident #14 was admitted to the residence on an unknown date. PantoprazoleA written practitioner's order, dated 1/25/24, directed the residence to administer pantoprazole sodium 40 mg twice daily. However, the March 2023 MAR revealed no evidence of documentation at the time of administration on 3/7, 3/11 morningdoses, 3/19, 3/20 evening doses and 3/24/24 morning dose. RosuvastatinA written practitioner's order, dated 2/29/24, directed the residence to administer rosuvastatin calcium 10 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/5/24. SertralineA written practitioner's order, dated 1/25/24, directed the residence to administer sertraline 50 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24. Docusate SodiumA written practitioner's order, dated 1/25/24, directed the residence to administer docusate sodium 100 mg twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24 evening dose. MontelukastA written practitioner's order, dated 1/25/24, directed the residence to administer montelukast sodium 10 mg at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/1/24. BuspironeA written practitioner's order, dated 1/25/24, directed the residence to administer buspirone 10 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/8 and 3/11/24 at 6:00 a.m. ClopidogrelA written practitioner's order, dated 1/25/24, directed the residence to administer clopidogrel 75 mg once daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2/24. d. Additional deficient practice was identified for Resident #10. On 3/28/24 at 11:00 a.m., the administrator stated she expected qualified medication administration persons to administer medications and document on the MAR. She stated she has done training with staff in the past regarding documentation on the MAR; however, the administrator stated there were no consequences put in place to prevent a recurrence. 4. Chapter VII regualtions governing assisted living residences, requires in part 14.31 that 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. Medication Cart/Medication Administration Record Audits completed from December 2023 to present revealed the form focused on three areas of the medication program: Medication administered as ordered, medication signed out appropriately, follow-up completed on any out of stock medications with both the practitioner and pharmacy and follow-up completed on any medication refusal not given. A second audit tool utilized in January 2024 read the residence only audited the medication cart and a list of staff names who signed the MAR. The audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered. On 3/26/24 at approximately 11:00 a.m., the residence's contracted consultant stated that neither she or the administrator had done a full audit of the resident records in relation to the practitioner's orders, MARs and medication cart. The consultant further stated there was a corporate nurse scheduled to assist with the audits on 3/27/24. On 3/28/24 at 11:07 a.m., the administrator stated she had been the administrator since July 2023. She stated she had not completed an audit to ensure the accuracy and completeness of the MARs. The administrator further stated the residence had been short staffed and she had not had time to look at the records for the residents. 5. Chapter VII regulations governing assisted living residences, requires in part 14.33 that the assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of: (A) A decline from a resident's baseline status; (B) A resident's pattern of refusal.a. The residence's Medication Services Policy, dated January 2024, read in part: The residence would communicate with practitioners to ensure accuracy of medications. b. Former Resident #19 was admitted to the residence on 12/1/21 with a diagnosis of constipation. A written practitioner's order, dated 7/5/23, directed the residence to administer Senna 8.6 mg once daily. However, the January 2024 MAR read the medication was not administered as the resident refused on 1/4, 1/5, 1/11-1/13, 1/19-1/22 and 1/25-1/27/24 for a total of 12 refused doses. c. Resident #3 was admitted to the residence on 12/24/20. A written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium bromide sulfate 0.5-2.5 mg four times daily. However, the March 2024 MAR read the resident refused the medication on 3/14, 3/19, 3/20 at noon, 3/24, 3/25 and 3/26/24 morning and noon for a total of seven refused doses. On 3/27/24 at 10:12 a.m., the practitioner for Resident #3 stated he had not been notified of any medication refusals. On 3/28/24 at 11:07 a.m., the administrator stated the residence did not have a formal process in place for notifying the practitioner of a pattern of refusals. She stated currently the qualified medication administration person who attempted to administer the medication was responsible for notifying the practitioner of all refusals.

Plan of correction · submitted by the facility

Resident #15 & 19: No longer reside at facilityResident #3: Diclofenac (changed to PRN 4/1), Lisinopril (omeprazole no longer administered after 2/29/24), Vitamin B-12 (D/C’d 4/1/24), Meclizine Hydrochloride (administered as directed starting 2/2/24)Resident #9, 10, 17, 22, 26-29: no specific medication issues cited. Documentation, infection control, and proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served will be addressed through education below. The staff will be retrained on the medication policy and the importance of proper medication administrator in compliance with Chapter 24 regulation, by date of compliance, these areas include proper documentation, infection control with the proper hand hygiene, notifying the medical provider for a pattern of refusals and ensuring medications are available to be served. The Administrator and RCC have been retrained on the medication policy. RCC and RN or designee will watch 2 Med passes weekly to ensure proper Qmap procedures are followed in all areas of medication administration. Documentation will be included in the monthly review during the QMP meeting. The area will remain as an area of focus for QMP for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

3/5/2024Revisit: Licensure Complaint · ID 8MXJ122 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 3/28/24 or all previous deficiencies/the previous deficiency cited on 9/29/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S D▼

Findings

Based on observation, interview and record review the residence failed to comply with authorized practitioner's orders affecting four of five sample residents (#3, #9, #10,#17) and two former residents (#15, #19). (Cross-reference B0290, S1160, S1350, S1604)This deficiency was cited previously during a state licensure complaint revisit 9/29/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #19 was prescribed antibiotics for a urinary tract infection on 1/24/24. However, the residence failed to ensure the prescription was filled. On 1/29/24 Former Resident #19 experienced a change in condition, was combative and had altered mental status. The former resident was subsequently transported to the emergency department, diagnosed with sepsis and a urinary tract infection. Former Resident #19 was administered intravenous (IV) antibiotics, fluids and was hospitalized for six days as a result of not receiving her antibiotics. Specifically, Former Resident #15 was prescribed lasix for edema on 2/14/24. However, the residence failed to ensure the prescription was filled and on 2/20/24 an external service provider notified the practitioner that the former resident had experienced swelling and edema. Former Resident #15 was subsequently transported to the emergency department (ED). Former Resident #15 was diagnosed with congestive heart failure and edema. The former resident was hospitalized for 15 days as a result of not receiving her prescribed medication and subsequently discharged to a skilled nursing facility. Findings Include:1. Residence Policya. The residence's Medication Services Policy, dated January 2024, read in part: Medication assistance services were provided by the residence by a qualified medication administration person (QMAP) who had completed the QMAP training and competency evaluation program. The medication assistance program consists of providing assistance with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living residences. Additionally, the policy read that the residence communicated with practitioners and pharmacists to ensure accuracy of medications. b. According to Good RX: "A urinary tract infection (UTI) is a common condition often caused by Escherichia coli bacteria in the urine. Antibiotics are the typical treatment for a UTI. In some cases, a UTI will go away on its own even if untreated. This is most likely to happen in adult women with no other health conditions. An untreated UTI can sometimes lead to serious complications and hospitalization. It ' s always a good idea to let your provider know you have UTI symptoms ... The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria), The symptoms of a UTI depend on where the infection is. Lower UTIs those involving the urethra and bladder are the most common type. Symptoms can include: Pain or burning when peeing (dysuria), Frequent and urgent urination, Pain in the pelvic area, Waking at night to urinate (nocturia), Blood in the urine (hematuria) ... Sepsis is a life-threatening condition caused by the body ' s response to infection. It happens when the immune system works to fight an infection, but ends up causing too much inflammation throughout the whole body. Each year, about 1.7 million adults in the U.S. get sepsis, and almost 270,000 die from it. UTIs cause up to 30% of cases of sepsis. Risk factors for developing sepsis include: Being over 65 years old, Having diabetes, Having a weakened immune system, Having a history of prior urinary tract procedures Sepsis is a serious condition, and it needs immediate medical attention. Healthcare providers use specific guidelines to diagnose sepsis. Sepsis symptoms include: Low or high body temperature, High heart rate, High breathing rate, Swelling in parts of the body, Change in mental status (such as confusion) ... So while you may get over a UTI on your own, the risks of not treating a UTI can be pretty high. Some untreated UTIs can cause serious health problems that may even require hospitalization. It ' s best to let your provider know if you have symptoms of a UTI. They can find the source of your symptoms and come up with a treatment plan." Reviewed 2024. Retreived https://www.goodrx.com/conditions/urinary-tract-infection/untreated-uti-risks-dangers. c. According to RXlist: "Lasix (furosemide) is an anthranilic acid derivative that is used as a strong diuretic in adults and children to treat excessive fluid accumulation (edema) caused by congestive heart failure, liver failure, renal failure, and nephritic syndrome ... Seek medical care or call 911 at once if you have the following serious side effects: Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheadedness, or passing out." Reviewed 2024. Retrieved https://www.rxlist.com/lasix-drug.htm#description. d. According to the Cleveland Clinic: "Congestive heart failure is a long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time. Medications and other treatments help manage symptoms like swelling. Congestive heart failure is life-limiting for many ... Congestive heart failure symptoms include: Shortness of breath. Waking up short of breath at night. Chest pain. Heart palpitations. Fatigue when you ' re active. Swelling in your ankles, legs and abdomen. Weight gain ... Reviewed 2024. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failure 2. Former Resident #19 was admitted to the residence on 12/1/21 with diagnoses including urinary tract infection, muscle weakness, vitamin deficiency, post polio syndrome and hypertension.a. AmoxicillinA written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 1/24/24 at 8:13 a.m., directed the residence to administer amoxicillin 500 mg potassium clavulanate 125 mg twice daily for seven days. However, the January 2024 medication administration record (MAR) read the medication was never administered. A residence progress note, dated 1/27/24, read in part: Staff brought food to Former Resident #19's room. The former resident was about to leave and was crying. When staff asked Former Resident #19 what was wrong she stated "she was scared as (expletive) and she feels intimidated." The administrator was notified. Hospital discharge orders, dated 1/29 through 2/5/24, read in part: Former Resident #19 was admitted to the hospital on 1/29/24 with symptoms including an altered mental status. Former Resident #19 was combative at the residence and was transported to the emergency department. The former resident tested positive for a urinary tract infection and would be treated with IV antibiotics, IV fluids and pain medication as needed. Former Resident #19 was admitted to the hospital. b. Vitamin D A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 2000 units once daily. However, the January 2024 MAR read the medication was not administered on 1/8, 1/9, 1/12-1/17 and 1/21-1/26/24 as the medication was out of stock, for a total of 14 missed doses.c. MultivitaminA written practitioner's order, dated 2/6/23, directed the residence to administer multivitamin once daily on 1/13-1/16,1/21-1/29/24 as the medication was on order, for a total of 13 missed doses. d. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/16, 1/17, 1/19, 1/21-1/29/24 as the medication was out of stock, for a total 11 missed doses. GabapentinA written practitioner's order, dated 2/6/23, directed the residence to administer gabapentin 100 mg once daily. However, the January 2024 MAR read the medication was not administered on 1/20-1/27/24 as the medication was out of stock, for a total of seven missed doses. f. Metoprolol A written practitioner's order dated, 2/6/23, directed the residence to administer metoprolol tartrate 12.5 mg twice daily. However, the January 2024 MAR read the medication was not administered on 1/28/24 at 7:00 p.m. as the medication was out of stock and on 1/29/24 at 7:00 a.m., the dose was not administered as the resident was confused, for a total of two missed doses. g. HydrocodoneA written practitioner's order, dated 2/6/23, directed the residence to administer hydrocodone acetaminophen 7.5-325 mg twice daily. However, the January 2024 MAR read the medication was not administered the morning dose on 1/21/24 as the medication was out of stock. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #19 stated the former resident was prescribed antibiotics for a urinary tract infection on 1/24/24. He stated the residence did not inform him Resident #19 had not received her antibiotics and as a result on 1/29/24 Former Resident #19 had a change in condition from baseline, was transported to the ED, was hospitalized and later required skilled nursing care. Additionally, the practitioner stated that missing gabapentin, even one dose, could cause the resident to experience nerve pain. On 3/28/24 at 11:00 a.m., the administrator stated on 1/24/24 Former Resident #19 had a change in condition. She stated she was not her normal self, did not want to eat and laid in bed sleeping all day. She stated the former resident was transported to the emergency department and subsequently diagnosed with a urinary tract infection. The administrator further stated Former Resident #19, after her hospitalization, was discharged to a skilled nursing facility as she required more care than what the residence was able to provide. Additionally, the administrator stated she thought the former resident was seen by her practitioner for a suspected urinary tract infection; however, the administrator stated she was not aware the practitioner ordered any medication. 3. Former Resident #15 was admitted to the residence on 12/16/18 with diagnoses of tachycardia, atrioventricular block, pacemaker and peripheral vascular disease. A written practitioner's order forwarded from the practitioner's medical practice to the residence and received on 2/14/24 at 4:00 p.m. directed the residence to administer furosemide (Lasix) 20 mg take 0.5 tablet once daily for swelling. A residence progress note, dated 2/20/23, read an external service provider notified the residence that Former Resident #15 had not received her prescription for lasix. The residence telephoned the pharmacy and no order was found. The external service provider stated Former Resident #15 had fluids in her legs and was sent to the ED via emergency medical services. An external service provider note, dated 2/20/24, read in part Former Resident #15 had increased edema of her extremities. The external service provider telephoned the practitioner, notified him of the resident's vitals and the practitioner agreed to have the resident receive emergency medical care. A hospitalization record, dated 2/20/24 through 3/6/24, read in part: Former Resident #15 was admitted to the hospital with diagnoses including: malaise, atherosclerotic heart disease, acute congestive heart failure and edema. The resident presented at the emergency department with shortness of breath and weight gain. The record further read Former Resident #15 "was supposed to be prescribed lasix however she never received the prescription ... Apparently in the past month or so (the resident) had 20 pound weight gain. Apparently the patient was consulted by medical staff there in the recent past concern for weight gain and edema and was supposed to be starting diuretic therapy when the provider checked on her today found her to be more edema and learned that she has not been receiving the diuretic and sent her to the emergency room." Resident #15 was swollen throughout the entire lower abdomen and lower extremities. Resident #15 was administered Lasix 60 mg injection upon admission. On 3/6/24, Former Resident #15 was discharged to a skilled nursing home. On 3/26/24 at 3:40 p.m., the January and February 2024 MARs for Former Resident #15 were requested. However, as of 3/28/24 no MARs were provided. On 3/27/24 at 10:12 a.m., the practitioner for Former Resident #15 stated on 2/14/24 the resident was prescribed Lasix due to edema. He stated approximately one week later the medication had not started and an external service provider telephoned him and explained the resident's condition had deteriorated and a decision was made to send the resident to the ED for urgent treatment. On 3/28/24 at 11:07 a.m., the administrator stated the external home health provider for Former Resident #15 was at the residence and noticed swelling and edema. She stated at that point the external home health provider went to the administrator's office to check on the prescription for Lasix which had been prescribed approximately one week prior. The administrator stated she checked and could tell the prescription was faxed to the pharmacy. However, she stated when she telephoned the pharmacy they reported not receiving the prescription. The administrator confirmed the former resident did not receive her medication and stated she should have followed up on the prescription. The administrator further added "it was probably one of the emails that I did not get to timely."4. Resident #3 was admitted to the residence on 2/24/20 with a diagnosis of gastroesophageal reflux disorder.a. Diclofenac A written practitioner's order, dated 1/31/24, directed the residence to administer diclofenac 1% topical gel 2 gm apply twice daily to neck and knees. However, the February through March 2024 MAR read the medication was not administered twice daily from 2/1-3/25/24 as it was labeled on the MAR as "as needed" medication for a total of 108 missed doses. b. LisinoprilA written practitioner's order, dated 1/3/24, directed the residence to discontinue omeprazole 40 mg and replace with pantoprazole 40 mg delayed release once daily. However, the February through March 2024 MARs read omeprazole was not discontinued and was administered in conjunction with pantoprazole from 2/1 and 2/4-2/29/24 for a total of 27 days. c. Vitamin B-12A written practitioner's order, dated 1/31/24, directed the residence to administer vitamin B-12 1000 mcg once daily. However, the March 2024 MAR read the medication was not administered from 3/15-3/26/24 as the medication was out of stock for a total of 11 missed doses.d. Meclizine HydrochlorideA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg once daily at noon. However, the February 2024 MAR read the medication was not administered on 2/1/24 as the resident was out of the residence for a total of one missed dose. On 3/28/24 at 11:00 a.m., the administrator stated she was not aware of the error with the pantoprazole. She stated the residence had difficulties obtaining prescriptions from the practitioner's and in addition, she stated the residence was also changing pharmacies. The administrator stated she had started her position at the residence in July 2023; however, the administrator stated she had not read the past deficiencies and was not sure why they had not been corrected. 4. Additional deficient practice was identified with Residents #9, #10 and #17.

Plan of correction · submitted by the facility

(Cross-reference B0290, S1160, S1350, S1604)Resident #15 & 19: No longer reside at facilityResident #3: Diclofenac (changed to PRN 4/1), Lisinopril (omeprazole no longer administered after 2/29/24), Vitamin B-12 (D/C’d 4/1/24), Meclizine Hydrochloride (administered as directed starting 2/2/24)Resident #9, 10, & 17: no specific medication issues cited. Medication orders not filled:The Facility has a new system in place to ensure that medication orders are filled and residents receive the medications. A Resident Care Coordinator( RCC) has been hired to over see the medications and this position/designee will review all medication orders upon a resident being seen by a medical provider or returned from the hospital to ensure that medications are ordered and delivered to the facility. A “ Medication order only email“ has been established so that medication orders do not get lost among other emails. The Resident Care Coordinator/designee will also review the Hospital log to ensure the medical provider provides new medication orders upon a re-admission. Out of stock issues:To correct missed doses due to out-of-stock issues, the facility has changed pharmacy and the Resident Care Coordinator/designee reviews the MAR sheets to ensure that the pharmacy has delivered all the medications. Transcription error – a medication was listed as PRN and it was routine. The RCC/designee and the Administrator/Nurse will have a double check system to review any new orders that are transcribed on the MAR. This process will be started immediately to ensure accuracy. The change in process has already been initiated. QMAP’s will be educated, by date of compliance, on medication orders not filled, out of stock medications, and transcription errors. The ensure on going compliance, the medication orders, supply and transcription will be added to the QMP and reviewed for 120 days. Per conversation with reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

1600Med/Med Adm-Rcrd Kpng MARS/S B▼

Findings

Based on interview and record review the residence failed to ensure staff documented on the medication administration record (MAR) at the time of medication administration affecting three of five sample residents (#3, #10, #14). (Cross-reference S1604)This deficiency was cited previously during a state licensure complaint revisit 9/29/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Residence PolicyThe residence's Medication Services Policy, dated January 2024, read in part: The residence would maintain current files on all medications. 2. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including gastroesophageal reflux disorder, hypertension.a. FluticasoneA written practitioner's order, dated 1/31/23, directed the residence to administer fluticasone propionate/salmeterol 500-50 mcg one puff twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 evening dose, 2/1-2/3 all doses, 2/7 evening dose, 2/17 evening., 2/24 and 2/27 evening doses, 2/29 morning dose, 3/9 morning dose and 3/21/24 evening dose. b. LisinoprilA written practitioner's order, dated 1/31/24, directed the residence to administer lisinopril 5 mg once daily. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/1-2/3 and 3/23/24. c. Gabapentin A written practitioner's order, dated 1/31/24, directed the residence to administer gabapentin 600 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 at bedtime, 2/2- 2/3 all doses and on 3/2/24 at noon. d. MeclizineA written practitioner's order, dated 1/31/24, directed the residence to administer meclizine hydrochloride 25 mg tablet at noon. However, the February through March 2024 MARs revealed no evidence of documentation at the time of administration on 2/2, 2/3 and 3/2/24. e. IpratropiumA written practitioner's order, dated 1/31/24, directed the residence to administer ipratropium 0.5 mg albuterol 3 mg four times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2 at noon and 3/21/24 at the evening dose and bedtime dose. f. SertralineA written practitioner's order, dated 1/31/24, directed the residence to administer sertraline 100 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/2 and 2/3/24.g. PantoprazoleA written practitioner's order, dated 1/31/24, directed the residence to administer pantoprazole sodium 40 mg once daily. However, the February 2024 MAR revealed no evidence of documentation at the time of administration on 2/1 and 2/2/24. h. SpirivaA written practitioner's order, dated 1/31/24, directed the residence to administer Spariva handihaler 18 mcg one puff by mouth once daily. However the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/9/24.3. Resident #14 was admitted to the residence on an unknown date.a. PantoprazoleA written practitioner's order, dated 1/25/24, directed the residence to administer pantoprazole sodium 40 mg twice daily. However, the March 2023 MAR revealed no evidence of documentation at the time of administration on 3/7, 3/11 morningdoses, 3/19, 3/20 evening doses and 3/24/24 morning dose. b. RosuvastatinA written practitioner's order, dated 2/29/24, directed the residence to administer rosuvastatin calcium 10 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/5/24.c. SertralineA written practitioner's order, dated 1/25/24, directed the residence to administer sertraline 50 mg once daily at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24. d. Docusate SodiumA written practitioner's order, dated 1/25/24, directed the residence to administer docusate sodium 100 mg twice daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/20/24 evening dose. e. MontelukastA written practitioner's order, dated 1/25/24, directed the residence to administer montelukast sodium 10 mg at bedtime. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/1/24.f. BuspironeA written practitioner's order, dated 1/25/24, directed the residence to administer buspirone 10 mg three times daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/8 and 3/11/24 at 6:00 a.m.g. ClopidogrelA written practitioner's order, dated 1/25/24, directed the residence to administer clopidogrel 75 mg once daily. However, the March 2024 MAR revealed no evidence of documentation at the time of administration on 3/2/24. 4. Additional deficient practice was identified for Resident #10. On 3/28/24 at 11:00 a.m., the administrator stated she expected qualified medication administration persons to administer medications and document on the MAR. She stated she has done training with staff in the past regarding documentation on the MAR; however, the administrator stated there were no consequences put in place to prevent a recurrence. The administrator further stated she had gone over this deficiency with the residence's contracted consultant and was not sure why it had not been corrected.

Plan of correction · submitted by the facility

(Cross-reference S1604)Correction: The facility has retained a nurse to review staff serving medication and retrain staff that are not properly documenting when the medication is served. The RCC and nurse or designee will observe medication passes twice weekly to watch for proper documentation, infection control measures, proper glove use and that the mediation administrator is compliant with Chapter 24 guidelines. All Qmap Staff will be retrained by date of compliance for the POC and training documentation will be filed in the staff records. The RCC/designee is reviewing MAR sheets daily during the weekdays to ensure staff are documenting and there are no holes in the MAR that are not properly addressed. Issues found will be addressed with staff as needed. To ensure continued compliance, all records reviewed will be discussed monthly in the QMP meetings and this area will remain an area of focus in the QMP for 120 days. Per conversation with POC reviewer, compliance date will be 45 days from POC submission. This will be adjusted to 45 days from POC acceptance once POC is accepted.

11/8/2023Licensure Complaint · ID Q1G5116 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO34099, was completed on 11/8/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1146Res Care Srvs-Comp Res Asmnt Annl/CICS/S B▼

Findings

Based on observation, record review, and interview, the residence failed to ensure a comprehensive assessment was updated whenever residents' conditions changed from baseline status, affecting two of two sample residents (#6, #14) who experienced a change in baseline status. (Cross-reference Q1150)Findings include:1. Resident AgreementThe residence's undated Resident Agreement read in part that the residence regularly observed the health status of the residents and identified any changes to their physical, mental, and emotional functioning. Further, the residence assisted residents with their health needs and needs for special services. 2. Resident #14 was admitted to the residence on 4/21/22 with diagnoses including type two diabetes, anxiety, and post-traumatic stress disorder. An assessment, dated 8/10/23, read in part that the resident had excessively dry skin that required frequent lotion application; however, the assessment contained no updated information regarding any changes in baseline condition regarding physical or emotional well-being for Resident #14. A practitioner's order for an external service provider (ESP) for Resident #14, dated 10/4/23, read in part that the practitioner referred the resident to ESP for skilled nursing care to treat a wound on her lower right extremity and skin breakdown on both lower extremities. A hospital discharge summary, dated 11/1/23, read in part that the resident was diagnosed with lower extremity cellulitis. The residence's weekly hospital log, dated 10/7-11/5/23, read in part that Resident #14 went to the hospital on 11/1/23 at 6:54 p.m. The log did not contain a return date or time. The residence's list of weekly resident practitioner visits read in part that Resident #14 wished to see the practitioner on Wednesday (11/1/23) for the week of 11/2/23. On 11/8/23 at approximately 11:20 a.m., the practitioner for Resident #14 stated that he saw the resident on 11/1/23 to follow up on her lower right leg wound that he ordered services from an external service provider to address on 10/4/23. He stated he diagnosed the resident with cellulitis of the lower right extremity when the area appeared reddened outside of the bandaged area. He added that he was unaware of whether or not the residence reassessed the resident after the initial change in physical condition. On 11/8/23 at 2:05 p.m., the administrator stated she was responsible for resident assessments. She stated that the residence reassessed a resident when the resident experienced a change in condition. She added that a change in condition included instances when a resident was transferred to another healthcare entity to receive additional care, changes in physical needs, increased care needs, mobility needs, or sustained falls. She stated that Resident #14 reported leg pain to her the week of 11/1/23, and she included the resident's name on the list to see the practitioner at his next visit to the residence. She stated she had not reviewed the discharge summary from the hospital for Resident #14 until the date of the onsite visit. She stated that she should have reassessed Resident #14 after the resident reported leg pain or after she returned from the hospital. She affirmed that if she had reassessed the resident, she would have likely increased skin monitoring. On 11/8/23 at 2:32 p.m., Resident #14 was in her bed with her legs elevated. Her right lower leg appeared swollen and bandaged. Resident #14 stated that she had reported leg pain approximately one month before to a residence staff member. She added the residence had not reassessed her after her report of pain. She stated she saw the practitioner on 11/1/23 and she chose to go to the hospital the same day for the same concern. She added that the residence had not reassessed her after the practitioner or hospital visit. 3. Additionally, the residence failed to ensure a comprehensive assessment was updated for Resident #6 when her condition changed from baseline after theresident reported symptoms of a urinary tract infection and sustained falls.

Plan of correction · submitted by the facility

1146Residents #6 & #14: resident assessment will be reviewed, by date of compliance, to ensure it accurately reflects residents’ baseline status. Administrator will be educated on ensuring that resident assessments are updated at least annually & after a resident change of condition. Administrator/designee will complete an audit of current resident assessments, by date of compliance, to ensure that they accurately reflect residents’ current condition and needs. Resident assessments will be reviewed and updated at least annually, and with any change of condition, to accurately reflect residents’ current condition and needs. Administrator/designee will complete an audit of fifteen resident charts per month, for three months, to ensure that resident assessments are up to date and reflect residents’ current conditions and needs. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

1150Res Care Srvs-Res CPS/S B▼

Findings

Based on record review and interview, the residence failed to ensure each resident care plan detailed specific personal service needs and preferences along with staff tasks necessary to meet those needs and identified all service providers along with care coordination arrangements, affecting two of two current residents (#6, #14) and one former resident (#18) with external service providers. (Cross-reference Q1146, Q1160)Findings include:1. Residence AgreementThe residence's undated Resident Agreement read in part that the residence regularly observed the health status of the residents and identified any changes to their physical, mental, and emotional functioning. Further, the residence assisted residents with their health needs and needs for special services. 2. Resident #14 was admitted to the residence on 4/21/22 with a diagnosis of type two diabetes and a later diagnosis of cellulitis. A care plan, dated 8/10/23, revealed that the residence listed no external services provider (ESP) on the care plan for Resident #14 despite the availability of a section for the residence to list ESPs. A practitioner's order for ESP for Resident #14, dated 10/4/23, read in part that the practitioner referred the resident for ESP skilled nursing care to treat a wound on her lower right extremity and skin breakdown on both lower extremities. On 11/8/23 at 7:20 a.m., Staff #13 stated that she was not sure which residents received services from ESPs. She added that she assumed the residence documented the information in the resident's care plans but was unsure. On 11/8/23 at approximately 10:50 a.m., the administrator stated Resident #14 received services from an ESP. She added that the addition of ESP services for a resident was a change in condition; therefore, the residence should have updated the care plan for Resident #14 to include the services she received from the ESP and had not. On 11/8/23 at approximately 11:10 a.m., the practitioner for Resident #14 stated that she received services from an ESP for wound care for her right leg. On 11/8/23 at approximately 2:42 p.m., Resident #14 stated she received wound care from an ESP.3. Additionally, the residence failed to ensure each resident care plan detailed specific personal service needs, staff tasks necessary to meet those needs, and all service providers along with care coordination arrangements for Resident #6 and Former Resident #18.

Plan of correction · submitted by the facility

1150Residents #6 & #14: care plan will be reviewed, by date of compliance, to ensure it accurately reflects residents’ baseline statusAdministrator will be educated on ensuring that care plans are updated at least annually & after a resident change of condition. Administrator/designee will complete an audit of current resident care plans, by date of compliance, to ensure that they accurately reflect residents’ current condition and needs. Resident care plans will be reviewed and updated at least annually, and with any change of condition, to accurately reflect residents’ current condition and needs. Administrator/designee will complete an audit of fifteen resident charts per month, for three months, to ensure that care plans are up to date and reflect residents’ current conditions and needs. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

1160Res Care Srvs-Care CoordS/S B▼

Findings

Based on observation, interview, and record review, the residence failed to coordinate care with known external service providers (ESP), affecting two of two sample residents (#6, #14) and one former resident (#18) who received services from an ESP. (Cross-reference Q1150) Findings include:1. Residence AgreementThe residence's undated Resident Agreement read that the residence assisted residents with their health needs and needs for special services. 2. Resident #14 was admitted to the residence on 4/21/22 with diagnoses including type two diabetes, anxiety, and post-traumatic stress disorder and a later diagnosis of cellulitis. A care plan, dated 8/10/23, revealed that the residence had not included an ESP for Resident #14. A practitioner's order for an ESP for Resident #14, dated 10/4/23, read in part that the practitioner referred the resident to ESP for skilled nursing care to treat a wound on her lower right extremity and skin breakdown on both lower extremities. A hospital discharge summary, dated 11/1/23, read in part that the resident was diagnosed with lower extremity cellulitis. On 11/8/23 at 7:20 a.m., Staff #13 stated that she was unsure which residents received services from an ESP.On 11/8/23 at approximately 11:20 a.m., the practitioner for Resident #14 stated that he saw the resident on 11/1/23 to treat cellulitis in her lower right leg. He added that on 11/3/23, he learned from the resident's ESP that the resident had visited the emergency department (ED) after the practitioner saw the resident on 11/1/23; however, he was unsure if there was communication between the residence and ESP directly or if the resident informed the ESP of the ED visit. On 11/8/23 at approximately 10:50 a.m., the administrator stated Resident #14 received services from an ESP. She stated that she had not accessed the ESP notes for any residents since she began at the residence in July 2023. In a later interview, she stated she was aware the residence was required to coordinate care with ESPs; however, the administrator stated she had not coordinated care with the ESP for Resident #14 and learned that the resident was receiving wound care from an ESP from the resident, not from residence staff or the ESP.On 11/8/23 at 2:32 p.m., Resident #14 was in her bed with her legs elevated. Her right lower leg appeared swollen and bandaged. Resident #14 stated that she received services from an ESP for wound care for her leg. She added that she contacted the ESP directly if there was a concern as she did not know the residence coordinated care with the ESP. 3. Additionally, the residence failed to coordinate care with known external service providers for Resident #6 and Former Resident #18.

Plan of correction · submitted by the facility

1160Residents #6 & #14: resident agreement will be reviewed, by date of compliance, to ensure it accurately reflects residents’ need for any outside specialized services. Resident #18: no longer resides at facility. Administrator will be educated on ensuring that resident agreements are updated to reflect resident needs for outside services and what is provided. Administrator/designee will complete an audit of current resident agreements, by date of compliance, to ensure that they accurately reflect residents’ current needs related to any outside services required. Resident agreements will be reviewed and updated at least annually, and with any change of condition, to accurately reflect residents’ current condition and needs, including coordination with outside services required. Administrator/designee will complete an audit of all resident charts with outside service needs monthly, for three months, to ensure that residents agreements are up to date and reflect residents’ current conditions and needs. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

1422Med/Med Adm-Gen Rq Proper AdmS/S D▼

Findings

Based on observation, record review, and interview, the residence failed to ensure each resident received proper administration, including medication administration compliance with authorized practitioner orders, affecting five of six sample residents (#3, #6, #14, #15, #17) for whom the residence administered medication. (Cross-reference Q1466)Findings include:Specifically, Resident #3 had a diagnosis of chronic obstructive pulmonary disease (COPD). The residence had a written practitioner's order for the resident, dated 1/12/23, directing the residence to administer Spiriva Handihaler 18 mcg, inhale the contents of one capsule daily. The residence failed to administer the medication on 10/1/23, from 10/3-10/20/23, and 10/23-10/25/23 for 22 missed doses. On 11/8/23, Resident #3 was short of breath and had to stop talking several times due to shortness of breath. The practitioner stated the resident's missed Spiriva doses led to worsened COPD symptoms, such as shortness of breath, which resulted in increased oxygen use. Additionally, Resident #3 stated she experienced increased anxiety when her Spiriva was out of stock. Specifically, Resident #14 had a diagnosis of anxiety and post-traumatic stress. The residence had a written practitioner's order for the resident, dated 7/27/22, directing the residence to administer buspirone hydrochloride 5 mg, one tablet, three times daily. The residence failed to administer the medication from 10/21-10/29/23 for a total of 22 missed doses. On 11/8/23, Resident #14 was tearful and reported feeling anxious. She added that her feelings of anxiety increased after she missed several doses of buspirone. The practitioner for Resident #14 stated that the resident's anxiety symptoms increased and that missed doses of buspirone hydrochloride contributed to the increased anxiety. Specifically, Resident #15 had a diagnosis of heart disease and subarachnoid hemorrhage. The residence had a written practitioner's order for the resident, dated 8/16/23, directing the residence to administer Carvedilol 12.5 mg, one tablet, twice daily. The residence failed to administer the medication from 10/22-10/26/22 for 10 missed doses. Resident #15 stated when she missed the medication, she felt tightness in her chest and anxiety. Additionally, the practitioner for Resident #15 stated that missed doses of Carvedilol caused chest tightness. He added he witnessed the resident's increased anxiety due to missed medications. 1. Reference and Residence PoliciesAccording to Mayo Clinic, "Tiotropium (Spiriva Hanidhaler) ... do not stop using this medicine ... without telling your doctor. To do so may increase the chance of having breathing problems." Mayo Clinic (2023) Tiotropium (Inhalation Route), retrieved from: https://www.mayoclinic.org/drugs-supplements/tiotropium-inhalation-route/precautions/drg-20066394The residence's undated Medication Administration Policy Statement read in part that the residence provided medication administration to residents per the practitioner's orders. Further, the residence was required to communicate with the practitioner, resident, family, and pharmacy to ensure residents had a supply of all current medications. The residence's undated Ordering Medications policy read in part that the residence followed up with the pharmacy daily if the residence had not received an ordered medication by the next business day with continued contact until the order was received. All medications that were not cycle-fill needed to be reordered promptly. A residence document, titled Refill Orders Only, was completed during the onsite visit and read in part that three residents required medication refills and had zero supply left. 2. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including COPD, oxygen dependence, and anxiety. a. Spiriva HandihalerA written practitioner's order, dated 1/12/23, directed the residence to administer Spiriva Handihaler 18 mcg, inhalation of the contents of one capsule daily. However, the October 2023 medication administration record (MAR) read the medication was not administered on 10/1/23, 10/2-10/20/23, 10/23-10/25/23 for 22 missed doses because the medication was on order or unavailable.b. Zinc OxideA written practitioner's order, dated 2/17/23, directed the residence to apply zinc oxide 40% twice daily. However, the October and November 2023 MARs read that the medication was not administered on 10/10-10/13/23, 10/18-10/30/23, and 11/1-11/7/23 for 38 missed doses because the medication was on order or unavailable.c. Benzonatate A written practitioner's order, dated 7/5/23, directed the residence to administer benzonatate 100 mg, one capsule four times daily. However, the October 2023 MAR read the medication was not administered on 10/20-10/24/23 for 17 doses because the medication was on order.d. MucinexA written practitioner's order, dated 2/15/23, directed the residence to administer Mucinex 600 mg, two tablets twice daily. However, the November 2023 MAR read the medication was not administered on 11/5-11/7/23 for six missed doses because the medication was on order. (Cross-reference Q1466)e. Sertraline HydrochlorideA written practitioner's order, dated 1/23/23, directed the residence to administer sertraline hydrochloride 100 mg, one tablet daily. However, the October 2023 MAR read the medication was not administered on 10/9-10/11/23 for three missed doses because the medication was on order. f. Wixela (fluticasone propionate and salmeterol)A written practitioner's order, dated 3/2/23, directed the residence to administer Wixela (fluticasone propionate and salmeterol) 500-50 mcg/act, one puff inhaled twice daily. However, the November 2023 MAR read the medication was not administered on 11/8/23 because the medication was on order. On 11/8/23 at 7:20 a.m., the fluticasone propionate and salmeterol inhaler was not in the medication cart. Staff #13 stated that fluticasone propionate was not in stock in the medication cart and, therefore, she could not administer the medication to Resident #3. She added that the administrator was the sole person who reordered medication, and the residence staff notified her of out of stock medications utilizing a reorder form. On 11/8/23 at 7:45 a.m., Contracted Staff #14 stated the residence trained her to complete a form for reordering medication; however, the residence had not told her who ordered medication or who to call with an urgent concern. She stated she gave the medication refill form to the qualified medication administration persons (QMAP) on the evening shift. She added she had worked four shifts at the residence. On 11/8/23 at 8:20 a.m., Resident #3 had shortness of breath and had to pause a few times to breathe during the interview. The resident stated that she had been out of her Spiriva for most of October 2023. She added going without the Spiriva inhaler increased her breathing difficulties; however, her practitioner increased her self-administered oxygen since then. She stated that her residence had not administered her fluticasone propionate inhaler during the onsite visit; however, she was not feeling the impact of the one missed dose. On 11/8/23 at approximately 11:00 a.m., the practitioner stated that Resident #3 had not been administered the Spiriva Handihaler for most of October 2023; however, the residence failed to notify him that the pharmacy had not delivered the medication. He added that the missed doses of Spiriva for the resident contributed to increased COPD symptoms, including wheezing and shortness of breath. He added that he had to increase her oxygen while the resident was active ongoingly to offset the increased difficulty breathing. The practitioner stated ongoing concerns regarding the residence not administering medication for multiple residents. On 11/8/23 at approximately 1:54 p.m., the administrator stated that the residence staff recently reported to her that the Spiriva inhaler had been out of stock for Resident #3. She added that she had not followed up with the practitioner or pharmacy but would have had she known sooner. She added she became aware of the increased oxygen for the resident during the onsite visit. She stated there were ongoing challenges with the pharmacy not sending an entire month's supply and not notifying the residence when a refill order was required. She stated that there was a breakdown in communication between the pharmacy, practitioner, and residence regarding refill orders, resulting in the residence not administering medication to multiple residents. She added that the residence was not set up with cycle-filled medication at the pharmacy, which resulted in increased refill requests. She stated she was the sole staff member to receive and reconcile medications and update the MAR to reduce inaccuracies. She stated the QMAP notified her through an ordering form of any required refills and was available via telephone during periods she was not at the residence, such as nights and weekends. 3. Additionally, the residence failed to ensure each resident received proper administration, including medication administration compliance with authorized practitioner orders for Residents #6 and #17.

Plan of correction · submitted by the facility

1422Resident #3, #6, #7, #15 and #17: residents are currently receiving medications as ordered and information is being documented appropriately. QMAP's will be re-educated by date of compliance on medication administration and following practitioner orders related to medication administration. The facility has changed the medication process to cycle fill for refilling medications. This should help to ensure that medications are not out of stock and administration can be completed. Administrator/designee will monitor cycle fill requirements to ensure that medications are received timely. Administrator/designee will audit medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring and that practitioner orders are being followed. Results of audits will be included in QMP process for next 3 months for review and/or recommendations for improvement, if necessary.

1466Med/Med Adm-Ordrs Ordr ClrfctnS/S A▼

Findings

Based on observation, interview, and record review, the residence failed to contact the authorized practitioner to clarify any incomplete or unclear orders and obtain new orders in writing, affecting one sample resident (#14). (Cross-reference Q1422)Findings include:The residence's undated Physician/Provider Orders policy read in part that the residence was required to contact the practitioner when a practitioner's order was unclear for clarification. Further, the residence was required to fax new orders generated from a hospital stay to the resident's primary practitioner for verification. Resident #14 was admitted to the residence on 4/21/22 with a diagnosis of type two diabetes and a later diagnosis of cellulitis. A written practitioner's order, dated 11/1/23, directed the residence to administer cephalexin 500 mg, one capsule twice daily for ten days. A hospital discharge summary, dated 11/1/23, read in part that Resident #14 went to the emergency department (ED) on 11/1/23 to check the resident's wound and was subsequently diagnosed with cellulitis of the right lower extremity. The hospital practitioner administered one injection of ceftriaxone 1 gram. Contrary to the written practitioner's order above, another written practitioner's order, dated 11/1/23, directed the residence to administer cephalexin 500 mg one capsule daily four times daily for seven days. The residence's November 2023 medication administration record (MAR) read that the residence administered cephalexin 500 mg, one capsule, twice daily from 11/3-11/8/23. On 11/8/23 at approximately 11:10 a.m., the practitioner for Resident #14 stated that the residence had not contacted him to clarify medication orders. He added he ordered cephalexin on the morning of 11/1/23, and the residence failed to notify him that the resident went to the ED later on 11/1/23 and that the hospital practitioner subsequently ordered cephalexin. He added he became aware of the hospital practitioner's order and visit by the external service provider (ESP) on 11/3/23. On 11/8/23 at approximately 2:00 p.m., the administrator stated that she was unaware that the resident returned from the ED on 11/1/23 with different practitioner orders as she had not reviewed them until the date of the onsite visit. She added she should have clarified the orders for Resident #14 with the practitioner. On 11/8/23 at 2:32 p.m., Resident #14 was in her bed with her legs elevated. Her right lower leg appeared swollen and bandaged. She stated she saw the practitioner on 11/1/23 due to the wound on her leg and went to the hospital the same day to check the same wound.

Plan of correction · submitted by the facility

1466Resident #14: order for ceftriaxone was clarified with practitioner. Administrator/designee will complete an audit, by date of compliance, of any resident who has returned to facility from hospital in past 90 days to ensure orders are accurate and were clarified as needed with practitioner. Administrator will be re-educated, by date of compliance, ensuring that orders are clarified as needed, with practitioner, when a resident returns from a hospital stay. All residents who return from a hospital stay will have previous orders and current orders cross checked to ensure that there are no orders needing clarification with practitioner. Administrator/designee will review all orders for residents returning from a hospital stay, for the next three months, to ensure that orders are accurate and will clarify any orders that do not match previous orders. Results of audits will be included in QMP process for 3 months for review and/or recommendations for improvement, if necessary.

2130HIR-Cntnt IncldS/S B▼

Findings

Based on observation, record review, and interview, the residence failed to ensure that resident records contained progress notes, which included 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. Additionally, the residence failed to ensure staff members documented, before the end of their shift, any out-of-the-ordinary event or issue regarding a resident that they observed or was reported to them, affecting four of seven sample residents (#3, #6, #14, #15, #17) who experienced out-of-the-ordinary events. (Cross-reference Q1146, Q1422)Findings include: 1. Residence AgreementThe residence's undated Resident Agreement read in part that the residence documented out of the ordinary events in the record for the residents. 2. Resident #14 was admitted to the residence on 4/21/22 with diagnoses including type two diabetes, anxiety, and post-traumatic stress disorder. A practitioner's order for an ESP for Resident #14, dated 10/4/23, read in part that the practitioner referred the resident to ESP for skilled nursing care to treat a wound on her lower right extremity and skin breakdown on both lower extremities. A hospital discharge summary, dated 11/1/23, read in part that the resident was diagnosed with lower extremity cellulitis. The residence's weekly hospital log, dated 10/7-11/5/23, read in part that Resident #14 went to the hospital on 11/1/23 at 6:54 p.m. The log did not contain a return date or time. The residence's list of weekly resident practitioner visits read in part that Resident #14 wished to see the practitioner on Wednesday (11/1/23) for the week of 11/2/23. On 11/8/23 at approximately 11:20 a.m., the practitioner for Resident #14 stated that he saw the resident on 11/1/23 to follow up on the condition of the resident's lower legs and subsequently diagnosed the resident with cellulitis as the leg was red and weeping. He stated that on 11/3/23, the external service provider (ESP) notified him that the resident visited the hospital emergency department (ED) on 11/1/23 after the practitioner saw the resident. He stated that in addition to the wound and cellulitis concerns for Resident #14, the resident experienced a recent increase in anxiety and tearfulness. He added he would consider increased anxiety and tearfulness a change in condition. On 11/8/23 at 2:05 p.m., the administrator stated that Resident #14 reported leg pain to her the week of 11/1/23. She added that the resident visited the ED on 11/1/23. She stated that a change in physical condition and a visit to the hospital were out-of-the-ordinary events. She stated that the residence's progress notes for residents contained no out-of-the-ordinary events. She added the residence's only other documentation were the residence's Weekly Hospital Log and communication logs, and neither contained the circumstances of hospitalizations or details of out-of-the-ordinary events. She stated that the residence had not documented the events for Resident #14 or other out-of-the-ordinary events for multiple residents. In a later interview, the administrator stated she was not aware that Resident #14 had reported pain a month prior to the onsite visit to a residence staff person. She affirmed that if the residence had documented out-of-the-ordinary events, she may have been aware of the concerns sooner. On 11/8/23 at 2:32 p.m., Resident #14 was in her bed with her legs elevated. Her right lower leg appeared swollen and bandaged. Resident #14 stated that she had reported leg pain approximately one month before to a residence staff member. She stated she saw the practitioner on 11/1/23 and went to the hospital the same day. She added that she had felt anxious in the past; however, it seemed more frequent in the previous two months. She stated the residence had not reassessed her after her increased expressions of anxiety. 3. Additionally, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affects a resident's physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address that resident's changing needs. Additionally, the residence failed to ensure staff members documented, before the end of their shift, any out-of-the-ordinary event or issue regarding a resident that they observed or was reported to them for Residents #6, #15, and #17.

Plan of correction · submitted by the facility

2130Residents #3, #6, #14, #15 & #17: each resident has a section in a binder for staff to document progress notes as needed. QMAP’s will be educated, by date of compliance, on ensuring that progress notes are completed for any out of the ordinary events or issue, resident change of condition, etc. Administrator/designee will create a binder to ensure that there is a place for staff to document progress notes as needed for residents. Administrator/designee will complete an audit of fifteen residents progress notes per month, for three months, to ensure that QMAP’s are documenting appropriately related to residents’ current conditions and needs, and any out of the ordinary events and/or issues. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

11/8/2023State Certification Complaint · ID QZPI113 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A certification complaint, prompted by #CO34100, was completed on 11/8/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0118Acf-Def Med AdmnS/S D▼

Findings

Based on observation, record review, and interview, the facility (residence) failed to ensure each participant (resident) received proper administration, including medication administration compliance with authorized practitioner orders, affecting five of six sample residents (#3, #6, #14, #15, #17) for whom the residence administered medication. Findings include:Specifically, Resident #3 had a diagnosis of chronic obstructive pulmonary disease (COPD). The residence had a written practitioner's order for the resident, dated 1/12/23, directing the residence to administer Spiriva Handihaler 18 mcg, inhale the contents of one capsule daily. The residence failed to administer the medication on 10/1/23, from 10/3-10/20/23, and 10/23-10/25/23 for 22 missed doses. On 11/8/23, Resident #3 was short of breath and had to stop talking several times due to shortness of breath. The practitioner stated the resident's missed Spiriva doses led to worsened COPD symptoms, such as shortness of breath, which resulted in increased oxygen use. Additionally, Resident #3 stated she experienced increased anxiety when her Spiriva was out of stock. Specifically, Resident #14 had a diagnosis of anxiety and post-traumatic stress. The residence had a written practitioner's order for the resident, dated 7/27/22, directing the residence to administer buspirone hydrochloride 5 mg, one tablet, three times daily. The residence failed to administer the medication from 10/21-10/29/23 for a total of 22 missed doses. On 11/8/23, Resident #14 was tearful and reported feeling anxious. She added that her feelings of anxiety increased after she missed several doses of buspirone. The practitioner for Resident #14 stated that the resident's anxiety symptoms increased and that missed doses of buspirone hydrochloride contributed to the increased anxiety. Specifically, Resident #15 had a diagnosis of heart disease and subarachnoid hemorrhage. The residence had a written practitioner's order for the resident, dated 8/16/23, directing the residence to administer Carvedilol 12.5 mg, one tablet, twice daily. The residence failed to administer the medication from 10/22 to 10/26/22 for 10 missed doses. Resident #15 stated when she missed the medication, she felt tightness in her chest and anxiety. Additionally, the practitioner for Resident #15 stated that missed doses of Carvedilol caused chest tightness. He added he witnessed the resident's increased anxiety due to missed medications. 1. Reference and Residence PoliciesAccording to Mayo Clinic, "Tiotropium (Spiriva Hanidhaler) ... do not stop using this medicine ... without telling your doctor. To do so may increase the chance of having breathing problems." Mayo Clinic (2023) Tiotropium (Inhalation Route), retrieved from: https://www.mayoclinic.org/drugs-supplements/tiotropium-inhalation-route/precautions/drg-20066394The residence's undated Medication Administration Policy Statement read in part that the residence provided medication administration to residents per the practitioner's orders. Further, the residence was required to communicate with the practitioner, resident, family, and pharmacy to ensure residents had a supply of all current medications. The residence's undated Ordering Medications policy read in part that the residence followed up with the pharmacy daily if the residence had not received an ordered medication by the next business day with continued contact until the order was received. All medications that were not cycle-fill needed to be reordered promptly. A residence document, titled Refill Orders Only, was completed during the onsite visit and read in part that three residents required medication refills and had zero supply left. 2. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including COPD, oxygen dependence, and anxiety. a. Spiriva HandihalerA written practitioner's order, dated 1/12/23, directed the residence to administer Spiriva Handihaler 18 mcg, inhalation of the contents of one capsule daily. However, the October 2023 medication administration record (MAR) read the medication was not administered on 10/1/23, 10/2-10/20/23, 10/23-10/25/23 for 22 missed doses because the medication was on order or unavailable.b. Zinc OxideA written practitioner's order, dated 2/17/23, directed the residence to apply zinc oxide 40% twice daily. However, the October and November 2023 MARs read that the medication was not administered on 10/10-10/13/23, 10/18-10/30/23, and 11/1-11/7/23 for 38 missed doses because the medication was on order or unavailable.c. Benzonatate A written practitioner's order, dated 7/5/23, directed the residence to administer benzonatate 100 mg, one capsule four times daily. However, the October 2023 MAR read the medication was not administered on 10/20-10/24/23 for 17 doses because the medication was on order.d. MucinexA written practitioner's order, dated 2/15/23, directed the residence to administer Mucinex 600 mg, two tablets twice daily. However, the November 2023 MAR read the medication was not administered on 11/5-11/7/23 for six missed doses because the medication was on order. (Cross-reference Q1466)e. Sertraline HydrochlorideA written practitioner's order, dated 1/23/23, directed the residence to administer sertraline hydrochloride 100 mg, one tablet daily. However, the October 2023 MAR read the medication was not administered on 10/9-10/11/23 for three missed doses because the medication was on order. f. Wixela (fluticasone propionate and salmeterol)A written practitioner's order, dated 3/2/23, directed the residence to administer Wixela (fluticasone propionate and salmeterol) 500-50 mcg/act, one puff inhaled twice daily. However, the November 2023 MAR read the medication was not administered on 11/8/23 because the medication was on order. On 11/8/23 at 7:20 a.m., the fluticasone propionate and salmeterol inhaler was not in the medication cart. Staff #13 stated that fluticasone propionate was not in stock in the medication cart and, therefore, she could not administer the medication to Resident #3. She added that the administrator was the sole person who reordered medication, and the residence staff notified her of out of stock medications utilizing a reorder form. On 11/8/23 at 7:45 a.m., Contracted Staff #14 stated the residence trained her to complete a form for reordering medication; however, the residence had not told her who ordered medication or who to call with an urgent concern. She stated she gave the medication refill form to the qualified medication administration persons (QMAP) on the evening shift. She added she had worked four shifts at the residence. On 11/8/23 at 8:20 a.m., Resident #3 had shortness of breath and had to pause a few times to breathe during the interview. The resident stated that she had been out of her Spiriva for most of October 2023. She added going without the Spiriva inhaler increased her breathing difficulties; however, her practitioner increased her self-administered oxygen since then. She stated that her residence had not administered her fluticasone propionate inhaler during the onsite visit; however, she was not feeling the impact of the one missed dose. On 11/8/23 at approximately 11:00 a.m., the practitioner stated that Resident #3 had not been administered the Spiriva Handihaler for most of October 2023; however, the residence failed to notify him that the pharmacy had not delivered the medication. He added that the missed doses of Spiriva for the resident contributed to increased COPD symptoms, including wheezing and shortness of breath. He added that he had to increase her oxygen while the resident was active ongoingly to offset the increased difficulty breathing. The practitioner stated ongoing concerns regarding the residence not administering medication for multiple residents. On 11/8/23 at approximately 1:54 p.m., the administrator stated that the residence staff recently reported to her that the Spiriva inhaler had been out of stock for Resident #3. She added that she had not followed up with the practitioner or pharmacy but would have had she known sooner. She added she became aware of the increased oxygen for the resident during the onsite visit. She stated there were ongoing challenges with the pharmacy not sending an entire month's supply and not notifying the residence when a refill order was required. She stated that there was a breakdown in communication between the pharmacy, practitioner, and residence regarding refill orders, resulting in the residence not administering medication to multiple residents. She added that the residence was not set up with cycle-filled medication at the pharmacy, which resulted in increased refill requests. She stated she was the sole staff member to receive and reconcile medications and update the MAR to reduce inaccuracies. She stated the QMAP notified her through an ordering form of any required refills and was available via telephone during periods she was not at the residence, such as nights and weekends. 3. Additionally, the residence failed to ensure each resident received proper administration, including medication administration compliance with authorized practitioner orders for Residents #6 and #17.

Plan of correction · submitted by the facility

118Resident #3, #6, #7, #15 and #17: residents are currently receiving medications as ordered and information is being documented appropriately. QMAP's will be re-educated by date of compliance on medication administration and following practitioner orders related to medication administration. The facility has changed the medication process to cycle fill for refilling medications. This should help to ensure that medications are not out of stock and administration can be completed. Administrator/designee will monitor cycle fill requirements to ensure that medications are received timely. Administrator/designee will audit medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring and that practitioner orders are being followed. Results of audits will be included in QMP process for next 3 months for review and/or recommendations for improvement, if necessary.

0212Acf-Part Elig AssessS/S B▼

Findings

Based on observation, record review, and interview, the facility (residence) failed to ensure a comprehensive assessment was updated whenever the participant ' s (resident ' s) conditions changed from baseline status, affecting two of two sample residents (#6, #14) who experienced a change in baseline status. (Cross-reference P0625)Findings include:1. Resident AgreementThe residence's undated Resident Agreement read in part that the residence regularly observed the health status of the residents and identified any changes to their physical, mental, and emotional functioning. Further, the residence assisted residents with their health needs and needs for special services. 2. Resident #14 was admitted to the residence on 4/21/22 with diagnoses including type two diabetes, anxiety, and post-traumatic stress disorder. An assessment, dated 8/10/23, read in part that the resident had excessively dry skin that required frequent lotion application; however, the assessment contained no updated information regarding any changes in baseline condition regarding physical or emotional well-being for Resident #14. A practitioner's order for an external service provider (ESP) for Resident #14, dated 10/4/23, read in part that the practitioner referred the resident to ESP for skilled nursing care to treat a wound on her lower right extremity and skin breakdown on both lower extremities. A hospital discharge summary, dated 11/1/23, read in part that the resident was diagnosed with lower extremity cellulitis. The residence's weekly hospital log, dated 10/7-11/5/23, read in part that Resident #14 went to the hospital on 11/1/23 at 6:54 p.m. The log did not contain a return date or time. The residence's list of weekly resident practitioner visits read in part that Resident #14 wished to see the practitioner on Wednesday (11/1/23) for the week of 11/2/23. On 11/8/23 at approximately 11:20 a.m., the practitioner for Resident #14 stated that he saw the resident on 11/1/23 to follow up on her lower right leg wound that he ordered services from external service provider to address on 10/4/23. He stated he diagnosed the resident with cellulitis of the lower right extremity when the area appeared reddened outside of the bandaged area. He added that he was unaware of whether or not the residence reassessed the resident after the initial change in physical condition. On 11/8/23 at 2:05 p.m., the administrator stated she was responsible for resident assessments. She stated that the residence reassessed a resident when the resident experienced a change in condition. She added that a change in condition included instances when a resident was transferred to another healthcare entity to receive additional care, changes in physical needs, increased care needs, mobility needs, or sustained falls. She stated that Resident #14 reported leg pain to her the week of 11/1/23, and she included the resident on the list to see the practitioner at his next visit to the residence. She stated she had not reviewed the discharge summary from the hospital for Resident #14 until the date of the onsite visit. She stated that she should have reassessed Resident #14 after the resident reported leg pain or after she returned from the hospital. She affirmed that if she had reassessed the resident, she would have likely increased skin monitoring. On 11/8/23 at 2:32 p.m., Resident #14 was in her bed with her legs elevated. Her right lower leg appeared swollen and bandaged. Resident #14 stated that she had reported leg pain approximately one month before to a residence staff member. She added the residence had not reassessed her after her report of pain. She stated she saw the practitioner on 11/1/23 and she chose to go to the hospital the same day for the same concern. She added that the residence had not reassessed her after the practitioner or hospital visit. 3. Additionally, the residence failed to ensure a comprehensive assessment was updated for Resident #6 when her condition changed from baseline after the resident had reported symptoms of a urinary tract infection and falls.

Plan of correction · submitted by the facility

212Residents #6 & 14: resident assessment will be reviewed, by date of compliance, to ensure it accurately reflects residents’ baseline status. Administrator will be educated on ensuring that resident assessments are updated at least annually & after a resident change of condition. Administrator/designee will complete an audit of current resident assessments, by date of compliance, to ensure that they accurately reflect residents’ current condition and needs. Resident assessments will be reviewed and updated at least annually, and with any change of condition, to accurately reflect residents’ current condition and needs. Administrator/designee will complete an audit of fifteen resident charts per month, for three months, to ensure that resident assessments are up to date and reflect residents’ current conditions and needs. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

0625Acf-Prov Role/Resp CarePln (cont)S/S B▼

Findings

Based on record review and interview, the facility (residence) failed to ensure each participant (resident) care plan detailed specific personal service needs and preferences along with staff tasks necessary to meet those needs and identified all service providers along with care coordination arrangements, affecting two of two current residents (#6, #14) and one former resident (#18) with external service providers. (Cross-reference P0212)Findings include:1. Reference and Resident AgreementChapter VII regulations governing assisted living residences, part 12.10, requires that each resident care plan shall:(A) Be developed with input from the resident and the resident ' s representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence, and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers along with care coordination arrangements; andThe residence's undated Resident Agreement read in part that the residence regularly observed the health status of the residents and identified any changes to their physical, mental, and emotional functioning. Further, the residence assisted residents with their health needs and needs for special services. 2. Resident #14 was admitted to the residence on 4/21/22 with a diagnosis of type two diabetes and a later diagnosis of cellulitis. A care plan, dated 8/10/23, revealed that the residence listed no external services provider (ESP) on the care plan for Resident #14 despite the availability of a section for the residence to list ESPs. A practitioner's order for ESP for Resident #14, dated 10/4/23, read in part that the practitioner referred the resident for ESP skilled nursing care to treat a wound on her lower right extremity and skin breakdown on both lower extremities. On 11/8/23 at 7:20 a.m., Staff #13 stated that she was not sure which residents received services from ESPs. She added that she assumed the residence documented the information in the resident's care plans but was unsure. On 11/8/23 at approximately 10:50 a.m., the administrator stated Resident #14 received services from an ESP. She added that the addition of ESP services for a resident was a change in condition; therefore, the residence should have updated the care plan for Resident #14 to include the services she received from the ESP and had not. On 11/8/23 at approximately 11:10 a.m., the practitioner for Resident #14 stated that she received services from an ESP for wound care for her right leg. On 11/8/23 at approximately 2:42 p.m., Resident #14 stated she received wound care from an ESP.3. Additionally, the residence failed to ensure each resident care plan detailed specific personal service needs, staff tasks necessary to meet those needs, and all service providers along with care coordination arrangements for Resident #6 and Former Resident #18.

Plan of correction · submitted by the facility

625Residents #6 & #14: resident agreement will be reviewed, by date of compliance, to ensure it accurately reflects residents’ need for any outside specialized services. Resident #18: no longer resides at facility. Administrator will be educated on ensuring that resident agreements are updated to reflect resident needs for outside services and what is provided. Administrator/designee will complete an audit of current resident agreements, by date of compliance, to ensure that they accurately reflect residents’ current needs related to any outside services required. Resident agreements will be reviewed and updated at least annually, and with any change of condition, to accurately reflect residents’ current condition and needs, including coordination with outside services required. Administrator/designee will complete an audit of all resident charts with outside service needs monthly, for three months, to ensure that residents agreements are up to date and reflect residents’ current conditions and needs. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

9/29/2023Revisit: Licensure Complaint · ID PFV314No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 9/29/23 for the previous deficiency cited on 5/17/23. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

9/29/2023Revisit: Licensure and Licensure Complaint (Combined) · ID ZCVZ122 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 9/29/23 for all previous deficiencies cited on 5/17/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of four sample residents (#3, #9, #10, #14). This deficiency was cited previously during a state licensure survey 5/17/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."2. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. a. Senna A written practitioner's order dated 12/7/22 directed the residence to administer senna 8.6-50 mg, twice daily. However, the September 2023 medication administration record (MAR) read the medication was not administered on 9/13 through 9/17/23 because the medication was not available.b. Simethicone A written practitioner's order dated 11/22/22 directed the residence to administer simethicone 80 mg once daily. However, the September 2023 MAR read the medication was not administered on 9/1, 9/2 and 9/4/23, because the medication was not available.c. CranberryA written practitioner's order dated 11/22/22 directed the residence to administer cranberry 500 mg, twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3 through 9/11/23 because the medication was not available.d. MagnesiumA written practitioner's order dated 11/22/22 directed the residence to administer magnesium 400 mg, daily. However, the September 2023 MAR read the medication was not administered on 9/4 and 9/5/23 because the medication was not available.e. FamotidineA written practitioner's order dated 8/2/22 directed the residence to administer famotidine 20 mg, twice daily. However, the September 2023 MAR read the medication was not administered on 9/4, the evening of 9/5 through 9/9, 9/10, 9/11, and the morning of 9/12/23 because the medication was not available. f. Levothyroxine A written practitioner's order dated 8/16/23 directed the residence to administer levothyroxine 88 mcg, daily. However, the September 2023 MAR read the medication was not administered on 9/8 because the medication was not available. g. Buspirone A written practitioner's order dated 8/16/23 directed the residence to administer buspirone 5 mg, three times daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/11 and 9/16, noon and evening on 9/18, and the evening of 9/19 because the medication was not available. h. AtorvastatinA written practitioner's order dated 8/23/23 directed the residence to administer atorvastatin 20 mg, every evening. However the September 2023 MAR read the medication was not administered on 9/27 and 9/28/23 because the medication was not available.i. MetoprololA written practitioner's order dated 8/23/23 directed the residence to administer metoprolol 25 mg, twice daily. However, the September 2023 MAR read the medication was not administered the evening of 9/8 and 9/9, 9/10 through 9/17, and the morning of 9/19 because the medication was not available. j. Fluticasone A written practitioner's order dated 6/21/23 directed the residence to administer fluticasone 500-50 mcg twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3, 9/4 through 9/6 and the morning of 9/7-9/18/23 because the medication was not available. On 9/29/23 at approximately 2:40 p.m. the administrator confirmed medications frequently ran out of supply. She stated the practitioner was responsible for signing orders when the pharmacy needed to refill a medication; however, the practitioner was not responsive and medications were not administered as required. Additional non compliance with practitioner's orders was revealed with Resident #3, #9, and #10.

Plan of correction · submitted by the facility

1468Resident #3, #9, #10, and #14: residents are currently receiving medications as ordered and information is being documented appropriately. QMAP's will be re-educated by date of compliance on medication administration and following practitioner orders related to medication administration. The facility is changing the medication process to cycle fill for refilling medications. Until that is completed, the Administrator/designee will create a log of medications needing refilled that will be completed by the staff administering medications. This log will be reviewed by the Administrator/designee daily, M-F, to ensure that medication refills are being requested timely to help ensure that medications are not out of stock. Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring and that practitioner orders are being followed. Results of audits will be included in QMP process for next 3 months for review and/or recommendations for improvement, if necessary.

1510Med/Med Adm-Rcrd Kpng MARS/S B▼

Findings

Based on record review and interview, the residence failed to accurately document each medication administration at the time the event was completed for each resident, affecting three of four sample residents (#3, #9, #14). This deficiency was cited previously during a state licensure survey 5/17/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."2. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Written practitioner's orders directed the residence to administer Simethicone 80 mg, daily; cranberry, 500 mg, twice daily; Preservision twice daily; famotidine 20 mg, twice daily; levothyroxine 88 mcg, daily; buspirone 5 mg, daily; furosemide 40 mg, daily; and fluticasone 500-50 mcg, twice daily. Review of the September 2023 medication administration record revealed no documentation as to whether or not the following medications were administered to the resident. Simethicone on 9/3, 9/5, 9/14/23. Cranberry on the evening of 9/5 and 9/13/23. Preservision on the evening of 9/14/23. Famotidine on 9/13 and 9/17/23. Levothyroxine on 9/9/23. Buspirone on the morning of 9/5 and the evening of 9/7, 9/9, 9/10, and 9/13/23. Metoprolol on the morning of 9/3 and 9/18/23; the evening of 9/24/23. Furosemide on 9/3 and 9/18/23. Fluticasone on the evening of 9/10, 9/12, 9/14, 9/19, 9/20, 9/21, 9/23 and 9/24/23. 3. Interviews On 9/29/23 at approximately 3:00 p.m. the administrator confirmed the administration of medication was not documented as required and stated she was not sure why staff were not documenting the administration of medication and she had been working with the staff to ensure proper documentation. Additional non compliance with documentation of medications was revealed with Resident #3 and #9.

Plan of correction · submitted by the facility

1510Resident #3, #9, #14: residents MAR’s will be audited, by date of compliance, to ensure information is being documented appropriately. Administrator/designee will complete an audit, by date of compliance, of current residents’ medication administration records for accuracy and completeness, including that each accurate documentation for each medication at time of administration. QMAP's will be re-educated by date of compliance on medication administration and appropriate documentation in resident MAR.The facility is changing the medication process to cycle fill for refilling medications. Until that is completed, the Administrator/designee will create a log of medications needing refilled that will be completed by the staff administering medications. This log will be reviewed daily. M-F, to ensure that medication refills are being requested to help ensure that medications are not out of stock. Administrator/designee will complete an audit of five resident records, three times per week, for twelve weeks, to review medication administration records for accuracy and completeness, and will resolve any issues identified. Results of audits will be included in QMP process for next 3 months for review and/or recommendations for improvement, if necessary.

9/29/2023Revisit: State Certification and State Certification Complaint (Combined) · ID YD9K151 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 9/29/23 for the previous deficiency cited on 5/17/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼

Findings

Based on observation, 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 four of four sample participants (residents) (#3, #9, #10, #14). This deficiency was cited previously during a state licensure survey 5/17/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, require the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."b. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Senna A written practitioner's order dated 12/7/22 directed the residence to administer senna 8.6-50 mg, twice daily. However, the September 2023 medication administration record (MAR) read the medication was not administered on 9/13 through 9/17/23 because the medication was not available. Simethicone A written practitioner's order dated 11/22/22 directed the residence to administer simethicone 80 mg once daily. However, the September 2023 MAR read the medication was not administered on 9/1, 9/2 and 9/4/23, because the medication was not available. CranberryA written practitioner's order dated 11/22/22 directed the residence to administer cranberry 500 mg, twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3 through 9/11/23 because the medication was not available. MagnesiumA written practitioner's order dated 11/22/22 directed the residence to administer magnesium 400 mg, daily. However, the September 2023 MAR read the medication was not administered on 9/4 and 9/5/23 because the medication was not available. FamotidineA written practitioner's order dated 8/2/22 directed the residence to administer famotidine 20 mg, twice daily. However, the September 2023 MAR read the medication was not administered on 9/4, the evening of 9/5 through 9/9, 9/10, 9/11, and the morning of 9/12/23 because the medication was not available. Levothyroxine A written practitioner's order dated 8/16/23 directed the residence to administer levothyroxine 88 mcg, daily. However, the September 2023 MAR read the medication was not administered on 9/8 because the medication was not available. Buspirone A written practitioner's order dated 8/16/23 directed the residence to administer buspirone 5 mg, three times daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/11 and 9/16, noon and evening on 9/18, and the evening of 9/19 because the medication was not available. AtorvastatinA written practitioner's order dated 8/23/23 directed the residence to administer atorvastatin 20 mg, every evening. However the September 2023 MAR read the medication was not administered on 9/27 and 9/28/23 because the medication was not available. MetoprololA written practitioner's order dated 8/23/23 directed the residence to administer metoprolol 25 mg, twice daily. However, the September 2023 MAR read the medication was not administered the evening of 9/8 and 9/9, 9/10through 9/17, and the morning of 9/19 because the medication was not available. Fluticasone A written practitioner's order dated 6/21/23 directed the residence to administer fluticasone 500-50 mcg twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3, 9/4 through 9/6 and the morning of 9/7-9/18/23 because the medication was not available. On 9/29/23 at approximately 2:40 p.m. the administrator confirmed medications frequently ran out of supply. She stated the practitioner was responsible for signing orders when the pharmacy needed to refill a medication; however, the practitioner was not responsive and medications were not administered as required. Additional non compliance with practitioner's orders was revealed with Resident #3, #9, and #10.2. Chapter VII regulations governing assisted living residences, part 14.29, requires all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.a. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."b. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Written practitioner's orders directed the residence to administer Simethicone 80 mg, daily; cranberry, 500 mg, twice daily; Preservision twice daily; famotidine 20 mg, twice daily; levothyroxine 88 mcg, daily; buspirone 5 mg, daily; furosemide 40 mg, daily; and fluticasone 500-50 mcg, twice daily. Review of the September 2023 medication administration record revealed no documentation as to whether or not the following medications were administered to the resident. Simethicone on 9/3, 9/5, 9/14/23. Cranberry on the evening of 9/5 and 9/13/23. Preservision on the evening of 9/14/23. Famotidine on 9/13 and 9/17/23. Levothyroxine on 9/9/23. Buspirone on the morning of 9/5 and the evening of 9/7, 9/9, 9/10, and 9/13/23. Metoprolol on the morning of 9/3 and 9/18/23; the evening of 9/24/23. Furosemide on 9/3 and 9/18/23. Fluticasone on the evening of 9/10, 9/12, 9/14, 9/19, 9/20, 9/21, 9/23 and 9/24/23. c. Interviews On 9/29/23 at approximately 3:00 p.m. the administrator confirmed the administration of medication was not documented as required and stated she was not sure why staff were not documenting the administration of medication and she had been working with the staff to ensure proper documentation. Additional non compliance with documentation of medications was revealed with Resident #3 and #9.

Plan of correction · submitted by the facility

630Resident #3, #9, #10, and #14: residents are currently receiving medications as ordered and information is being documented appropriately. QMAP's will be re-educated by date of compliance on medication administration and following practitioner orders related to medication administration. The facility is changing the medication process to cycle fill for refilling medications. Until that is completed, the Administrator/designee will create a log of medications needing refilled that will be completed by the staff administering medications. This log will be reviewed daily. M-F, to ensure that medication refills are being requested to help ensure that medications are not out of stock. Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring and that practitioner orders are being followed.

9/29/2023Revisit: Licensure Complaint · ID TE43141 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 9/29/23 for the previous deficiency cited on 5/17/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼

Findings

Based on observation, 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 four of four sample participants (residents) (#3, #9, #10, #14). This deficiency was cited previously during a state licensure survey 5/17/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, require the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."b. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Senna A written practitioner's order dated 12/7/22 directed the residence to administer senna 8.6-50 mg, twice daily. However, the September 2023 medication administration record (MAR) read the medication was not administered on 9/13 through 9/17/23 because the medication was not available. Simethicone A written practitioner's order dated 11/22/22 directed the residence to administer simethicone 80 mg once daily. However, the September 2023 MAR read the medication was not administered on 9/1, 9/2 and 9/4/23, because the medication was not available. CranberryA written practitioner's order dated 11/22/22 directed the residence to administer cranberry 500 mg, twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3 through 9/11/23 because the medication was not available. MagnesiumA written practitioner's order dated 11/22/22 directed the residence to administer magnesium 400 mg, daily. However, the September 2023 MAR read the medication was not administered on 9/4 and 9/5/23 because the medication was not available. FamotidineA written practitioner's order dated 8/2/22 directed the residence to administer famotidine 20 mg, twice daily. However, the September 2023 MAR read the medication was not administered on 9/4, the evening of 9/5 through 9/9, 9/10, 9/11, and the morning of 9/12/23 because the medication was not available. Levothyroxine A written practitioner's order dated 8/16/23 directed the residence to administer levothyroxine 88 mcg, daily. However, the September 2023 MAR read the medication was not administered on 9/8 because the medication was not available. Buspirone A written practitioner's order dated 8/16/23 directed the residence to administer buspirone 5 mg, three times daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/11 and 9/16, noon and evening on 9/18, and the evening of 9/19 because the medication was not available. AtorvastatinA written practitioner's order dated 8/23/23 directed the residence to administer atorvastatin 20 mg, every evening. However the September 2023 MAR read the medication was not administered on 9/27 and 9/28/23 because the medication was not available. MetoprololA written practitioner's order dated 8/23/23 directed the residence to administer metoprolol 25 mg, twice daily. However, the September 2023 MAR read the medication was not administered the evening of 9/8 and 9/9, 9/10through 9/17, and the morning of 9/19 because the medication was not available. Fluticasone A written practitioner's order dated 6/21/23 directed the residence to administer fluticasone 500-50 mcg twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3, 9/4 through 9/6 and the morning of 9/7-9/18/23 because the medication was not available. On 9/29/23 at approximately 2:40 p.m. the administrator confirmed medications frequently ran out of supply. She stated the practitioner was responsible for signing orders when the pharmacy needed to refill a medication; however, the practitioner was not responsive and medications were not administered as required. Additional non compliance with practitioner's orders was revealed with Resident #3, #9, and #10.2. Chapter VII regulations governing assisted living residences, part 14.29, requires all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.a. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."b. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Written practitioner's orders directed the residence to administer Simethicone 80 mg, daily; cranberry, 500 mg, twice daily; Preservision twice daily; famotidine 20 mg, twice daily; levothyroxine 88 mcg, daily; buspirone 5 mg, daily; furosemide 40 mg, daily; and fluticasone 500-50 mcg, twice daily. Review of the September 2023 medication administration record revealed no documentation as to whether or not the following medications were administered to the resident. Simethicone on 9/3, 9/5, 9/14/23. Cranberry on the evening of 9/5 and 9/13/23. Preservision on the evening of 9/14/23. Famotidine on 9/13 and 9/17/23. Levothyroxine on 9/9/23. Buspirone on the morning of 9/5 and the evening of 9/7, 9/9, 9/10, and 9/13/23. Metoprolol on the morning of 9/3 and 9/18/23; the evening of 9/24/23. Furosemide on 9/3 and 9/18/23. Fluticasone on the evening of 9/10, 9/12, 9/14, 9/19, 9/20, 9/21, 9/23 and 9/24/23. c. Interviews On 9/29/23 at approximately 3:00 p.m. the administrator confirmed the administration of medication was not documented as required and stated she was not sure why staff were not documenting the administration of medication and she had been working with the staff to ensure proper documentation. Additional non compliance with documentation of medications was revealed with Resident #3 and #9.

Plan of correction · submitted by the facility

630Resident #3, #9, #10, and #14: residents are currently receiving medications as ordered and information is being documented appropriately. QMAP's will be re-educated by date of compliance on medication administration and following practitioner orders related to medication administration. The facility is changing the medication process to cycle fill for refilling medications. Until that is completed, the Administrator/designee will create a log of medications needing refilled that will be completed by the staff administering medications. This log will be reviewed daily. M-F, to ensure that medication refills are being requested to help ensure that medications are not out of stock. Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring and that practitioner orders are being followed.

9/29/2023Revisit: Licensure Complaint · ID RHKP131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 9/29/23 for all previous deficiencies cited on 5/17/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼

Findings

Based on observation, 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 four of four sample participants (residents) (#3, #9, #10, #14). This deficiency was cited previously during a state licensure survey 5/17/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, require the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."b. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Senna A written practitioner's order dated 12/7/22 directed the residence to administer senna 8.6-50 mg, twice daily. However, the September 2023 medication administration record (MAR) read the medication was not administered on 9/13 through 9/17/23 because the medication was not available. Simethicone A written practitioner's order dated 11/22/22 directed the residence to administer simethicone 80 mg once daily. However, the September 2023 MAR read the medication was not administered on 9/1, 9/2 and 9/4/23, because the medication was not available. CranberryA written practitioner's order dated 11/22/22 directed the residence to administer cranberry 500 mg, twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3 through 9/11/23 because the medication was not available. MagnesiumA written practitioner's order dated 11/22/22 directed the residence to administer magnesium 400 mg, daily. However, the September 2023 MAR read the medication was not administered on 9/4 and 9/5/23 because the medication was not available. FamotidineA written practitioner's order dated 8/2/22 directed the residence to administer famotidine 20 mg, twice daily. However, the September 2023 MAR read the medication was not administered on 9/4, the evening of 9/5 through 9/9, 9/10, 9/11, and the morning of 9/12/23 because the medication was not available. Levothyroxine A written practitioner's order dated 8/16/23 directed the residence to administer levothyroxine 88 mcg, daily. However, the September 2023 MAR read the medication was not administered on 9/8 because the medication was not available. Buspirone A written practitioner's order dated 8/16/23 directed the residence to administer buspirone 5 mg, three times daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/11 and 9/16, noon and evening on 9/18, and the evening of 9/19 because the medication was not available. AtorvastatinA written practitioner's order dated 8/23/23 directed the residence to administer atorvastatin 20 mg, every evening. However the September 2023 MAR read the medication was not administered on 9/27 and 9/28/23 because the medication was not available. MetoprololA written practitioner's order dated 8/23/23 directed the residence to administer metoprolol 25 mg, twice daily. However, the September 2023 MAR read the medication was not administered the evening of 9/8 and 9/9, 9/10through 9/17, and the morning of 9/19 because the medication was not available. Fluticasone A written practitioner's order dated 6/21/23 directed the residence to administer fluticasone 500-50 mcg twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3, 9/4 through 9/6 and the morning of 9/7-9/18/23 because the medication was not available. On 9/29/23 at approximately 2:40 p.m. the administrator confirmed medications frequently ran out of supply. She stated the practitioner was responsible for signing orders when the pharmacy needed to refill a medication; however, the practitioner was not responsive and medications were not administered as required. Additional non compliance with practitioner's orders was revealed with Resident #3, #9, and #10.2. Chapter VII regulations governing assisted living residences, part 14.29, requires all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.a. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."b. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Written practitioner's orders directed the residence to administer Simethicone 80 mg, daily; cranberry, 500 mg, twice daily; Preservision twice daily; famotidine 20 mg, twice daily; levothyroxine 88 mcg, daily; buspirone 5 mg, daily; furosemide 40 mg, daily; and fluticasone 500-50 mcg, twice daily. Review of the September 2023 medication administration record revealed no documentation as to whether or not the following medications were administered to the resident. Simethicone on 9/3, 9/5, 9/14/23. Cranberry on the evening of 9/5 and 9/13/23. Preservision on the evening of 9/14/23. Famotidine on 9/13 and 9/17/23. Levothyroxine on 9/9/23. Buspirone on the morning of 9/5 and the evening of 9/7, 9/9, 9/10, and 9/13/23. Metoprolol on the morning of 9/3 and 9/18/23; the evening of 9/24/23. Furosemide on 9/3 and 9/18/23. Fluticasone on the evening of 9/10, 9/12, 9/14, 9/19, 9/20, 9/21, 9/23 and 9/24/23. c. Interviews On 9/29/23 at approximately 3:00 p.m. the administrator confirmed the administration of medication was not documented as required and stated she was not sure why staff were not documenting the administration of medication and she had been working with the staff to ensure proper documentation. Additional non compliance with documentation of medications was revealed with Resident #3 and #9.

Plan of correction · submitted by the facility

630Resident #3, #9, #10, and #14: residents are currently receiving medications as ordered and information is being documented appropriately. QMAP's will be re-educated by date of compliance on medication administration and following practitioner orders related to medication administration. The facility is changing the medication process to cycle fill for refilling medications. Until that is completed, the Administrator/designee will create a log of medications needing refilled that will be completed by the staff administering medications. This log will be reviewed daily. M-F, to ensure that medication refills are being requested to help ensure that medications are not out of stock. Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring and that practitioner orders are being followed.

9/29/2023Revisit: State Certification and State Certification Complaint (Combined) · ID EI5T121 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 9/29/23 for all previous deficiencies cited on 5/17/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼

Findings

Based on observation, 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 four of four sample participants (residents) (#3, #9, #10, #14). This deficiency was cited previously during a state licensure survey 5/17/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, require the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."b. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Senna A written practitioner's order dated 12/7/22 directed the residence to administer senna 8.6-50 mg, twice daily. However, the September 2023 medication administration record (MAR) read the medication was not administered on 9/13 through 9/17/23 because the medication was not available. Simethicone A written practitioner's order dated 11/22/22 directed the residence to administer simethicone 80 mg once daily. However, the September 2023 MAR read the medication was not administered on 9/1, 9/2 and 9/4/23, because the medication was not available. CranberryA written practitioner's order dated 11/22/22 directed the residence to administer cranberry 500 mg, twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3 through 9/11/23 because the medication was not available. MagnesiumA written practitioner's order dated 11/22/22 directed the residence to administer magnesium 400 mg, daily. However, the September 2023 MAR read the medication was not administered on 9/4 and 9/5/23 because the medication was not available. FamotidineA written practitioner's order dated 8/2/22 directed the residence to administer famotidine 20 mg, twice daily. However, the September 2023 MAR read the medication was not administered on 9/4, the evening of 9/5 through 9/9, 9/10, 9/11, and the morning of 9/12/23 because the medication was not available. Levothyroxine A written practitioner's order dated 8/16/23 directed the residence to administer levothyroxine 88 mcg, daily. However, the September 2023 MAR read the medication was not administered on 9/8 because the medication was not available. Buspirone A written practitioner's order dated 8/16/23 directed the residence to administer buspirone 5 mg, three times daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/11 and 9/16, noon and evening on 9/18, and the evening of 9/19 because the medication was not available. AtorvastatinA written practitioner's order dated 8/23/23 directed the residence to administer atorvastatin 20 mg, every evening. However the September 2023 MAR read the medication was not administered on 9/27 and 9/28/23 because the medication was not available. MetoprololA written practitioner's order dated 8/23/23 directed the residence to administer metoprolol 25 mg, twice daily. However, the September 2023 MAR read the medication was not administered the evening of 9/8 and 9/9, 9/10through 9/17, and the morning of 9/19 because the medication was not available. Fluticasone A written practitioner's order dated 6/21/23 directed the residence to administer fluticasone 500-50 mcg twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3, 9/4 through 9/6 and the morning of 9/7-9/18/23 because the medication was not available. On 9/29/23 at approximately 2:40 p.m. the administrator confirmed medications frequently ran out of supply. She stated the practitioner was responsible for signing orders when the pharmacy needed to refill a medication; however, the practitioner was not responsive and medications were not administered as required. Additional non compliance with practitioner's orders was revealed with Resident #3, #9, and #10.2. Chapter VII regulations governing assisted living residences, part 14.29, requires all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.a. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."b. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Written practitioner's orders directed the residence to administer Simethicone 80 mg, daily; cranberry, 500 mg, twice daily; Preservision twice daily; famotidine 20 mg, twice daily; levothyroxine 88 mcg, daily; buspirone 5 mg, daily; furosemide 40 mg, daily; and fluticasone 500-50 mcg, twice daily. Review of the September 2023 medication administration record revealed no documentation as to whether or not the following medications were administered to the resident. Simethicone on 9/3, 9/5, 9/14/23. Cranberry on the evening of 9/5 and 9/13/23. Preservision on the evening of 9/14/23. Famotidine on 9/13 and 9/17/23. Levothyroxine on 9/9/23. Buspirone on the morning of 9/5 and the evening of 9/7, 9/9, 9/10, and 9/13/23. Metoprolol on the morning of 9/3 and 9/18/23; the evening of 9/24/23. Furosemide on 9/3 and 9/18/23. Fluticasone on the evening of 9/10, 9/12, 9/14, 9/19, 9/20, 9/21, 9/23 and 9/24/23. c. Interviews On 9/29/23 at approximately 3:00 p.m. the administrator confirmed the administration of medication was not documented as required and stated she was not sure why staff were not documenting the administration of medication and she had been working with the staff to ensure proper documentation. Additional non compliance with documentation of medications was revealed with Resident #3 and #9.

Plan of correction · submitted by the facility

630Resident #3, #9, #10, and #14: residents are currently receiving medications as ordered and information is being documented appropriately. QMAP's will be re-educated by date of compliance on medication administration and following practitioner orders related to medication administration. The facility is changing the medication process to cycle fill for refilling medications. Until that is completed, the Administrator/designee will create a log of medications needing refilled that will be completed by the staff administering medications. This log will be reviewed daily. M-F, to ensure that medication refills are being requested to help ensure that medications are not out of stock. Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring and that practitioner orders are being followed.

9/29/2023Revisit: Licensure Complaint · ID K1GZ14No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 9/29/23 for the previous deficiency cited on 5/17/23. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

9/29/2023Revisit: Licensure Complaint · ID ELBO131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 9/29/23 for all previous deficiencies cited on 5/17/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of four sample residents (#3, #9, #10, #14). This deficiency was cited previously during a state licensure survey 5/17/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."2. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. a. Senna A written practitioner's order dated 12/7/22 directed the residence to administer senna 8.6-50 mg, twice daily. However, the September 2023 medication administration record (MAR) read the medication was not administered on 9/13 through 9/17/23 because the medication was not available.b. Simethicone A written practitioner's order dated 11/22/22 directed the residence to administer simethicone 80 mg once daily. However, the September 2023 MAR read the medication was not administered on 9/1, 9/2 and 9/4/23, because the medication was not available.c. CranberryA written practitioner's order dated 11/22/22 directed the residence to administer cranberry 500 mg, twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3 through 9/11/23 because the medication was not available.d. MagnesiumA written practitioner's order dated 11/22/22 directed the residence to administer magnesium 400 mg, daily. However, the September 2023 MAR read the medication was not administered on 9/4 and 9/5/23 because the medication was not available.e. FamotidineA written practitioner's order dated 8/2/22 directed the residence to administer famotidine 20 mg, twice daily. However, the September 2023 MAR read the medication was not administered on 9/4, the evening of 9/5 through 9/9, 9/10, 9/11, and the morning of 9/12/23 because the medication was not available. f. Levothyroxine A written practitioner's order dated 8/16/23 directed the residence to administer levothyroxine 88 mcg, daily. However, the September 2023 MAR read the medication was not administered on 9/8 because the medication was not available. g. Buspirone A written practitioner's order dated 8/16/23 directed the residence to administer buspirone 5 mg, three times daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/11 and 9/16, noon and evening on 9/18, and the evening of 9/19 because the medication was not available. h. AtorvastatinA written practitioner's order dated 8/23/23 directed the residence to administer atorvastatin 20 mg, every evening. However the September 2023 MAR read the medication was not administered on 9/27 and 9/28/23 because the medication was not available.i. MetoprololA written practitioner's order dated 8/23/23 directed the residence to administer metoprolol 25 mg, twice daily. However, the September 2023 MAR read the medication was not administered the evening of 9/8 and 9/9, 9/10 through 9/17, and the morning of 9/19 because the medication was not available. j. Fluticasone A written practitioner's order dated 6/21/23 directed the residence to administer fluticasone 500-50 mcg twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3, 9/4 through 9/6 and the morning of 9/7-9/18/23 because the medication was not available. On 9/29/23 at approximately 2:40 p.m. the administrator confirmed medications frequently ran out of supply. She stated the practitioner was responsible for signing orders when the pharmacy needed to refill a medication; however, the practitioner was not responsive and medications were not administered as required. Additional non compliance with practitioner's orders was revealed with Resident #3, #9, and #10.

Plan of correction · submitted by the facility

1468Resident #3, #9, #10, and #14: residents are currently receiving medications as ordered and information is being documented appropriately. QMAP's will be re-educated by date of compliance on medication administration and following practitioner orders related to medication administration. The facility is changing the medication process to cycle fill for refilling medications. Until that is completed, the Administrator/designee will create a log of medications needing refilled that will be completed by the staff administering medications. This log will be reviewed by the Administrator/designee daily, M-F, to ensure that medication refills are being requested timely to help ensure that medications are not out of stock. Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring and that practitioner orders are being followed. Results of audits will be included in QMP process for next 3 months for review and/or recommendations for improvement, if necessary.

9/29/2023Revisit: Licensure Complaint · ID E8FU14No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 9/29/23 for the previous deficiency cited on 5/17/23. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

9/29/2023State Certification Complaint · ID 8XY7111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification complaint, prompted by #CO32525 and #CO33741, was completed on 9/29/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼

Findings

Based on observation, 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 four of four sample participants (residents) (#3, #9, #10, #14). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, require the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."b. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Senna A written practitioner's order dated 12/7/22 directed the residence to administer senna 8.6-50 mg, twice daily. However, the September 2023 medication administration record (MAR) read the medication was not administered on 9/13 through 9/17/23 because the medication was not available. Simethicone A written practitioner's order dated 11/22/22 directed the residence to administer simethicone 80 mg once daily. However, the September 2023 MAR read the medication was not administered on 9/1, 9/2 and 9/4/23, because the medication was not available. CranberryA written practitioner's order dated 11/22/22 directed the residence to administer cranberry 500 mg, twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3 through 9/11/23 because the medication was not available. MagnesiumA written practitioner's order dated 11/22/22 directed the residence to administer magnesium 400 mg, daily. However, the September 2023 MAR read the medication was not administered on 9/4 and 9/5/23 because the medication was not available. FamotidineA written practitioner's order dated 8/2/22 directed the residence to administer famotidine 20 mg, twice daily. However, the September 2023 MAR read the medication was not administered on 9/4, the evening of 9/5 through 9/9, 9/10, 9/11, and the morning of 9/12/23 because the medication was not available. Levothyroxine A written practitioner's order dated 8/16/23 directed the residence to administer levothyroxine 88 mcg, daily. However, the September 2023 MAR read the medication was not administered on 9/8 because the medication was not available. Buspirone A written practitioner's order dated 8/16/23 directed the residence to administer buspirone 5 mg, three times daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/11 and 9/16, noon and evening on 9/18, and the evening of 9/19 because the medication was not available. AtorvastatinA written practitioner's order dated 8/23/23 directed the residence to administer atorvastatin 20 mg, every evening. However the September 2023 MAR read the medication was not administered on 9/27 and 9/28/23 because the medication was not available. MetoprololA written practitioner's order dated 8/23/23 directed the residence to administer metoprolol 25 mg, twice daily. However, the September 2023 MAR read the medication was not administered the evening of 9/8 and 9/9, 9/10 through 9/17, and the morning of 9/19 because the medication was not available. Fluticasone A written practitioner's order dated 6/21/23 directed the residence to administer fluticasone 500-50 mcg twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3, 9/4 through 9/6 and the morning of 9/7-9/18/23 because the medication was not available. On 9/29/23 at approximately 2:40 p.m. the administrator confirmed medications frequently ran out of supply. She stated the practitioner was responsible for signing orders when the pharmacy needed to refill a medication; however, the practitioner was not responsive and medications were not administered as required. Additional non compliance with practitioner's orders was revealed with Resident #3, #9, and #10.2. Chapter VII regulations governing assisted living residences, part 14.29, requires all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.a. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."b. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Written practitioner's orders directed the residence to administer Simethicone 80 mg, daily; cranberry, 500 mg, twice daily; Preservision twice daily; famotidine 20 mg, twice daily; levothyroxine 88 mcg, daily; buspirone 5 mg, daily; furosemide 40 mg, daily; and fluticasone 500-50 mcg, twice daily. Review of the September 2023 medication administration record revealed no documentation as to whether or not the following medications were administered to the resident. Simethicone on 9/3, 9/5, 9/14/23. Cranberry on the evening of 9/5 and 9/13/23. Preservision on the evening of 9/14/23. Famotidine on 9/13 and 9/17/23. Levothyroxine on 9/9/23. Buspirone on the morning of 9/5 and the evening of 9/7, 9/9, 9/10, and 9/13/23. Metoprolol on the morning of 9/3 and 9/18/23; the evening of 9/24/23. Furosemide on 9/3 and 9/18/23. Fluticasone on the evening of 9/10, 9/12, 9/14, 9/19, 9/20, 9/21, 9/23 and 9/24/23. c. Interviews On 9/29/23 at approximately 3:00 p.m. the administrator confirmed the administration of medication was not documented as required and stated she was not sure why staff were not documenting the administration of medication and she had been working with the staff to ensure proper documentation. Additional non compliance with documentation of medications was revealed with Resident #3 and #9.

Plan of correction · submitted by the facility

630Resident #3, #9, #10, and #14: residents are currently receiving medications as ordered and information is being documented appropriately. QMAP's will be re-educated by date of compliance on medication administration and following practitioner orders related to medication administration. The facility is changing the medication process to cycle fill for refilling medications. Until that is completed, the Administrator/designee will create a log of medications needing refilled that will be completed by the staff administering medications. This log will be reviewed daily. M-F, to ensure that medication refills are being requested to help ensure that medications are not out of stock. Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring and that practitioner orders are being followed.

9/29/2023Licensure Complaint · ID 8MXJ114 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO32524 and #CO33740, was completed on 9/29/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0734Stff Rq-First Aid 1 Stff Onsite CPRS/S B▼

Findings

Based on record review and interview, the residence failed to have at least one staff member onsite at all times who has 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 52 current residents. Findings include:1. References and Residence Policya. According to 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-20056600b. According to the American Red Cross: "Obstructed Airway Care for Adults ... If the patient is able to speak to you or is coughing forcefully: Encourage the patient to keep coughing but be prepared to clear the airway if the patient's condition changes ... Obtain consent ... Perform abdominal thrusts ... Perform alternate techniques-back blows, chest thrusts, or airway management ... Continue to clear the airway ... If the patient becomes unresponsive, carefully lower them to a firm, flat surface, while protecting their head. Immediately begin CPR, starting with chest compressions. After each set of compressions and before ventilation, open the patient's mouth and look for the object-if seen, remove it using a finger sweep." American Red Cross (2019) Skill Sheet: Obstructed Airway Care for Adults and Children, retrieved from: https://www.redcrosslearning.com/course-bin/bls-healthcare-resuscitation/app/content/a/en-US/resources/SS-Obstructed-Airway-Care-for-Adults-and-Children.pdfc. The residence's undated CPR, First Aid policy, read in part: "(The residence) maintains at least one staff member on duty 24 hours per day, 7 days per week that is certified in First Aid and cardiopulmonary resuscitation (CPR) from a nationally recognized organization such as the American Red Cross, the American Heart Association, National Safety Council, or American Safety and Health Institute. The certification shall be in Adult First Aid or include Adult First Aid."2. Record ReviewOn 9/29/23, the August and September 2023 staff schedule revealed Staff #11 and #12 worked from 10:00 p.m. to 6:00 a.m. Sunday through Thursday each week in August and September 2023. The two staff members were the sole caregivers at the residence during their shift. A review of CPR certifications revealed that the neither the administrator nor Staff #2-#7 had current certification in CPR.Review of the personnel files for Staff #11 did not reveal evidence that he was certified in CPR or first aid. A review of the personnel file for Staff #12 revealed she had a CPR certification that expired in May of 2023. 3. InterviewOn 9/29/23 at approximately 9:20 a.m., the administrator confirmed that there was not a CPR certified staff member on every shift. She stated the residence was working on coordinating a training; however, the training had not been completed or scheduled yet.

Plan of correction · submitted by the facility

734Facility has reviewed scheduled to ensure that there is a staff member on each shift with a nationally recognized CPR certification. Records are kept identifying the staff name, certification provider, issue date, and expiration date. Staff with current CPR certification will now be identified on the schedule, to ensure that all shifts have at least one staff member certified in CPR, as well as posted in several areas throughout the building. The Administrator/designee will start a log of all current staff members, that will reviewed monthly, to identify any staff member with an expiring CPR certification. The identified staff members will be required to complete new/updated CPR certification. Newly hired staff without a current CPR certification from a nationally recognized provider will be offered training. The monitoring of the log will be included in QMP process for three months for review and recommendations for improvement, if necessary.

1034Res Ad/D/C-Res Agr Anul Rvw/CHOWS/S A▼

Findings

Based on record review and interview the residence failed to review its resident agreement annually and update or amend them as necessary, affecting one former resident (#13). Findings include:Former Resident #13 was admitted to the residence on 9/19/17 with multiple diagnoses including respiratory failure, brain aneurysm, and chronic obstructive pulmonary disorder. The resident agreement for Former Resident #13 was signed and dated 9/24/17 and read in part, "the (residence) staff will not perform CPR. In the event a resident's breathing or heart stops, staff will call 911 for Emergency Medical Technicians (EMTs). Responding EMT personnel will perform CPR (cardiopulmonary resuscitation) on the resident if he or she does not have a Do Not Resuscitate (DNR) order, or other advanced directive declining CPR, on file with the facility. "There was no updated resident agreement in the record for Former Resident #13. On 9/29/23 at approximately 2:15 p.m. the administrator confirmed the agreement was not reviewed annually and newer residents had an updated agreement that read CPR was provided by the staff.

Plan of correction · submitted by the facility

Residents #13: no longer resides at facilityAdministrator will be educated on ensuring that resident agreements are updated annually, or as necessary. Administrator/designee will complete an audit of current resident agreements, by date of compliance, to ensure that they are current and have been updated at least annually. Resident agreements will be reviewed and updated at least annually, and with any change of condition, to accurately reflect residents’ current condition and needs. Administrator/designee will complete an audit of five resident charts per month, for three months, to ensure that resident agreements are up to date and reflect residents’ current conditions and needs. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of four sample residents (#3, #9, #10, #14). Findings include:1. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."2. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. a. Senna A written practitioner's order dated 12/7/22 directed the residence to administer senna 8.6-50 mg, twice daily. However, the September 2023 medication administration record (MAR) read the medication was not administered on 9/13 through 9/17/23 because the medication was not available.b. Simethicone A written practitioner's order dated 11/22/22 directed the residence to administer simethicone 80 mg once daily. However, the September 2023 MAR read the medication was not administered on 9/1, 9/2 and 9/4/23, because the medication was not available.c. CranberryA written practitioner's order dated 11/22/22 directed the residence to administer cranberry 500 mg, twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3 through 9/11/23 because the medication was not available.d. MagnesiumA written practitioner's order dated 11/22/22 directed the residence to administer magnesium 400 mg, daily. However, the September 2023 MAR read the medication was not administered on 9/4 and 9/5/23 because the medication was not available.e. FamotidineA written practitioner's order dated 8/2/22 directed the residence to administer famotidine 20 mg, twice daily. However, the September 2023 MAR read the medication was not administered on 9/4, the evening of 9/5 through 9/9, 9/10, 9/11, and the morning of 9/12/23 because the medication was not available. f. Levothyroxine A written practitioner's order dated 8/16/23 directed the residence to administer levothyroxine 88 mcg, daily. However, the September 2023 MAR read the medication was not administered on 9/8 because the medication was not available. g. Buspirone A written practitioner's order dated 8/16/23 directed the residence to administer buspirone 5 mg, three times daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/11 and 9/16, noon and evening on 9/18, and the evening of 9/19 because the medication was not available. h. AtorvastatinA written practitioner's order dated 8/23/23 directed the residence to administer atorvastatin 20 mg, every evening. However the September 2023 MAR read the medication was not administered on 9/27 and 9/28/23 because the medication was not available.i. MetoprololA written practitioner's order dated 8/23/23 directed the residence to administer metoprolol 25 mg, twice daily. However, the September 2023 MAR read the medication was not administered the evening of 9/8 and 9/9, 9/10 through 9/17, and the morning of 9/19 because the medication was not available. j. Fluticasone A written practitioner's order dated 6/21/23 directed the residence to administer fluticasone 500-50 mcg twice daily. However, the September 2023 MAR read the medication was not administered on the evening of 9/3, 9/4 through 9/6 and the morning of 9/7-9/18/23 because the medication was not available. On 9/29/23 at approximately 2:40 p.m. the administrator confirmed medications frequently ran out of supply. She stated the practitioner was responsible for signing orders when the pharmacy needed to refill a medication; however, the practitioner was not responsive and medications were not administered as required. Additional non compliance with practitioner's orders was revealed with Resident #3, #9, and #10.

Plan of correction

The state did not require a plan of correction for this citation.

1510Med/Med Adm-Rcrd Kpng MARS/S B▼

Findings

Based on record review and interview, the residence failed to accurately document each medication administration at the time the event was completed for each resident, affecting three of four sample residents (#3, #9, #14). Findings include:1. Residence Policy The residence's undated Medication Services Policy Statement read in part, "The medication assistance program consists of the following services for all residents electing to participate in the program: communication with physicians and pharmacists to ensure accuracy of medications...Aiding with monitoring and/or administering medications within the limits set forth in state regulations governing assisted living facilities. Maintaining current files on all medications, both prescription and non-prescription."2. Resident #14 was admitted to the residence on 4/21/22 with multiple diagnoses including type two diabetes, post traumatic stress disorder, anxiety and hypertension. Written practitioner's orders directed the residence to administer Simethicone 80 mg, daily; cranberry, 500 mg, twice daily; Preservision twice daily; famotidine 20 mg, twice daily; levothyroxine 88 mcg, daily; buspirone 5 mg, daily; furosemide 40 mg, daily; and fluticasone 500-50 mcg, twice daily. Review of the September 2023 medication administration record revealed no documentation as to whether or not the following medications were administered to the resident. Simethicone on 9/3, 9/5, 9/14/23. Cranberry on the evening of 9/5 and 9/13/23. Preservision on the evening of 9/14/23. Famotidine on 9/13 and 9/17/23. Levothyroxine on 9/9/23. Buspirone on the morning of 9/5 and the evening of 9/7, 9/9, 9/10, and 9/13/23. Metoprolol on the morning of 9/3 and 9/18/23; the evening of 9/24/23. Furosemide on 9/3 and 9/18/23. Fluticasone on the evening of 9/10, 9/12, 9/14, 9/19, 9/20, 9/21, 9/23 and 9/24/23. 3. Interviews On 9/29/23 at approximately 3:00 p.m. the administrator confirmed the administration of medication was not documented as required and stated she was not sure why staff were not documenting the administration of medication and she had been working with the staff to ensure proper documentation. Additional non compliance with documentation of medications was revealed with Resident #3 and #9.

Plan of correction

The state did not require a plan of correction for this citation.

5/16/2023Revisit: Licensure Complaint · ID E8FU131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 5/17/23 for the previous deficiency cited on 1/11/21. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 7/1/20 and the Chapter VII regulations were implemented on 6/14/21. The deficiency cited for Event E8FU12 was cited prior to the regulation revision that was implemented on 6/14/21.

Plan of correction

The state did not require a plan of correction for this citation.

0540Admin-Dts RespS/S B▼

Findings

Based on interview and record review, the administrator failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 48 current residents. Findings include:Chapter II regulations governing assisted living residences, part 12.2.2, requires the following:Infection Control Officer(A) Applicability(1) The requirements of this part 12.2.2 shall apply to the following licensed facility types only, except where otherwise indicated:(a) Assisted Living Residences.(B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following:(1) Completing an infection prevention and control training from a nationally-recognized provider within two (2) weeks of appointment/designation that meets the following requirements based on facility type;(b) Infection Control Officers at assisted living residences and all group homes for persons with intellectual and developmental disabilities shall complete at least 1.5 hours of initial training.(3) Providing on-site management of infectious disease prevention and response activities and general infection prevention duties;(4) Ensuring the facility complies with Department reporting requirements related to infectious diseases;(5) Providing facility access to, and ensuring proper supply, use, handling, and implementation of Personal Protective Equipment (PPE) and disinfectants, used per manufacturer's guidelines;(6) Maintaining a facility respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard (29 CFR 1910.134);(7) Advising and educating residents, staff, and visitors on current precautions being taken in the facility for infectious diseases and the prevention of their spread; and(8) Notifying residents, designated representatives, and staff of updated Centers for Disease Control (CDC) vaccination recommendations, and ensuring vaccines for infectious diseases are available to staff and residents inside their facility within sixty (60) days of any update to the CDC's vaccine recommendations. The 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 assign at least one staff member to complete training in infection prevention and control (IPC) and provide on-site management of infectious disease prevention and response activities and general infection prevention duties. The residence's undated COVID-19 ongoing vaccination and treatment plan read in part that the vaccination and treatment coordinators of the residence were the acting administrator (AA) and the resident care coordinator (RCC). On 5/16/23 at 9:45 a.m., documentation of training in infection prevention and control was requested for either the AA or the RCC.On 5/16/23 at 12:10 p.m., the acting administrator stated she was not aware of the requirement for the staff member responsible for the site management of the facility's IPC program to complete IPC training from a nationally-recognized provider. At 1:45 p.m., she stated that the administrator of record, who was no longer an employee at the residence, had completed the required training. She added, however, that neither she nor the RCC completed the required training.

Plan of correction · submitted by the facility

Administrator will complete IP Certification by date of compliance. Management Company/designee will monitor to ensure that facility continues to have a staff member assigned to IP duties who has completed the certification requirements. This will be included in QMP process for review and recommendations for improvement, if necessary.

5/16/2023State Certification and State Certification Complaint (Combined) · ID EI5T113 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A recertification survey with complaints #CO31703 and #CO32061 was completed on 5/17/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0212Acf-Part Elig AssessS/S B▼

Findings

Based on record review and interview, the facility (residence) failed to document a comprehensive assessment in the resident's health information record and conduct an assessment whenever there was a significant change in the participant's (resident's) needs, affecting three of three sample residents (#6-#8). Findings include:1. Residence PolicyThe residence's Change of Condition Policy, dated 6/17/22, read in part that if a change in condition lasted longer than two weeks, the residence completed a comprehensive assessment. 2. Record Reviewa. Resident #6 was admitted to the residence on 8/5/21. On 5/16/23 and 5/17/23, the resident record for Resident #6 did not include any assessments at all. On 5/17/23 at 10:20 a.m., the acting administrator (AA) stated the assessment for Resident #6 should have been in the resident record, but she acknowledged that it was not. She stated she was aware of the requirement that the residence keep the comprehensive assessment documented in writing in the resident's health information record. The AA stated the former management team, who worked at the residence prior to her start date on 2/28/23, did not maintain resident records properly.b. Resident #7 was admitted to the residence on 7/24/21 with diagnoses including dementia and depression. An assessment, dated 6/13/22, read in part that Resident #7 required assistance with bathing two times weekly and required minimal assistance and reminders with dressing. On 5/16/23 at 11:07 a.m., Staff #5 stated that for three weeks prior to the onsite investigation, Resident #7 refused shower assistance, so she did not provide the assistance. On 5/16/23 at 8:19 a.m., a staff who wished to remain anonymous stated Resident #7 required assistance with showering and dressing. However, she consistently refused assistance with showers and changing her clothes. She stated the residence did not reassess the resident when she started refusing care approximately four months prior to the onsite investigation. On 5/16/23 at approximately 12:30 p.m., a staff member who wished to remain anonymous stated that Resident #7 frequently refused assistance with bathing and dressing. S/he stated that only two staff were able to assist her with bathing because they attempted more than once and they used a verbal tone and approach that the resident responded to in a positive manner. The anonymous staff stated that the acting administrator was responsible for updating resident assessments when there was a change in baseline status, but she did not do so for Resident #7. On 5/17/23 at 8:40 a.m., Staff #6 stated Resident #7 had been refusing bathing assistance for three months prior to the onsite investigation. She stated she was not aware as to whether the resident's assessment was updated.c. Resident #8 was admitted to the residence on 6/1/21 with diagnoses including neurocognitive disorder and vascular dementia. An assessment, dated 5/24/21, read in part that Resident #8 read that the resident was on a diuretic which caused increased urination, that the resident was incontinent, and that the resident used incontinence products. In addition, the assessment read that the resident utilized the toilet with no assistance. On 5/16/23 at 11:07 a.m., Staff #5 stated that Resident #8 was incontinent and required two hour checks because he had bowel and bladder incontinence. She stated staff sometimes had to change his clothing in the middle of the day due to incontinence. On 5/16/23 at approximately 12:30 p.m., a staff member who wished to remain anonymous stated Resident #8 had been demonstrating increased confusion and disorientation for at least two months prior to the onsite investigation. S/he added that during this time, he had more incontinence of bowel and bladder, needed reminders for all meals, and was observed using a dining room chair instead of his walker. The anonymous staff stated the residence did not update the comprehensive assessment when the resident had a change in baseline status. On 5/16/23 at 8:19 a.m., a staff who wished to remain anonymous stated Resident #8 had several bladder and bowel accidents daily for at least two months prior to the onsite investigation. S/he stated he now required full staff assistance with bathing, toileting, and getting dressed. On 5/17/23 at 8:40 a.m., Staff #6 stated Resident #8 required full assistance with showering, dressing, and toileting. She stated for approximately the nine months up to the date of the onsite investigation, the resident had steadily declined and needed more assistance with all cares. On 5/17/23 at 10:20 a.m., the acting administrator stated she was currently responsible for completing assessments 30 days after the resident's admission date, 90 days after the resident's admission date, and annually. She stated she was aware of the requirement to update resident assessments whenever the resident's condition changed from baseline status. The AA stated when she started working at the residence (2/28/23), Residents #7 and #8 were already in their current condition, but she acknowledged she had not reviewed or updated the assessments at all. She added that the former management team should have completed an assessment when the residents' condition changed from baseline status, but they failed to do so.

Plan of correction · submitted by the facility

Resident #6, #7, #8: assessment will be reviewed, by date of compliance, to ensure that it is up to dateAdministrator will be educated on ensuring that assessments are updated after a resident change of conditionAdministrator/designee will complete an audit of current resident assessments, by date of compliance, to ensure that they accurately reflect residents’ current condition and needsResident assessments will be reviewed and updated at least annually, and with any change of condition, to accurately reflect residents’ current condition and needs. Administrator/designee will complete an audit of fifteen resident charts per month, for three months, to ensure that assessments are up to date and reflect residents’ current conditions and needs. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

0626Acf-Prov Role/Resp Env StndsS/S B▼

Findings

Based on observation, record review, and interview, the residence (facility) failed to provide an environment that supported individual comfort and preference and maintained a home-like quality and feel, affecting two of two residents (participants) (#6, #11) whose room had mice. Findings include:1. References and Residence Policya. According to the Centers for Disease Control and Prevention (CDC), "Mice are known to carry many diseases. These diseases can spread to people directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people. Many diseases do not cause any apparent illness in rodents, so you cannot tell if a rodent is carrying a disease just by looking at it. Infestation of rodents in and around the home is the main reason disease spreads from rodents to people. Two classic signs of rodent presence are rodent droppings and gnaw marks." CDC (1/3/23) How to Control Wild Rodent Infestations, retrieved from: https://www.cdc.gov/healthypets/pets/wildlife/rodent-control.html b. According to Terminix.com, "Mouse droppings are generally an eighth to a quarter of an inch in length ... Mouse droppings may resemble dark grains of rice." Terminix. Com (2023) How to Identify Mouse Droppings, retrieved from: https://www.terminix.com/rodents/mice/how-to-identify-mouse-droppings/ c. The residence's Pest Control Policy, dated 8/16/22, read in part that the administrator was assigned the responsibility of coordinating efforts to effectively control or eradicate unwanted pests. 2. Record ReviewA document titled Weekly Operations Report, dated for the week of 5/8/23 to 5/14/23 and provided by the acting administrator (AA), read in part that the shared room of Residents #6 and #11 had mice. It further read that the "exterminator has been called but will not come in until the room is clean. (The AA) called (an outside agency representative) to assist; (the AA) spoke with (the) resident and (she) agreed to allow staff to help clean out her room. Once it has been clean (sic) the exterminator will come in."3. ObservationsTwo photos on the phone of an anonymous staff, dated 5/13/23 at 2:25 p.m. were provided. One photo revealed six pellets resembling mouse excrement near a computer monitor on the table in the common living area of Resident #6 and #11's room. Another photo revealed five pellets resembling mouse excrement on Resident #6's bed. On 5/16/23, at 1:27 p.m., a room shared by Residents #6 and #11 consisted of a shared common area and two separate bedrooms. The common area contained approximately 12 stacks of cardboard boxes, plastic storage bins, bags and other items that measured approximately four feet in height. It covered an approximate area of six feet by four feet of the floor in the shared common area of the room. Behind the door of Resident #6's bedroom door, there were three stacked boxes. Next to the resident's bed were two stacked boxes, and the floor was covered with a number of miscellaneous personal items including at least four blankets, several bags of unknown items, a table lamp, two boxes of vinyl gloves, incontinence supplies, clothing, a bathroom rug, and a box for a 32 inch television. On a table in the common area of the room were approximately 10 pellets resembling mouse excrement. Within Resident #6's bedroom there was one pellet on the heating unit under the window and two pellets on a table. On 5/16/23 at 3:13 p.m., one small plastic black box containing mouse poison was under the table in the shared common area of Resident #6 and #11's room. Another similar box was behind the door of Resident #6's bedroom. 4. Interviews On 5/16/23 at 8:19 a.m., a staff member who wished to remain anonymous stated s/he had reported to the AA within the three months prior to the onsite investigation that s/he had seen evidence of live mice in Resident #6's room likely due to clutter that accumulated in the resident's room. S/he stated s/he had not seen a pest control company assess or treat the mice, adding that s/he did not see that the residence had taken action to mitigate the infestation. The anonymous staff stated that s/he and two other staff saw live mice in the room within two months prior to the onsite investigation, adding that s/he had seen a mouse leave Resident #6's room and enter the adjacent shared room where Resident #11 resided. S/he stated mice and mouse droppings did not lend to safe and sanitary living conditions. On 5/16/23 at 9:36 a.m., the AA stated that Resident #6 complained that there were live mice in her room approximately one week prior to the onsite investigation. She stated the resident did not allow staff to go through her belongings to clean out the room. The AA stated she called a pest control company, who came to the residence and informed her that they could not treat the room until the resident's room was clean. She added that she had also telephoned an outside agency representative (OAR) to advise her on how to approach cleaning the resident's room but had not yet received a return telephone call. On 5/16/23 at 11:07 a.m., Staff #5 stated she had heard from an unknown staff that Resident #6 had live mice in her room approximately three months prior to the onsite investigation. On 5/16/23 at 2:28 p.m., the OAR stated she had a voicemail message from 5/15/23 (the day before the onsite investigation) from the AA. She stated that the AA did not leave details about the reason for her call in the voicemail. On 5/16/23 at 2:59 p.m., the resident care coordinator (RCC) stated an unknown staff had reported to her that they had seen mouse excrement in Resident #6 and #11's shared room, but they did not report seeing live mice. She stated she reached out to a pest control company with whom the residence had no contract approximately one and one half weeks prior to the onsite investigation. The RCC stated she asked a representative from the pest control company what access they needed to the room in order to assess and treat a mouse infestation. She stated the unknown representative responded that the workers would need access to the corners of the residents' rooms. The RCC stated she and the AA decided to wait to schedule an appointment with the pest control company until the rooms were cleaned. On 5/16/23 at 3:13 p.m., Resident #6 stated she had seen a mouse in her room approximately one week prior to the onsite investigation. She stated she had notified staff about the mice. She stated that a staff member had assisted her with organizing her room approximately two months prior to the onsite investigation, and she saw a mouse which "scared her out the door." Resident #6 stated the residence would not take steps to treat her room for mice without cleaning and organizing her things, but she did not want staff to go through her belongings. Resident #6 stated she bought mouse poison, but it was not effective. She stated she had seen mouse droppings on her dishes, and she had to wash them before and after each time she used them. Resident #6 stated she had seen them come out of her bedroom and go into Resident #11's bedroom. She stated having mice and mouse droppings in the home was not sanitary, but she had not seen that the residence had taken action to mitigate the problem. On 5/17/23 at 7:50 a.m. a manager at the pest control company (that the RCC stated she had called) stated that the company had no record that anyone from the residence's address, including the AA and RCC, had called at all within the last two to three weeks of the onsite investigation. He stated the pest control company would not have refused to come to the residence due to clutter or boxes, adding that they would have sent out a representative to the residence no matter what the conditions were, contrary to the AA and RCC's interviews and documentation above. On 5/17/23 at 8:40 a.m., Staff #6 stated that Staff #7 had shown her photos of mouse excrement she had seen in Residents #6 and #11's room on 5/13/23. She stated Staff #7 had sent these photos to the RCC. She stated she did not see anyone from a pest control company at the residence for the nine months that she had worked at the residence. Staff #6 stated that having mice and mouse excrement in the resident rooms was "absolutely" unsanitary and not safe. She added, however, that the AA and RCC stated they would not schedule a pest control appointment until the room was cleaned. She stated that this was "not fair" to Resident #11 nor to the residents living in rooms adjacent to theirs. On 5/17/23 at 9:15 a.m., Staff #8 stated that Resident #11 reported to her that she had seen a mouse approximately two weeks prior to the onsite investigation. She stated she reported it to the AA who called a pest control company the next day, contrary to the above interviews. Staff #8 stated she had heard from other staff that the pest control company came to the residence. On 5/17/23 at 10:20 a.m., the AA stated that Resident #11 had reported seeing live mice on her bed. She stated, however, that she had not seen them and no staff had sent her photos of the mouse droppings. The AA then stated, contrary to her previous statement, that Staff #7 had sent her photos, but she thought they were bed bugs at first.

Plan of correction · submitted by the facility

Resident #6 & #11: Pest control company was contacted and was on-site on 5/20/23 and addressed cited pest problems in resident’s rooms, no further issues noted. Contract executed with Pest Control company to provide services to facility quarterly, and as needed in between services. Administrator/designee will complete an audit of all resident rooms, at least monthly, for three months, to ensure that resident rooms remain pest free, and will resolve any issues identified. Results of audits will be included in QMP process for 3 months for review and/or recommendations for improvement, if necessary.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼

Findings

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Plan of correction · submitted by the facility

Resident #3, #9, #10: residents are currently receiving medications as ordered and information is being documented appropriately. Resident #12: no longer resides at facilityAdministrator/designee will complete an audit, by date of compliance, of current residents’ medication administration records for accuracy and completeness, including that each has a legible list of the names of the persons utilizing the record for medication administration, their signatures and initials, and resolve any issues identified. QMAP's will be re-educated by date of compliance on medication administration and appropriate documentation in resident MAR.Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring. Administrator/designee will complete an audit, at least quarterly, of resident medication administration records for accuracy and completeness, and will resolve any issues identified. Results of audits will be included in QMP process for 3 months for review and/or recommendations for improvement, if necessary.

9999Final observationsSurveyor note▼

Findings

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. 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. C.3. The Care Plan must include proper documentation supporting the modification, which includes but is not limited to:a. Identification of a specific and individualized assessed need;b. Documentation of the positive interventions and less intrusive methods that have been used to support the well-being and needs of the participant;c. Informed consent of the participant or their guardian/other legal representative;d. Documentation of the participant's case manager involvement of any rights modification; ande. Modifications to the Care Plan and supporting documentation must be reviewed, at a minimum, on an annual basis.

Plan of correction

The state did not require a plan of correction for this citation.

5/16/2023Revisit: Licensure Complaint · ID ELBO122 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 5/17/23 for all previous deficiencies cited on 1/11/21. Deficiencies were cited. The regulations governing Assisted Living Residences were revised and the new regulations were implemented on 6/14/21. The deficiencies cited for Event ELBO11 were cited prior to the regulation revision that was implemented on 6/14/21.

Plan of correction

The state did not require a plan of correction for this citation.

0540Admin-Dts RespS/S B▼

Findings

Based on interview and record review, the administrator failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 48 current residents. Findings include:Chapter II regulations governing assisted living residences, part 12.2.2, requires the following:Infection Control Officer(A) Applicability(1) The requirements of this part 12.2.2 shall apply to the following licensed facility types only, except where otherwise indicated:(a) Assisted Living Residences.(B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following:(1) Completing an infection prevention and control training from a nationally-recognized provider within two (2) weeks of appointment/designation that meets the following requirements based on facility type;(b) Infection Control Officers at assisted living residences and all group homes for persons with intellectual and developmental disabilities shall complete at least 1.5 hours of initial training.(3) Providing on-site management of infectious disease prevention and response activities and general infection prevention duties;(4) Ensuring the facility complies with Department reporting requirements related to infectious diseases;(5) Providing facility access to, and ensuring proper supply, use, handling, and implementation of Personal Protective Equipment (PPE) and disinfectants, used per manufacturer's guidelines;(6) Maintaining a facility respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard (29 CFR 1910.134);(7) Advising and educating residents, staff, and visitors on current precautions being taken in the facility for infectious diseases and the prevention of their spread; and(8) Notifying residents, designated representatives, and staff of updated Centers for Disease Control (CDC) vaccination recommendations, and ensuring vaccines for infectious diseases are available to staff and residents inside their facility within sixty (60) days of any update to the CDC's vaccine recommendations. The 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 assign at least one staff member to complete training in infection prevention and control (IPC) and provide on-site management of infectious disease prevention and response activities and general infection prevention duties. The residence's undated COVID-19 ongoing vaccination and treatment plan read in part that the vaccination and treatment coordinators of the residence were the acting administrator (AA) and the resident care coordinator (RCC). On 5/16/23 at 9:45 a.m., documentation of training in infection prevention and control was requested for either the AA or the RCC.On 5/16/23 at 12:10 p.m., the acting administrator stated she was not aware of the requirement for the staff member responsible for the site management of the facility's IPC program to complete IPC training from a nationally-recognized provider. At 1:45 p.m., she stated that the administrator of record, who was no longer an employee at the residence, had completed the required training. She added, however, that neither she nor the RCC completed the required training.

Plan of correction · submitted by the facility

Administrator will complete IP Certification by date of compliance. Management Company/designee will monitor to ensure that facility continues to have a staff member assigned to IP duties who has completed the certification requirements. This will be included in QMP process for review and recommendations for improvement, if necessary.

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interview the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting three of three sample residents (#3, #9, #10) and one former resident (#12) whose medications administration records (MARs) were reviewed. This deficiency was cited previously during a state licensure survey on 1/11/21. Although the residence corrected this deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's medication administration policy, dated June 2022, read in part that if a resident was unavailable to receive a scheduled medication or if the medication itself was unavailable, the qualified medication administration person (QMAP) circled their initials and then documented the reason for the missed medication on the reverse side of the medication administration record (MAR). All medication requests from the pharmacy and family members were documented on a prescription reorder log; medications not received by the next working day were followed up on daily until the medication was received. Staff were to notify the administrator and resident care coordinator (RCC) of any missed doses. 2. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including anxiety, chronic obstructive pulmonary disease, gastroesophageal reflux disease (GERD), skin irritation, and osteoarthritis.a. Zinc OxideA written practitioner's order, dated 2/6/23, directed the residence to administer zinc oxide 40% topical ointment twice daily. However, the March, April, and May 2023 MARs read the residence failed to administer the medication for the morning doses on 3/7-3/9, 3/19-3/24, 3/28-3/31, 4/4-4/6, 4/23-4/27, and 5/2-5/5. Additionally, the residence failed to administer the evening doses on 3/4, 3/7-3/9, 3/11-3/20, 3/23, 3/24, 3/26-3/31, 5/1-5/7, 5/9, 5/10, and 5/13/23, for a total of 57 missed doses.b. FluticasoneA written practitioner's order, dated 2/6/23, directed the residence to administer fluticasone 250 mcg-salmeterol 50 mcg one puff twice daily. However, the March, April, and May 2023 MARs read the residence failed to administer the medication for the morning doses on 3/8, 3/14, 3/15, 4/16-5/2/23. Additionally, the residence failed to administer the evening doses on 3/12-3/15, 4/16-4/27, and 4/30-5/2/23, for a total of 39 missed doses.c. BenzonatateA written practitioner's order, dated 3/8/23, directed the residence to administer benzonatate 100 mg three times daily. However, the April and May 2023 MARs read the residence failed to administer the medication for one dose on 3/8/23, for two doses on 5/4/23 and for all three doses 4/25-5/3/23, for a total of 30 missed doses.d. SpirivaA written practitioner's order, dated 2/6/23, directed the residence to administer Spiriva 18 mcg and inhalation capsule daily. However, the March, April, and May 2023 MARs read the residence failed to administer the medication on 3/30, 4/16-4/20, 4/23-5/3, and 5/5/23, for a total of 18 missed doses.e. GuaifenesinA written practitioner's order, dated 2/6/23, directed the residence to administer guaifenesin 1200 mg twice daily. However, the March and April 2023 MARs read the residence failed to administer the medication for the morning doses on 3/19-3/24, 3/26, and 3/27/23. Additionally, the residence failed to administer the evening doses on 3/12, 3/16-3/18, 3/20-3/24, 4/29/23, for a total of 18 missed doses.f. SertralineA written practitioner's order, dated 2/6/23, directed the residence to administer sertraline 100 mg daily. However the March, April, and May 2023 MARs read the residence failed to administer the medication on 3/28-4/2 and 5/4/23, for a total of seven missed doses.g. MeclizineA written practitioner's order, dated 2/6/23, directed the residence to administer meclizine 25 mg daily. However, the April 2023 MAR read the residence failed to administer the medication on 4/2-4/5/23, for a total of four missed doses.h. Vitamin B12A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin B12 1000 mcg daily. However the March 2023 MAR read the residence failed to administer the medication on 3/7-3/9, and 3/16, for a total of four missed doses.i. AspirinA written practitioner's order, dated 2/6/23, directed the residence to administer aspirin 81 mg daily. However the March 2023 MAR read the residence failed to administer the medication on 3/7 and 3/8/23, for a total of two missed doses.j. FurosemideA written practitioner's order, dated 2/6/23, directed the residence to administer furosemide 20 mg daily. However the March 2023 MAR read the residence failed to administer the medication on 3/30 and 3/31/23, for a total of two missed doses.k. OmeprazoleA written practitioner's order, dated 2/6/23, directed the residence to administer omeprazole 40 mg daily. However, the March 2023 MARs read the residence failed to administer the medication on 3/30/31, for one missed dose. 3. Resident #9 was admitted to the residence on 7/23/16 with diagnoses including bipolar disorder, anxiety, paranoia, GERD, hypothyroidism, chronic pain, and arthritis.a. SertralineA written practitioner's order, dated 3/5/23, directed the residence to administer sertraline 50 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/6-3/18, 3/20, and 3/21/23, for a total of 17 missed doses.b. LatudaA written practitioner's order, dated 3/5/23, directed the residence to administer Latuda 40 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/5-3/16, 3/19, 4/5,4/13/23, for a total of 15 missed doses.c. FluticasoneA written practitioner's order, dated 3/5/23, directed the residence to administer fluticasone 50 mcg two sprays in each nostril daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/14-3/19, 4/7, and 4/23/23, for a total of eight missed doses. d. MetoprololA written practitioner's order, dated 3/5/23, directed the residence to administer metoprolol 25 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/19 and 3/29-4/4/23, for a total of eight missed doses.e. ClopidogrelA written practitioner's order, dated 3/5/23, directed the residence to administer clopidogrel 75 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/29-4/42/23, for a total of seven missed doses.f. OlanzapineA written practitioner's order, dated 3/5/23, directed the residence to administer olanzapine 7.5 mg at bedtime. However, the March 2023 MAR read the residence failed to administer the medication on 3/28-3/31/23, for a total of three missed doses.g. SimethiconeA written practitioner's order, dated 3/5/23, directed the residence to administer simethicone 125 mg three times daily. However, the March 2023 MAR read the residence failed to administer the medication for one dose on 3/17-3/19 and 4/1/23, for two doses on 3/16/23, for a total of six missed doses.h. AcetaminophenA written practitioner's order, dated 3/5/23, directed the residence to administer acetaminophen 1000 mg three times daily. However, the March and April 2023 MAR read the residence failed to administer the medication for three doses on 3/31/23, for two doses on 4/1, and one dose on 4/22/23, for a total of six missed doses.i. FamotidineA written practitioner's order, dated 3/5/23, directed the residence to administer famotidine 10 mg every night. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/27, 3/30, and 4/20/23, for a total of three missed doses.j. Isosorbide MononitrateA written practitioner's order, dated 3/5/23, directed the residence to administer isosorbide mononitrate 30 mg daily. However, the April MAR read the residence failed to administer the medication on 4/1-4/3/23, for a total of three missed doses.k. BuspironeA written practitioner's order, dated 3/5/23, directed the residence to administer buspirone 15 mg three times daily. However, the March 2023 MAR read the residence failed to administer the medication for one dose on 3/26 and 3/27/23, for a total of two missed doses.l. LamotrigineA written practitioner's order, dated 3/5/23, directed the residence to administer lamotrigine 300 mg daily. However, the April 2023 MAR read the residence failed to administer the medication on 4/2 and 4/3/23, for a total of two missed doses. m. LevothyroxineA written practitioner's order, dated 3/5/23, directed the residence to administer levothyroxine 75 mcg daily. However, the April 2023 MAR read that the residence failed to administer the medication on 4/24/23, for one missed dose. 4. Resident #10 was admitted to the residence on 2/17/22 with diagnoses including dementia, hypokalemia, hyperlipidemia, hypothyroidism, and hypertension.a. HydrochlorothiazideA written practitioner's order, dated 2/6/23, directed the residence to administer hydrochlorothiazide 50 mg daily. However the March and April 2023 MARs read the residence failed to administer the medication on 3/22-3/26, 3/29, and 4/1-4/10/23, for a total of 16 missed doses. b. MetoprololA written practitioner's order, dated 2/6/23, directed the residence to administer metoprolol 25 mg every morning and every night. However, the March 2023 MAR read the residence failed to administer the medication for the morning doses on 3/22-3/25, 3/27, and 4/12/23. Additionally, the residence failed to administer the evening doses on 3/15-3/18, 3/20-3/22, and 3/24-3/26/23, for a total of 16 missed doses. c. AspirinA written practitioner's order, dated 2/6/23, directed the residence to administer aspirin 81 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/7-3/9, 3/14-3/16, 3/19-3/24, 3/30, and 4/2/23, for a total of 14 missed doses. d. Potassium ChlorideA written practitioner's order, dated 2/6/23, directed the residence to administer potassium chloride 20 mEq daily. However the March and April MARs read the residence failed to administer the medication on 3/22-3/26, 3/29, and 3/31-4/6/23, for a total of 13 missed doses. e. Vitamin D3A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 50 mcg. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/22-3/25, and 3/28-4/4/23, for a total of 12 missed doses.f. FluoxetineA written practitioner's order, dated 2/6/23, directed the residence to administer fluoxetine 40 mg every morning. However, the April 2023 MAR read the residence failed to administer the medication on 4/1-4/11/23, for a total of 11 missed doses.g. LevothyroxineA written practitioner's order, dated 2/6/23, directed the residence to administer levothyroxine 137 mcg daily. However, the March, April, and May 2023 MARs read the residence failed to administer the medication on 3/16, 4/4-4/6, 4/9, 4/10, and 5/11-5/15/23, for a total of 11 missed doses. h. MelatoninA written practitioner's order, dated 2/6/23, directed the residence to administer melatonin 5 mg at bedtime. However the March 2023 MAR read the residence failed to administer the medication on 3/16-3/19, 3/22, and 3/25-3/28/23, for a total of nine missed doses.i. LosartanA written practitioner's order, dated 2/6/23, directed the residence to administer losartan 75 mg every morning. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/30-4/2/23, for a total of four missed doses.j. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine 10 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/30-4/2/23, for a total of four missed doses.k. NeurivaA written practitioner's order, dated 2/6/23, directed the residence to administer Neuriva one tablet daily. However, the April 2023 MAR read the residence failed to administer the medication on 4/2, 4/4, 4/5, and 4/11/23, for a total of four missed doses.l. Centrum SilverA written practitioner's order, dated 2/6/23, directed the residence to administer Centrum Silver one tablet daily. However, the April 2023 MAR read the residence failed to administer the medication on 4/2 and 4/4/223, for a total of two missed doses. 5. Former Resident #12 was admitted to the residence on 11/2/21 with diagnoses including anemia, anxiety, bipolar disorder, depression, GERD, history of ankle fracture, arthritis, and cyclic vomiting syndrome.a. Diclofenac Sodium 1% GelA written practitioner's order, dated 2/4/23, directed the residence to administer diclofenac sodium 1% gel every six hours. However, the March and April 2023 MARs read the residence failed to administer the medication for one dose on 3/1-3/9, 3/12-3/20, 3/27, and 4/2-4/8/23; for two doses on 3/22, 3/29, and 3/30/23; and for three doses on 3/21, 3/23, 3/24, and 3/28/23, for a total of 44 missed doses.b. LubiprostoneA written practitioner's order, dated 2/4/23, directed the residence to administer lubiprostone 24 mcg twice daily. However, the March 2023 MAR read the residence failed to administer the medication for the morning doses on 3/4, 3/5, 3/7-3/15, 3/17-3/21/23. Additionally, the residence failed to administer the evening doses on 3/4-3/10, 3/12-3/18/23, for a total of 30 missed doses.c. DuloxetineA written practitioner's order, dated 2/4/23, directed the residence to administer duloxetine 60 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/2-3/13, and 3/15-3/18/23, for a total of 16 missed doses.d. LamotrigineA written practitioner's order, dated 2/4/23, directed the residence to administer lamotrigine 50 mg daily. However, the March MAR read the residence failed to administer the medication on 3/4-3/10 and 3/12-3/19/23, for a total of 15 missed doses.e. LisinoprilA written practitioner's order, dated 2/4/23, directed the residence to administer lisinopril 10 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/4, 3/5, 3/7-3/15, 3/17-3/19/23, for a total of 14 missed doses.f. MethimazoleA written practitioner's order, dated 2/4/23, directed the residence to administer methimazole 5 mg at bedtime. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/1-3/10 and 3/12-3/14/23, for a total of 13 missed doses.g. OmeprazoleA written practitioner's order, dated 2/4/23, directed the residence to administer omeprazole 20 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/3-3/15/23, for a total of 13 missed doses.h. OxybutyninA written practitioner's order, dated 2/4/23, directed the residence to administer oxybutynin 5 mg twice daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/3-3/15/23, for a total of 13 missed doses.i. Sertraline A written practitioner's order, dated 2/4/23, directed the residence to administer sertraline 150 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/4, 3/5, 3/8, 3/9, 3/13-3/15, and 3/17-3/21/23, for a total of 12 missed doses.j. Vitamin D3A written practitioner's order, dated 2/4/23, directed the residence to administer vitamin D3 25 mcg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/20-3/24, 3/26-3/30, 4/2, and 4/5/23, for a total of 12 missed doses.k. ClopidogrelA written practitioner's order, dated 2/4/23, directed the residence to administer clopidogrel 75 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/4, 3/5, and 3/7-3/15/23, for a total of 11 missed doses.l. AtorvastatinA written practitioner's order, dated 2/4/23, directed the residence to administer atorvastatin 80 mg at bedtime. However, the March 2023 MAR read the residence failed to administer the medication on 3/2-3/8, 3/10, 3/12, and 3/19/23, for a total of 10 missed doses.m. BiotinA written practitioner's order, dated 2/4/23, directed the residence to administer biotin 10 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/4, 3/5, 3/8, 3/9, 3/13, 4/4, and 4/5/23, for a total of seven missed doses.n. MeloxicamA written practitioner's order, dated 2/4/23, directed the residence to administer Meloxicam 7.5 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/10-3/13/23, for a total of four missed doses. 6. InterviewsOn 5/16/23 at 7:25 a.m., Staff #4 stated when she first started working at the residence, approximately 2 months prior to the onsite investigation, there was a period of time when the pharmacy was not delivering medications as ordered. She stated the administrator of record and the former RCC failed to follow up with the pharmacyOn 5/16/23 at 3:39 p.m., the acting administrator (AA) stated that circled QMAP initials on the MARs meant that the QMAP had not administered the medication as ordered by their practitioner, likely because the medications were out of stock. She acknowledged that there were no reasons listed on the back of the MAR as to why the staff's initials were circled. On 5/17/23 at 10:20 a.m., the AA stated she was aware of the requirement for the residence to comply with practitioner's orders, and she added there were pharmacy-related obstacles that the residence sometimes could not prevent. She stated she expected the residence staff to ensure all residents had at least a seven day supply of all medications. The AA stated that this deficiency that was previously cited was not corrected because the pharmacy sometimes sent fewer pills than required for the month. She added that the package had a sticker from the pharmacy on it that read that the pharmacy owed them the remainder of the medications for the month, meaning they would send them at a later date. The stated the pharmacy often sent the remainder after the residents ran out of medications, and the staff was unable to administer them because they were not in stock.

Plan of correction · submitted by the facility

Resident #3, #9, #10: residents MAR’s will be audited, by date of compliance, to ensure information is being documented appropriately. Resident #12: no longer resides in facilityAdministrator/designee will complete an audit, by date of compliance, of current residents’ medication administration records for accuracy and completeness, including that each has a legible list of the names of the persons utilizing the record for medication administration, their signatures and initials, and resolve any issues identified. QMAP's will be re-educated by date of compliance on medication administration and appropriate documentation in resident MAR.Administrator/designee will complete an audit, at least quarterly, of resident medication administration records for accuracy and completeness, and will resolve any issues identified. Results of audits will be included in QMP process for 3 months for review and/or recommendations for improvement, if necessary.

5/16/2023Revisit: Licensure Complaint · ID K1GZ131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 5/17/23 for the previous deficiency cited on 1/11/21. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 6/14/21. The deficiency cited for Event K1ZG12 was cited prior to the regulation revision that was implemented on 6/14/21.

Plan of correction

The state did not require a plan of correction for this citation.

0540Admin-Dts RespS/S B▼

Findings

Based on interview and record review, the administrator failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 48 current residents. Findings include:Chapter II regulations governing assisted living residences, part 12.2.2, requires the following:Infection Control Officer(A) Applicability(1) The requirements of this part 12.2.2 shall apply to the following licensed facility types only, except where otherwise indicated:(a) Assisted Living Residences.(B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following:(1) Completing an infection prevention and control training from a nationally-recognized provider within two (2) weeks of appointment/designation that meets the following requirements based on facility type;(b) Infection Control Officers at assisted living residences and all group homes for persons with intellectual and developmental disabilities shall complete at least 1.5 hours of initial training.(3) Providing on-site management of infectious disease prevention and response activities and general infection prevention duties;(4) Ensuring the facility complies with Department reporting requirements related to infectious diseases;(5) Providing facility access to, and ensuring proper supply, use, handling, and implementation of Personal Protective Equipment (PPE) and disinfectants, used per manufacturer's guidelines;(6) Maintaining a facility respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard (29 CFR 1910.134);(7) Advising and educating residents, staff, and visitors on current precautions being taken in the facility for infectious diseases and the prevention of their spread; and(8) Notifying residents, designated representatives, and staff of updated Centers for Disease Control (CDC) vaccination recommendations, and ensuring vaccines for infectious diseases are available to staff and residents inside their facility within sixty (60) days of any update to the CDC's vaccine recommendations. The 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 assign at least one staff member to complete training in infection prevention and control (IPC) and provide on-site management of infectious disease prevention and response activities and general infection prevention duties. The residence's undated COVID-19 ongoing vaccination and treatment plan read in part that the vaccination and treatment coordinators of the residence were the acting administrator (AA) and the resident care coordinator (RCC). On 5/16/23 at 9:45 a.m., documentation of training in infection prevention and control was requested for either the AA or the RCC.On 5/16/23 at 12:10 p.m., the acting administrator stated she was not aware of the requirement for the staff member responsible for the site management of the facility's IPC program to complete IPC training from a nationally-recognized provider. At 1:45 p.m., she stated that the administrator of record, who was no longer an employee at the residence, had completed the required training. She added, however, that neither she nor the RCC completed the required training.

Plan of correction · submitted by the facility

Resident #3, #9, #10: residents are currently receiving medications as ordered and information is being documented appropriately. Resident #12: no longer resides at facilityQMAP's will be re-educated by date of compliance on medication administration and appropriate documentation in resident MAR.Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring. Results of audits will be included in QMP process for next 3 months for review and/or recommendations for improvement, if necessary.

5/16/2023Revisit: Licensure Complaint · ID PFV3131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 5/17/23 for the previous deficiency cited on 1/11/21. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 7/1/20 and the Chapter VII regulations were implemented on 6/14/21. The deficiency cited for Event PFV312 was cited prior to the regulation revision that was implemented on 6/14/21.

Plan of correction

The state did not require a plan of correction for this citation.

0540Admin-Dts RespS/S B▼

Findings

Based on interview and record review, the administrator failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 48 current residents. Findings include:Chapter II regulations governing assisted living residences, part 12.2.2, requires the following:Infection Control Officer(A) Applicability(1) The requirements of this part 12.2.2 shall apply to the following licensed facility types only, except where otherwise indicated:(a) Assisted Living Residences.(B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following:(1) Completing an infection prevention and control training from a nationally-recognized provider within two (2) weeks of appointment/designation that meets the following requirements based on facility type;(b) Infection Control Officers at assisted living residences and all group homes for persons with intellectual and developmental disabilities shall complete at least 1.5 hours of initial training.(3) Providing on-site management of infectious disease prevention and response activities and general infection prevention duties;(4) Ensuring the facility complies with Department reporting requirements related to infectious diseases;(5) Providing facility access to, and ensuring proper supply, use, handling, and implementation of Personal Protective Equipment (PPE) and disinfectants, used per manufacturer's guidelines;(6) Maintaining a facility respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard (29 CFR 1910.134);(7) Advising and educating residents, staff, and visitors on current precautions being taken in the facility for infectious diseases and the prevention of their spread; and(8) Notifying residents, designated representatives, and staff of updated Centers for Disease Control (CDC) vaccination recommendations, and ensuring vaccines for infectious diseases are available to staff and residents inside their facility within sixty (60) days of any update to the CDC's vaccine recommendations. The 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 assign at least one staff member to complete training in infection prevention and control (IPC) and provide on-site management of infectious disease prevention and response activities and general infection prevention duties. The residence's undated COVID-19 ongoing vaccination and treatment plan read in part that the vaccination and treatment coordinators of the residence were the acting administrator (AA) and the resident care coordinator (RCC). On 5/16/23 at 9:45 a.m., documentation of training in infection prevention and control was requested for either the AA or the RCC.On 5/16/23 at 12:10 p.m., the acting administrator stated she was not aware of the requirement for the staff member responsible for the site management of the facility's IPC program to complete IPC training from a nationally-recognized provider. At 1:45 p.m., she stated that the administrator of record, who was no longer an employee at the residence, had completed the required training. She added, however, that neither she nor the RCC completed the required training.

Plan of correction · submitted by the facility

Administrator will complete IP Certification by date of compliance. Management Company/designee will monitor to ensure that facility continues to have a staff member assigned to IP duties who has completed the certification requirements. This will be included in QMP process for review and recommendations for improvement, if necessary.

5/16/2023Revisit: Licensure Complaint · ID RHKP121 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 5/17/23 for the previous deficiency cited on 1/11/21. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼

Findings

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Plan of correction · submitted by the facility

Resident #3, #9, #10: residents are currently receiving medications as ordered and information is being documented appropriately. Resident #12: no longer resides at facilityAdministrator/designee will complete an audit, by date of compliance, of current residents’ medication administration records for accuracy and completeness, including that each has a legible list of the names of the persons utilizing the record for medication administration, their signatures and initials, and resolve any issues identified. QMAP's will be re-educated by date of compliance on medication administration and appropriate documentation in resident MAR.Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring. Administrator/designee will complete an audit, at least quarterly, of resident medication administration records for accuracy and completeness, and will resolve any issues identified. Results of audits will be included in QMP process for 3 months for review and/or recommendations for improvement, if necessary.

5/16/2023Revisit: Licensure Complaint · ID TE43131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 5/17/23 for the previous deficiency cited on 1/11/21. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼

Findings

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Plan of correction · submitted by the facility

Resident #3, #9, #10: residents are currently receiving medications as ordered and information is being documented appropriately. Resident #12: no longer resides at facilityAdministrator/designee will complete an audit, by date of compliance, of current residents’ medication administration records for accuracy and completeness, including that each has a legible list of the names of the persons utilizing the record for medication administration, their signatures and initials, and resolve any issues identified. QMAP's will be re-educated by date of compliance on medication administration and appropriate documentation in resident MAR.Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring. Administrator/designee will complete an audit, at least quarterly, of resident medication administration records for accuracy and completeness, and will resolve any issues identified. Results of audits will be included in QMP process for 3 months for review and/or recommendations for improvement, if necessary.

5/16/2023Revisit: State Certification and State Certification Complaint (Combined) · ID YD9K141 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A certification revisit was completed on 5/17/23 for the the previous deficiency cited on 1/11/21. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0630Acf-Prov Role/Resp-Svc Req Med admn Pol/PrS/S B▼

Findings

This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Plan of correction · submitted by the facility

Resident #3, #9, #10: residents are currently receiving medications as ordered and information is being documented appropriately. Resident #12: no longer resides at facilityAdministrator/designee will complete an audit, by date of compliance, of current residents’ medication administration records for accuracy and completeness, including that each has a legible list of the names of the persons utilizing the record for medication administration, their signatures and initials, and resolve any issues identified. QMAP's will be re-educated by date of compliance on medication administration and appropriate documentation in resident MAR.Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring. Administrator/designee will complete an audit, at least quarterly, of resident medication administration records for accuracy and completeness, and will resolve any issues identified. Results of audits will be included in QMP process for 3 months for review and/or recommendations for improvement, if necessary.

5/16/2023Licensure and Licensure Complaint (Combined) · ID ZCVZ1111 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey with complaints #CO31702, #CO32000, and #CO32059 was completed on 5/17/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0260LicProc-ContOblig LOI chngs-CpctyS/S B▼

Findings

Based on observations, record review and interview, the licensee failed to notify the department of a change in administrator, at least 30 calendar days in advance, affecting 48 current residents. Findings include: 1. Record ReviewOn 5/16/23, the department's database read that the administrator of record, not the acting administrator, was the current administrator of the residence. 2. ObservationOn 5/16/23 At 11:38 a.m., the acting administrator (AA) provided a business card with her name identifying her as the administrator of the residence. 2. InterviewsOn 5/16/23 at 7:15 a.m., the residence's chef stated he had worked at the residence for approximately three months. He stated the AA started as the administrator of the residence approximately one month after he was hired. On 5/16/23 at 7:25 a.m., Staff #4 stated the AA had been the administrator for at least two months prior to the onsite investigation. On 5/16/23 at 8:19 a.m., a staff who wished to remain anonymous stated the acting administrator was hired as the administrator approximately two months prior to the onsite investigation. On 5/16/23 at 9:36 a.m., the AA stated she had been the administrator of the residence for approximately one month. At 1:45 p.m., she stated that she was aware of the requirement to notify the department within 30 days when there was a change in administrator, adding it was the residence's management company's responsibility. The AA, however, was unable to speak as to why the management company had not yet done so. On 5/16/23 at 11:07 a.m., Staff #5 stated that the AA started as the residence's administrator approximately three months prior to the onsite investigation. On 5/16/23 at 12:32 p.m., the business office manager stated that the AA officially became the administrator of the residence on 2/28/23. She stated that a representative from the residence's management company should have notified the department of the change in administrator. On 5/17/23 at 10:39 a.m., a representative from the department confirmed the residence had not submitted a request to change the administrator of record. The representative sent email correspondence that confirmed the administrator of record was listed as the current administrator as of 5/17/23.

Plan of correction · submitted by the facility

Change of Administrator notification was completed on 5/17/23Management Company/designee will notify the state within 30 days, or sooner if possible, of any facility administrator change. This will be completed through the state web portal as required. Management Company/designee will complete an audit to monitor, quarterly or with any change in administrator, to ensure that any future administrator change is completed timely. Results of audits will be included in QMP process for 3 months for review and/or recommendations for improvement, if necessary.

0290LicProc-DeptOvrst-Srvy/Inspct Ensr Cmply-POCS/S B▼

Findings

Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting 48 current residents. Findings include:1. ReferenceRegulations governing assisted living residences, part 18.8, requires that resident records shall contain, but not be limited to, the following items:(A) Face Sheet;(B) Practitioner order;(C) Individualized resident care plan;(E) Medication Administration Record. 2. Record Reviewa. On 5/16/23 at 9:31 a.m., the following records were requested:Resident #6: Progress notes 3/1/23-5/16/23Resident #7: Face sheet, progress notes 3/1/23-5/16/23Resident #8: Face sheet, progress notes 3/1/23-5/16/23Resident #9: Medication administration records for March to May 2023 and written practitioner's ordersResident #10: Face sheet, progress notes 3/1/23-5/16/23, medication administration records for March to May 2023, and written practitioner's ordersResident #3: Medication administration records for March to May 2023 and written practitioner's ordersFormer Resident #12: Face sheet, progress notes 3/1/23-5/16/23, and written practitioner's orders.b. On 5/16/23 at 11:30 a.m., the following records were again requested:Resident #7: Face sheetResident #8: Face sheet Resident #9: Face sheet and written practitioner's orders.c. On 5/16/23, at 1:35 p.m. (approximately four hours after the original request), face sheets for Residents #7, #8, and #10 were provided.d. On 5/16/23 at 1:55 p.m. (approximately four and one-half hours after the original request), the April and May 2023 MARs for Residents #3, #9, and #10 were provided.e. On 5/16/23 at 2:08 p.m., the following records were provided (approximately four and one-half hours after the original request):Resident #3: March 2023 MARResident #10: March 2023 MARResident #9: written practitioner's orders.f. On 5/16/23 at 2:50 p.m.. the following records were again requested:Former Resident #12: Face sheet, written practitioner's orders, and progress notes.g. On 5/16/23 at 3:25 p.m., the following requested items were provided (approximately six hours after the original request):Resident #3: Written practitioner's ordersResident #6: Progress notesFormer Resident #12: Face sheet, written practitioner's orders, and progress notes. 3. InterviewsOn 5/16/23 at 12:32 p.m., the business office manager stated the acting administrator (AA) started her employment with the residence on 2/28/23. On 5/17/23 at 10:20 a.m., the AA stated she was unable to provide resident records as requested because the residence had used written documentation for all resident records, adding that they had no electronic documentation. She stated that the resident's documentation was filed in a box that was locked in a residence storage room. The AA stated there was turnover in the resident care coordinator (RCC) position prior to the start of her emplorment, adding that each RCC had their own filing system which made it difficult to retrieve requested documents. She stated that this was the reason she was unable to provide documents upon request.

Plan of correction · submitted by the facility

Facility will ensure that it provides, upon request, residence documents, staff information, and other records as requested by the department in a timely manner. Administrator/designee will complete an audit of current resident charts, by date of compliance, to ensure that each has a face sheet, practitioner orders, care plans, and MAR’s. Management Company/designee will monitor during any future survey to ensure that facility provides, upon request, residence documents, staff information, and other records as requested by the department in a timely manner, during any future survey. Administrator/designee will complete an audit of fifteen resident charts per month, for three months, to ensure that they have a face sheet, practitioner orders, care plans, and MAR’s. Management Company/designee will review audits completed for other citations (cross reference #1110, #1146, #1510, #1514, #1144, & #1468) for three months to ensure documentation is being completed and available. Results of audits will be included in QMP process for 3 months for review and/or recommendations for improvement, if necessary.

0540Admin-Dts RespS/S B▼

Findings

Based on interview and record review, the administrator failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 48 current residents. Findings include:Chapter II regulations governing assisted living residences, part 12.2.2, requires the following:Infection Control Officer(A) Applicability(1) The requirements of this part 12.2.2 shall apply to the following licensed facility types only, except where otherwise indicated:(a) Assisted Living Residences.(B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following:(1) Completing an infection prevention and control training from a nationally-recognized provider within two (2) weeks of appointment/designation that meets the following requirements based on facility type;(b) Infection Control Officers at assisted living residences and all group homes for persons with intellectual and developmental disabilities shall complete at least 1.5 hours of initial training.(3) Providing on-site management of infectious disease prevention and response activities and general infection prevention duties;(4) Ensuring the facility complies with Department reporting requirements related to infectious diseases;(5) Providing facility access to, and ensuring proper supply, use, handling, and implementation of Personal Protective Equipment (PPE) and disinfectants, used per manufacturer's guidelines;(6) Maintaining a facility respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard (29 CFR 1910.134);(7) Advising and educating residents, staff, and visitors on current precautions being taken in the facility for infectious diseases and the prevention of their spread; and(8) Notifying residents, designated representatives, and staff of updated Centers for Disease Control (CDC) vaccination recommendations, and ensuring vaccines for infectious diseases are available to staff and residents inside their facility within sixty (60) days of any update to the CDC's vaccine recommendations. The 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 assign at least one staff member to complete training in infection prevention and control (IPC) and provide on-site management of infectious disease prevention and response activities and general infection prevention duties. The residence's undated COVID-19 ongoing vaccination and treatment plan read in part that the vaccination and treatment coordinators of the residence were the acting administrator (AA) and the resident care coordinator (RCC). On 5/16/23 at 9:45 a.m., documentation of training in infection prevention and control was requested for either the AA or the RCC.On 5/16/23 at 12:10 p.m., the acting administrator stated she was not aware of the requirement for the staff member responsible for the site management of the facility's IPC program to complete IPC training from a nationally-recognized provider. At 1:45 p.m., she stated that the administrator of record, who was no longer an employee at the residence, had completed the required training. She added, however, that neither she nor the RCC completed the required training.

Plan of correction · submitted by the facility

Administrator will complete IP Certification by date of compliance. Management Company/designee will monitor to ensure that facility continues to have a staff member assigned to IP duties who has completed the certification requirements. This will be included in QMP process for review and recommendations for improvement, if necessary.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Based on observation, record review, and interview, the residence failed to make available, either directly or indirectly through a resident agreement, a physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting two of two sample residents (#6, #11) whose room had mice. (Cross-reference Q2712)Findings include:1. References and Residence Policya. According to the Centers for Disease Control and Prevention (CDC), "Mice are known to carry many diseases. These diseases can spread to people directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people. Many diseases do not cause any apparent illness in rodents, so you cannot tell if a rodent is carrying a disease just by looking at it. Infestation of rodents in and around the home is the main reason disease spreads from rodents to people. Two classic signs of rodent presence are rodent droppings and gnaw marks." CDC (1/3/23) How to Control Wild Rodent Infestations, retrieved from: https://www.cdc.gov/healthypets/pets/wildlife/rodent-control.html b. According to Terminix.com, "Mouse droppings are generally an eighth to a quarter of an inch in length ... Mouse droppings may resemble dark grains of rice." Terminix. Com (2023) How to Identify Mouse Droppings, retrieved from: https://www.terminix.com/rodents/mice/how-to-identify-mouse-droppings/ c. The residence's Pest Control Policy, dated 8/16/22, read in part that the administrator was assigned the responsibility of coordinating efforts to effectively control or eradicate unwanted pests. 2. Record ReviewA document titled Weekly Operations Report, dated for the week of 5/8/23 to 5/14/23 and provided by the acting administrator (AA), read in part that the shared room of Residents #6 and #11 had mice. It further read that the "exterminator has been called but will not come in until the room is clean. (The AA) called (an outside agency representative) to assist; (the AA) spoke with (the) resident and (she) agreed to allow staff to help clean out her room. Once it has been clean (sic) the exterminator will come in."3. ObservationsTwo photos on the phone of an anonymous staff, dated 5/13/23 at 2:25 p.m. were provided. One photo revealed six pellets resembling mouse excrement near a computer monitor on the table in the common living area of Resident #6 and #11's room. Another photo revealed five pellets resembling mouse excrement on Resident #6's bed. On 5/16/23, at 1:27 p.m., a room shared by Residents #6 and #11 consisted of a shared common area and two separate bedrooms. The common area contained approximately 12 stacks of cardboard boxes, plastic storage bins, bags and other items that measured approximately four feet in height. It covered an approximate area of six feet by four feet of the floor in the shared common area of the room. Behind the door of Resident #6's bedroom door, there were three stacked boxes. Next to the resident's bed were two stacked boxes, and the floor was covered with a number of miscellaneous personal items including at least four blankets, several bags of unknown items, a table lamp, two boxes of vinyl gloves, incontinence supplies, clothing, a bathroom rug, and a box for a 32 inch television. On a table in the common area of the room were approximately 10 pellets resembling mouse excrement. Within Resident #6's bedroom there was one pellet on the heating unit under the window and two pellets on a table. On 5/16/23 at 3:13 p.m., one small plastic black box containing mouse poison was under the table in the shared common area of Resident #6 and #11's room. Another similar box was behind the door of Resident #6's bedroom. 4. Interviews On 5/16/23 at 8:19 a.m., a staff member who wished to remain anonymous stated s/he had reported to the AA within the three months prior to the onsite investigation that s/he had seen evidence of live mice in Resident #6's room likely due to clutter that accumulated in the resident's room. S/he stated s/he had not seen a pest control company assess or treat the mice, adding that s/he did not see that the residence had taken action to mitigate the infestation. The anonymous staff stated that s/he and two other staff saw live mice in the room within two months prior to the onsite investigation, adding that s/he had seen a mouse leave Resident #6's room and enter the adjacent shared room where Resident #11 resided. S/he stated mice and mouse droppings did not lend to safe and sanitary living conditions. On 5/16/23 at 9:36 a.m., the AA stated that Resident #6 complained that there were live mice in her room approximately one week prior to the onsite investigation. She stated the resident did not allow staff to go through her belongings to clean out the room. The AA stated she called a pest control company, who came to the residence and informed her that they could not treat the room until the resident's room was clean. She added that she had also telephoned an outside agency representative (OAR) to advise her on how to approach cleaning the resident's room but had not yet received a return telephone call. On 5/16/23 at 11:07 a.m., Staff #5 stated she had heard from an unknown staff that Resident #6 had live mice in her room approximately three months prior to the onsite investigation. On 5/16/23 at 2:28 p.m., the OAR stated she had a voicemail message from 5/15/23 (the day before the onsite investigation) from the AA. She stated that the AA did not leave details about the reason for her call in the voicemail. On 5/16/23 at 2:59 p.m., the resident care coordinator (RCC) stated an unknown staff had reported to her that they had seen mouse excrement in Resident #6 and #11's shared room, but they did not report seeing live mice. She stated she reached out to a pest control company with whom the residence had no contract approximately one and one half weeks prior to the onsite investigation. The RCC stated she asked a representative from the pest control company what access they needed to the room in order to assess and treat a mouse infestation. She stated the unknown representative responded that the workers would need access to the corners of the residents' rooms. The RCC stated she and the AA decided to wait to schedule an appointment with the pest control company until the rooms were cleaned. On 5/16/23 at 3:13 p.m., Resident #6 stated she had seen a mouse in her room approximately one week prior to the onsite investigation. She stated she had notified staff about the mice. She stated that a staff member had assisted her with organizing her room approximately two months prior to the onsite investigation, and she saw a mouse which "scared her out the door." Resident #6 stated the residence would not take steps to treat her room for mice without cleaning and organizing her things, but she did not want staff to go through her belongings. Resident #6 stated she bought mouse poison, but it was not effective. She stated she had seen mouse droppings on her dishes, and she had to wash them before and after each time she used them. Resident #6 stated she had seen them come out of her bedroom and go into Resident #11's bedroom. She stated having mice and mouse droppings in the home was not sanitary, but she had not seen that the residence had taken action to mitigate the problem. On 5/17/23 at 7:50 a.m. a manager at the pest control company (that the RCC stated she had called) stated that the company had no record that anyone from the residence's address, including the AA and RCC, had called at all within the last two to three weeks of the onsite investigation. He stated the pest control company would not have refused to come to the residence due to clutter or boxes, adding that they would have sent out a representative to the residence no matter what the conditions were, contrary to the AA and RCC's interviews and documentation above. On 5/17/23 at 8:40 a.m., Staff #6 stated that Staff #7 had shown her photos of mouse excrement she had seen in Residents #6 and #11's room on 5/13/23. She stated Staff #7 had sent these photos to the RCC. She stated she did not see anyone from a pest control company at the residence for the nine months that she had worked at the residence. Staff #6 stated that having mice and mouse excrement in the resident rooms was "absolutely" unsanitary and not safe. She added, however, that the AA and RCC stated they would not schedule a pest control appointment until the room was cleaned. She stated that this was "not fair" to Resident #11 nor to the residents living in rooms adjacent to theirs. On 5/17/23 at 9:15 a.m., Staff #8 stated that Resident #11 reported to her that she had seen a mouse approximately two weeks prior to the onsite investigation. She stated she reported it to the AA who called a pest control company the next day, contrary to the above interviews. Staff #8 stated she had heard from other staff that the pest control company came to the residence. On 5/17/23 at 10:20 a.m., the AA stated that Resident #11 had reported seeing live mice on her bed. She stated, however, that she had not seen them and no staff had sent her photos of the mouse droppings. The AA then stated, contrary to her previous statement, that Staff #7 had sent her photos, but she thought they were bed bugs at first.

Plan of correction · submitted by the facility

Resident #6 & #11: Pest control company was contacted and was on-site on 5/20/23 and addressed cited pest problems in resident’s rooms, no further issues noted. Contract executed with Pest Control company to provide services to facility quarterly, and as needed in between services. Administrator/designee will complete an audit of all resident rooms, at least monthly, for three months, to ensure that resident rooms remain pest free, and will resolve any issues identified. Results of audits will be included in QMP process for next 3 months for review and/or recommendations for improvement, if necessary.

1144Res Care Srvs-Comp Res Asmnt Wrt/HIRS/S A▼

Findings

Based on record review and interview, the residence failed to document and keep a comprehensive assessment in the resident's health information record, affecting one of three sample residents (#6). Findings include:The residence's Health Information Management Policy, dated 6/17/22, read in part that the residence maintained a separate record for each resident and retained the records for the number of years required by the department. Resident #6 was admitted to the residence on 8/5/21. On 5/16/23 and 5/17/23, the resident record for Resident #6 did not include any assessments at all. On 5/17/23 at 10:20 a.m., the acting administrator (AA) stated the assessment for Resident #6 should have been in the resident record, but she acknowledged that it was not. She stated she was aware of the requirement that the residence keep the comprehensive assessment documented in writing in the resident's health information record. The AA stated the former management team, who worked at the residence prior to her start date on 2/28/23, did not maintain resident records properly.

Plan of correction · submitted by the facility

Resident #6: assessment will be reviewed, by date of compliance, to ensure that it is up to dateAdministrator will be educated on ensuring that assessments are updated after a resident change of conditionAdministrator/designee will complete an audit of current resident assessments, by date of compliance, to ensure that they accurately reflect residents’ current condition and needsResident assessments will be reviewed and updated at least annually, and with any change of condition, to accurately reflect residents’ current condition and needs. Administrator/designee will complete an audit of fifteen resident charts per month, for three months, to ensure that assessments are up to date and reflect residents’ current conditions and needs. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

1146Res Care Srvs-Comp Res Asmnt Annl/CICS/S B▼

Findings

Based on record review and interview, the residence failed to update each resident care plan at least annually and whenever the resident's condition changed from baseline status, affecting two of three sample residents (#7, #8). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(B) Information regarding the resident's overall health and physical functioning ability;(G) Individual bathroom routines, sleep and awake patterns;(H) Reactions to the environment and others, including changes that may occur at certain times or in certain circumstances.b, The residence's Change of Condition Policy, dated 6/17/22, read in part that if a change in condition lasted longer than two weeks, the residence completed a comprehensive assessment. 2. Resident #7 was admitted to the residence on 7/24/21 with diagnoses including dementia and depression. An assessment, dated 6/13/22, read in part that Resident #7 required assistance with bathing two times weekly and required minimal assistance and reminders with dressing. On 5/16/23 at 11:07 a.m., Staff #5 stated that for three weeks prior to the onsite investigation, Resident #7 refused shower assistance, so she did not provide the assistance. On 5/16/23 at 8:19 a.m., a staff who wished to remain anonymous stated Resident #7 required assistance with showering and dressing. However, she consistently refused assistance with showers and changing her clothes. She stated the residence did not reassess the resident when she started refusing care approximately four months prior to the onsite investigation. On 5/16/23 at approximately 12:30 p.m., a staff member who wished to remain anonymous stated that Resident #7 frequently refused assistance with bathing and dressing. S/he stated that only two staff were able to assist her with bathing because they attempted more than once and they used a verbal tone and approach that the resident responded to in a positive manner. The anonymous staff stated that the acting administrator was responsible for updating resident assessments when there was a change in baseline status, but she did not do so for Resident #7. On 5/17/23 at 8:40 a.m., Staff #6 stated Resident #7 had been refusing bathing assistance for three months prior to the onsite investigation. She stated she was not aware as to whether the resident's assessment was updated. 3. Resident #8 was admitted to the residence on 6/1/21 with diagnoses including neurocognitive disorder and vascular dementia. An assessment, dated 5/24/21, read in part that Resident #8 read that the resident was on a diuretic which caused increased urination, that the resident was incontinent, and that the resident used incontinence products. In addition, the assessment read that the resident utilized the toilet with no assistance. On 5/16/23 at 11:07 a.m., Staff #5 stated that Resident #8 was incontinent and required two hour checks because he had bowel and bladder incontinence. She stated staff sometimes had to change his clothing in the middle of the day due to incontinence. On 5/16/23 at approximately 12:30 p.m., a staff member who wished to remain anonymous stated Resident #8 had been demonstrating increased confusion and disorientation for at least two months prior to the onsite investigation. S/he added that during this time, he had more incontinence of bowel and bladder, needed reminders for all meals, and was observed using a dining room chair instead of his walker. The anonymous staff stated the residence did not update the comprehensive assessment when the resident had a change in baseline status. On 5/16/23 at 8:19 a.m., a staff who wished to remain anonymous stated Resident #8 had several bladder and bowel accidents daily for at least two months prior to the onsite investigation. S/he stated he now required full staff assistance with bathing, toileting, and getting dressed. On5/17/23 at 8:40 a.m., Staff #6 stated Resident #8 required full assistance with showering, dressing, and toileting. She stated for approximately the nine months up to the date of the onsite investigation, the resident had steadily declined and needed more assistance with all cares. On 5/17/23 at 10:20 a.m., the acting administrator stated she was currently responsible for completing assessments 30 days after the resident's admission date, 90 days after the resident's admission date, and annually. She stated she was aware of the requirement to update resident assessments whenever the resident's condition changed from baseline status. The AA stated when she started working at the residence (2/28/23), Residents #7 and #8 were already in their current condition, but she acknowledged she had not reviewed or updated the assessments at all. She added that the former management team should have completed an assessment when the residents' condition changed from baseline status, but they failed to do so.

Plan of correction · submitted by the facility

Residents #7 & 8: care plan will be reviewed, by date of compliance, to ensure it accurately reflects residents’ baseline statusAdministrator will be educated on ensuring that care plans are updated at least annually & after a resident change of conditionAdministrator/designee will complete an audit of current resident care plans, by date of compliance, to ensure that they accurately reflect residents’ current condition and needsResident care plans will be reviewed and updated at least annually, and with any change of condition, to accurately reflect residents’ current condition and needsAdministrator/designee will complete an audit of fifteen resident charts per month, for three months, to ensure that care plans are up to date and reflect residents’ current conditions and needs. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interview the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting three of three sample residents (#3, #9, #10) and one former resident (#12) whose medications administration records (MARs) were reviewed. (Cross-reference Q1510)Findings include:1. Residence PolicyThe residence's medication administration policy, dated June 2022, read in part that if a resident was unavailable to receive a scheduled medication or if the medication itself was unavailable, the qualified medication administration person (QMAP) circled their initials and then documented the reason for the missed medication on the reverse side of the medication administration record (MAR). All medication requests from the pharmacy and family members were documented on a prescription reorder log; medications not received by the next working day were followed up on daily until the medication was received. Staff were to notify the administrator and resident care coordinator (RCC) of any missed doses. 2. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including anxiety, chronic obstructive pulmonary disease, gastroesophageal reflux disease (GERD), skin irritation, and osteoarthritis.a. Zinc OxideA written practitioner's order, dated 2/6/23, directed the residence to administer zinc oxide 40% topical ointment twice daily. However, the March, April, and May 2023 MARs read the residence failed to administer the medication for the morning doses on 3/7-3/9, 3/19-3/24, 3/28-3/31, 4/4-4/6, 4/23-4/27, and 5/2-5/5. Additionally, the residence failed to administer the evening doses on 3/4, 3/7-3/9, 3/11-3/20, 3/23, 3/24, 3/26-3/31, 5/1-5/7, 5/9, 5/10, and 5/13/23, for a total of 57 missed doses.b. FluticasoneA written practitioner's order, dated 2/6/23, directed the residence to administer fluticasone 250 mcg-salmeterol 50 mcg one puff twice daily. However, the March, April, and May 2023 MARs read the residence failed to administer the medication for the morning doses on 3/8, 3/14, 3/15, 4/16-5/2/23. Additionally, the residence failed to administer the evening doses on 3/12-3/15, 4/16-4/27, and 4/30-5/2/23, for a total of 39 missed doses.c. BenzonatateA written practitioner's order, dated 3/8/23, directed the residence to administer benzonatate 100 mg three times daily. However, the April and May 2023 MARs read the residence failed to administer the medication for one dose on 3/8/23, for two doses on 5/4/23 and for all three doses 4/25-5/3/23, for a total of 30 missed doses.d. SpirivaA written practitioner's order, dated 2/6/23, directed the residence to administer Spiriva 18 mcg and inhalation capsule daily. However, the March, April, and May 2023 MARs read the residence failed to administer the medication on 3/30, 4/16-4/20, 4/23-5/3, and 5/5/23, for a total of 18 missed doses.e. GuaifenesinA written practitioner's order, dated 2/6/23, directed the residence to administer guaifenesin 1200 mg twice daily. However, the March and April 2023 MARs read the residence failed to administer the medication for the morning doses on 3/19-3/24, 3/26, and 3/27/23. Additionally, the residence failed to administer the evening doses on 3/12, 3/16-3/18, 3/20-3/24, 4/29/23, for a total of 18 missed doses.f. SertralineA written practitioner's order, dated 2/6/23, directed the residence to administer sertraline 100 mg daily. However the March, April, and May 2023 MARs read the residence failed to administer the medication on 3/28-4/2 and 5/4/23, for a total of seven missed doses.g. MeclizineA written practitioner's order, dated 2/6/23, directed the residence to administer meclizine 25 mg daily. However, the April 2023 MAR read the residence failed to administer the medication on 4/2-4/5/23, for a total of four missed doses.h. Vitamin B12A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin B12 1000 mcg daily. However the March 2023 MAR read the residence failed to administer the medication on 3/7-3/9, and 3/16, for a total of four missed doses.i. AspirinA written practitioner's order, dated 2/6/23, directed the residence to administer aspirin 81 mg daily. However the March 2023 MAR read the residence failed to administer the medication on 3/7 and 3/8/23, for a total of two missed doses.j. FurosemideA written practitioner's order, dated 2/6/23, directed the residence to administer furosemide 20 mg daily. However the March 2023 MAR read the residence failed to administer the medication on 3/30 and 3/31/23, for a total of two missed doses.k. OmeprazoleA written practitioner's order, dated 2/6/23, directed the residence to administer omeprazole 40 mg daily. However, the March 2023 MARs read the residence failed to administer the medication on 3/30/31, for one missed dose. 3. Resident #9 was admitted to the residence on 7/23/16 with diagnoses including bipolar disorder, anxiety, paranoia, GERD, hypothyroidism, chronic pain, and arthritis.a. SertralineA written practitioner's order, dated 3/5/23, directed the residence to administer sertraline 50 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/6-3/18, 3/20, and 3/21/23, for a total of 17 missed doses.b. LatudaA written practitioner's order, dated 3/5/23, directed the residence to administer Latuda 40 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/5-3/16, 3/19, 4/5,4/13/23, for a total of 15 missed doses.c. FluticasoneA written practitioner's order, dated 3/5/23, directed the residence to administer fluticasone 50 mcg two sprays in each nostril daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/14-3/19, 4/7, and 4/23/23, for a total of eight missed doses. d. MetoprololA written practitioner's order, dated 3/5/23, directed the residence to administer metoprolol 25 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/19 and 3/29-4/4/23, for a total of eight missed doses.e. ClopidogrelA written practitioner's order, dated 3/5/23, directed the residence to administer clopidogrel 75 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/29-4/42/23, for a total of seven missed doses.f. OlanzapineA written practitioner's order, dated 3/5/23, directed the residence to administer olanzapine 7.5 mg at bedtime. However, the March 2023 MAR read the residence failed to administer the medication on 3/28-3/31/23, for a total of three missed doses.g. SimethiconeA written practitioner's order, dated 3/5/23, directed the residence to administer simethicone 125 mg three times daily. However, the March 2023 MAR read the residence failed to administer the medication for one dose on 3/17-3/19 and 4/1/23, for two doses on 3/16/23, for a total of six missed doses.h. AcetaminophenA written practitioner's order, dated 3/5/23, directed the residence to administer acetaminophen 1000 mg three times daily. However, the March and April 2023 MAR read the residence failed to administer the medication for three doses on 3/31/23, for two doses on 4/1, and one dose on 4/22/23, for a total of six missed doses.i. FamotidineA written practitioner's order, dated 3/5/23, directed the residence to administer famotidine 10 mg every night. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/27, 3/30, and 4/20/23, for a total of three missed doses.j. Isosorbide MononitrateA written practitioner's order, dated 3/5/23, directed the residence to administer isosorbide mononitrate 30 mg daily. However, the April MAR read the residence failed to administer the medication on 4/1-4/3/23, for a total of three missed doses.k. BuspironeA written practitioner's order, dated 3/5/23, directed the residence to administer buspirone 15 mg three times daily. However, the March 2023 MAR read the residence failed to administer the medication for one dose on 3/26 and 3/27/23, for a total of two missed doses.l. LamotrigineA written practitioner's order, dated 3/5/23, directed the residence to administer lamotrigine 300 mg daily. However, the April 2023 MAR read the residence failed to administer the medication on 4/2 and 4/3/23, for a total of two missed doses. m. LevothyroxineA written practitioner's order, dated 3/5/23, directed the residence to administer levothyroxine 75 mcg daily. However, the April 2023 MAR read that the residence failed to administer the medication on 4/24/23, for one missed dose. 4. Resident #10 was admitted to the residence on 2/17/22 with diagnoses including dementia, hypokalemia, hyperlipidemia, hypothyroidism, and hypertension.a. HydrochlorothiazideA written practitioner's order, dated 2/6/23, directed the residence to administer hydrochlorothiazide 50 mg daily. However the March and April 2023 MARs read the residence failed to administer the medication on 3/22-3/26, 3/29, and 4/1-4/10/23, for a total of 16 missed doses. b. MetoprololA written practitioner's order, dated 2/6/23, directed the residence to administer metoprolol 25 mg every morning and every night. However, the March 2023 MAR read the residence failed to administer the medication for the morning doses on 3/22-3/25, 3/27, and 4/12/23. Additionally, the residence failed to administer the evening doses on 3/15-3/18, 3/20-3/22, and 3/24-3/26/23, for a total of 16 missed doses. c. AspirinA written practitioner's order, dated 2/6/23, directed the residence to administer aspirin 81 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/7-3/9, 3/14-3/16, 3/19-3/24, 3/30, and 4/2/23, for a total of 14 missed doses. d. Potassium ChlorideA written practitioner's order, dated 2/6/23, directed the residence to administer potassium chloride 20 mEq daily. However the March and April MARs read the residence failed to administer the medication on 3/22-3/26, 3/29, and 3/31-4/6/23, for a total of 13 missed doses. e. Vitamin D3A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 50 mcg. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/22-3/25, and 3/28-4/4/23, for a total of 12 missed doses.f. FluoxetineA written practitioner's order, dated 2/6/23, directed the residence to administer fluoxetine 40 mg every morning. However, the April 2023 MAR read the residence failed to administer the medication on 4/1-4/11/23, for a total of 11 missed doses.g. LevothyroxineA written practitioner's order, dated 2/6/23, directed the residence to administer levothyroxine 137 mcg daily. However, the March, April, and May 2023 MARs read the residence failed to administer the medication on 3/16, 4/4-4/6, 4/9, 4/10, and 5/11-5/15/23, for a total of 11 missed doses. h. MelatoninA written practitioner's order, dated 2/6/23, directed the residence to administer melatonin 5 mg at bedtime. However the March 2023 MAR read the residence failed to administer the medication on 3/16-3/19, 3/22, and 3/25-3/28/23, for a total of nine missed doses.i. LosartanA written practitioner's order, dated 2/6/23, directed the residence to administer losartan 75 mg every morning. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/30-4/2/23, for a total of four missed doses.j. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine 10 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/30-4/2/23, for a total of four missed doses.k. NeurivaA written practitioner's order, dated 2/6/23, directed the residence to administer Neuriva one tablet daily. However, the April 2023 MAR read the residence failed to administer the medication on 4/2, 4/4, 4/5, and 4/11/23, for a total of four missed doses.l. Centrum SilverA written practitioner's order, dated 2/6/23, directed the residence to administer Centrum Silver one tablet daily. However, the April 2023 MAR read the residence failed to administer the medication on 4/2 and 4/4/223, for a total of two missed doses. 5. Former Resident #12 was admitted to the residence on 11/2/21 with diagnoses including anemia, anxiety, bipolar disorder, depression, GERD, history of ankle fracture, arthritis, and cyclic vomiting syndrome.a. Diclofenac Sodium 1% GelA written practitioner's order, dated 2/4/23, directed the residence to administer diclofenac sodium 1% gel every six hours. However, the March and April 2023 MARs read the residence failed to administer the medication for one dose on 3/1-3/9, 3/12-3/20, 3/27, and 4/2-4/8/23; for two doses on 3/22, 3/29, and 3/30/23; and for three doses on 3/21, 3/23, 3/24, and 3/28/23, for a total of 44 missed doses.b. LubiprostoneA written practitioner's order, dated 2/4/23, directed the residence to administer lubiprostone 24 mcg twice daily. However, the March 2023 MAR read the residence failed to administer the medication for the morning doses on 3/4, 3/5, 3/7-3/15, 3/17-3/21/23. Additionally, the residence failed to administer the evening doses on 3/4-3/10, 3/12-3/18/23, for a total of 30 missed doses.c. DuloxetineA written practitioner's order, dated 2/4/23, directed the residence to administer duloxetine 60 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/2-3/13, and 3/15-3/18/23, for a total of 16 missed doses.d. LamotrigineA written practitioner's order, dated 2/4/23, directed the residence to administer lamotrigine 50 mg daily. However, the March MAR read the residence failed to administer the medication on 3/4-3/10 and 3/12-3/19/23, for a total of 15 missed doses.e. LisinoprilA written practitioner's order, dated 2/4/23, directed the residence to administer lisinopril 10 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/4, 3/5, 3/7-3/15, 3/17-3/19/23, for a total of 14 missed doses.f. MethimazoleA written practitioner's order, dated 2/4/23, directed the residence to administer methimazole 5 mg at bedtime. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/1-3/10 and 3/12-3/14/23, for a total of 13 missed doses.g. OmeprazoleA written practitioner's order, dated 2/4/23, directed the residence to administer omeprazole 20 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/3-3/15/23, for a total of 13 missed doses.h. OxybutyninA written practitioner's order, dated 2/4/23, directed the residence to administer oxybutynin 5 mg twice daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/3-3/15/23, for a total of 13 missed doses.i. Sertraline A written practitioner's order, dated 2/4/23, directed the residence to administer sertraline 150 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/4, 3/5, 3/8, 3/9, 3/13-3/15, and 3/17-3/21/23, for a total of 12 missed doses.j. Vitamin D3A written practitioner's order, dated 2/4/23, directed the residence to administer vitamin D3 25 mcg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/20-3/24, 3/26-3/30, 4/2, and 4/5/23, for a total of 12 missed doses.k. ClopidogrelA written practitioner's order, dated 2/4/23, directed the residence to administer clopidogrel 75 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/4, 3/5, and 3/7-3/15/23, for a total of 11 missed doses.l. AtorvastatinA written practitioner's order, dated 2/4/23, directed the residence to administer atorvastatin 80 mg at bedtime. However, the March 2023 MAR read the residence failed to administer the medication on 3/2-3/8, 3/10, 3/12, and 3/19/23, for a total of 10 missed doses.m. BiotinA written practitioner's order, dated 2/4/23, directed the residence to administer biotin 10 mg daily. However, the March and April 2023 MARs read the residence failed to administer the medication on 3/4, 3/5, 3/8, 3/9, 3/13, 4/4, and 4/5/23, for a total of seven missed doses.n. MeloxicamA written practitioner's order, dated 2/4/23, directed the residence to administer Meloxicam 7.5 mg daily. However, the March 2023 MAR read the residence failed to administer the medication on 3/10-3/13/23, for a total of four missed doses. 6. InterviewsOn 5/16/23 at 7:25 a.m., Staff #4 stated when she first started working at the residence, approximately 2 months prior to the onsite investigation, there was a period of time when the pharmacy was not delivering medications as ordered. She stated the administrator of record and the former RCC failed to follow up with the pharmacyOn 5/16/23 at 3:39 p.m., the acting administrator (AA) stated that circled QMAP initials on the MARs meant that the QMAP had not administered the medication as ordered by their practitioner, likely because the medications were out of stock. She acknowledged that there were no reasons listed on the back of the MAR as to why the staff's initials were circled. On 5/17/23 at 10:20 a.m., the AA stated she was aware of the requirement for the residence to comply with practitioner's orders, and she added there were pharmacy-related obstacles that the residence sometimes could not prevent. She stated she expected the residence staff to ensure all residents had at least a seven day supply of all medications. The AA stated that the pharmacy sometimes sent fewer pills than required for the month. The AA added that the package had a sticker from the pharmacy on it that read that the pharmacy owed them the remainder of the medications for the month, meaning they would send them at a later date. She stated the pharmacy often sent the remainder after the residents ran out of medications, and the staff was unable to administer them because they were not in stock.

Plan of correction · submitted by the facility

Resident #3, #9, #10: residents are currently receiving medications as ordered and information is being documented appropriately. Resident #12: no longer resides in facilityQMAP's will be re-educated by date of compliance on medication administration and appropriate documentation in resident MAR.Administrator/designee will monitor medication administration for one QMAP medication pass, 3x per week for 1 month, then 1x per week for 2 months, to ensure that accurate and appropriate documentation is occurring. Results of audits will be included in QMP process for next 3 months for review and/or recommendations for improvement, if necessary.

1510Med/Med Adm-Rcrd Kpng MARS/S B▼

Findings

Based on interviews and record reviews, the residence failed to document accurate information in the medication administration record (MAR); and, failed to ensure each MAR had a legible list of the names of the persons utilizing the record for medication administration, their signatures and initials, affecting three of three sample residents (#3, #9, #10) and one former resident (#12) whose medications administration records (MARs) were reviewed. Findings include:1. Residence PolicyThe residence's medication administration policy, dated June 2022, read in part that each qualified medication administration person (QMAP) signed and initialed a MAR signature list each month for each resident. Any QMAP administering a medication must initial the MAR in the appropriate date/time block, as well as signing and initialing the reverse of the MAR to establish their identity and role. The MAR was a legal document, and all documentation on the MAR was complete and accurate. Each QMAP was responsible for documenting on the MAR for each medication scheduled during their shift. As each medication was administered, the responsible QMAP initialed the appropriate box on the MAR.2. Resident #3 was admitted to the residence on 2/24/20 with diagnoses including anxiety, chronic obstructive pulmonary disease, gastroesophageal reflux disease (GERD), skin irritation, and osteoarthritis.a. Zinc OxideA written practitioner's order, dated 2/6/23, directed the residence to administer zinc oxide 40% topical ointment twice daily. However, the March, April, and May 2023 MARs revealed blank spaces for the administration of the medication for the morning doses on 3/15, 3/16, 3/25, 3/27, 4/10, 4/12-4/15, 4/20-4/22. Additionally, the MARs revealed blank spaces for the evening doses on 3/21, 3/22, 3/25, 4/30, 5/11, 5/12, and 5/14/23.b. FluticasoneA written practitioner's order, dated 2/6/23, directed the residence to administer fluticasone 250 mcg-salmeterol 50 mcg one puff twice daily. However, the March, April, and May 2023 MARs revealed blank spaces for the administration of the medication for the morning dose on 4/12/23. Additionally, the MARs revealed blank spaces for the administration of the medication for the evening doses on 3/11, 4/8, 4/14, 4/15, 5/8, and 5/12/23.c. GuaifenesinA written practitioner's order, dated 2/6/23, directed the residence to administer guaifenesin 1200 mg twice daily. However, the March, April, and May 2023 MARs revealed blank spaces for the administration of the medication for the morning dose on 3/25/23. Additionally, the MARs revealed blank spaces for the administration of the medication for the evening doses on 3/15, 3/25, 3/26, 4/28, and 5/12/23.d. MeclizineA written practitioner's order, dated 2/6/23, directed the residence to administer meclizine 25 mg daily. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication on 3/26, 3/27, 4/17, and 4/20/23.e. BenzonatateA written practitioner's order, dated 3/8/23, directed the residence to administer benzonatate 100 mg three times daily. However, the March and May 2023 MARs revealed blank spaces for the administration of the medication for one dose on 3/27 and one dose on 5/12/23.f. SpirivaA written practitioner's order, dated 2/6/23, directed the residence to administer Spiriva 18 mcg and inhalation capsule daily. However, the April 2023 MAR revealed a blank space for the administration of the medication on 4/12/23. g. FurosemideA written practitioner's order, dated 2/6/23, directed the residence to administer furosemide 20 mg daily. However, the April 2023 MAR revealed a blank space for the administration of the medication on 4/23/13.3. Resident #9 was admitted to the residence on 7/23/16 with diagnoses including bipolar disorder, anxiety, paranoia, GERD, hypothyroidism, chronic pain, and arthritis.a. SertralineA written practitioner's order, dated 3/5/23, directed the residence to administer sertraline 50 mg daily. However, the Marchand April 2023 MARs revealed blank spaces for the administration of the medication on 3/24, 4/2, 4/9, and 4/24/23.b. LatudaA written practitioner's order, dated 3/5/23, directed the residence to administer Latuda 40 mg daily. However, the April 2023 MAR revealed blank spaces for the administration of the medication 4/1-4/4 and 4/11/23. c. FluticasoneA written practitioner's order, dated 3/5/23, directed the residence to administer fluticasone 50 mcg two sprays in each nostril daily. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication for the evening doses on 3/24 and 4/15/23.d. MetoprololA written practitioner's order, dated 3/5/23, directed the residence to administer metoprolol 25 mg daily. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication on 3/20, 4/9, and 4/15/23.e. ClopidogrelA written practitioner's order, dated 3/5/23, directed the residence to administer clopidogrel 75 mg daily. However, the March 2023 MAR revealed blank spaces for the administration of the medication on 3/19 and 3/27/23.f. OlanzapineA written practitioner's order, dated 3/5/23, directed the residence to administer olanzapine 7.5 mg at bedtime. However, the April 2023 MAR revealed blank spaces for the administration of the medication 4/2, 4/9, and 4/24/23. g. SimethiconeA written practitioner's order, dated 3/5/23, directed the residence to administer simethicone 125 mg three times daily. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication for one dose on 3/12, 3/19-3/21, 3/24, 3/25, 3/27, 3/29, 4/14, and 4/15/23; the April 2023 MAR revealed blank spaces for two doses on 4/9/23.h. AcetaminophenA written practitioner's order, dated 3/5/23, directed the residence to administer acetaminophen 1000 mg three times daily. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication for three doses on 4/9/23; two doses on 3/19, 3/21/23; and for one dose on 3/29, 4/15, and 4/16/23. i. FamotidineA written practitioner's order, dated 3/5/23, directed the residence to administer famotidine 10 mg every night. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication on 3/18, 3/25, 3/29, and 4/2/23.j. Isosorbide MononitrateA written practitioner's order, dated 3/5/23, directed the residence to administer isosorbide mononitrate 30 mg daily. However, the March and April MARs revealed blank spaces for the administration of the medication on 3/21-3/25 and 4/15/23. k. BuspironeA written practitioner's order, dated 3/5/23, directed the residence to administer buspirone 15 mg three times daily. However, the April 2023 MAR revealed blank spaces for the administration of the medication for one dose on 4/12, 4/20, 4/21, 4/23, and 4/29/13.l. LamotrigineA written practitioner's order, dated 3/5/23, directed the residence to administer lamotrigine 300 mg daily. However, the March 2023 MAR revealed blank spaces for the administration of the medication for one dose on 3/19, 3/24, and 3/31/23.m. LevothyroxineA written practitioner's order, dated 3/5/23, directed the residence to administer levothyroxine 75 mcg daily. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication on 3/10 and 4/20/23.4. Resident #10 was admitted to the residence on 2/17/22 with diagnoses including dementia, hypokalemia, hyperlipidemia, hypothyroidism, and hypertension.a. HydrochlorothiazideA written practitioner's order, dated 2/6/23, directed the residence to administer hydrochlorothiazide 50 mg daily. However the March 2023 MAR revealed blank spaces for the administration of the medication on 3/16, 3/18, 3/19, 3/21, and 3/30/23.b. MetoprololA written practitioner's order, dated 2/6/23, directed the residence to administer metoprolol 25 mg every morning and every night. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication for the morning doses on 3/16, 3/18, 3/26, and 4/21/23. Additionally, the MARs revealed blank spaces for the administration of the medication for the evening doses on 3/19 and 5/6/23.c. AspirinA written practitioner's order, dated 2/6/23, directed the residence to administer aspirin 81 mg daily. However, the March 2023 MAR revealed blank spaces for the administration of the medications on 3/18 and 3/27/23.d. Potassium ChlorideA written practitioner's order, dated 2/6/23, directed the residence to administer potassium chloride 20 mEq daily. However the March and April MARs revealed blank spaces for the administration of the medication on 3/16, 3/18, 3/19, 3/21, 3/30, and 4/11/23.e. Vitamin D3A written practitioner's order, dated 2/6/23, directed the residence to administer vitamin D3 50 mcg. However, the March and April 2023 MARs revealed a blank space for the administration of the medication on 3/16/23.f. FluoxetineA written practitioner's order, dated 2/6/23, directed the residence to administer fluoxetine 40 mg every morning. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication on 3/16, 3/18, 3/18, and 4/21/23.g. LevothyroxineA written practitioner's order, dated 2/6/23, directed the residence to administer levothyroxine 137 mcg daily. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication on 3/18 and 4/21/23. h. LosartanA written practitioner's order, dated 2/6/23, directed the residence to administer losartan 75 mg every morning. However, the March 2023 MAR revealed blank spaces for the administration of the medication on 3/16, 3/18, and 3/27/23. i. AmlodipineA written practitioner's order, dated 2/6/23, directed the residence to administer amlodipine 10 mg daily. However, the March 2023 MAR revealed blank spaces for the administration of the medication on 3/16, 3/18, and 3/27/23.j. NeurivaA written practitioner's order, dated 2/6/23, directed the residence to administer Neuriva one tablet daily. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication on 3/1-3/31, 4/2, 4/8, 4/10, 4/14-4/17, and 4/23/23. k. Centrum SilverA written practitioner's order, dated 2/6/23, directed the residence to administer Centrum Silver one tablet daily. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication on 3/1-3/31, 4/2, 4/8, 4/10, 4/12, 4/14-4/17, and 4/23/23.5. Former Resident #12 was admitted to the residence on 11/2/21 with diagnoses including anemia, anxiety, bipolar disorder, depression, GERD, history of ankle fracture, arthritis, and cyclic vomiting syndrome.a. Diclofenac Sodium 1% GelA written practitioner's order, dated 2/4/23, directed the residence to administer diclofenac sodium 1% gel every six hours. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication for one dose on 3/1-3/6, 3/8, 3/9, 3/14, 3/21, 3/23, 3/24, 3/28, 3/30, 3/31, 4/1, 4/4, 4/5, and 4/6/23; two doses on 3/12, 3/15, 3/22, 3/25, 4/2/23; three doses on 3/10, 3/13, 3/16-3/20, 3/26/23, and four doses on 3/11/23.b. LubiprostoneA written practitioner's order, dated 2/4/23, directed the residence to administer lubiprostone 24 mcg twice daily. However, the March 2023 MAR revealed blank spaces for the administration of the medication for the morning doses on 3/6 and 3/16/23. Additionally, the March 2023 MAR revealed blank spaces for the administration of the medication for the evening doses on 3/11 and 3/19/23.c. DuloxetineA written practitioner's order, dated , directed the residence to administer duloxetine 60 mg daily. However, the March 2023 MAR revealed a blank space for the administration of the medication on 3/19/23.d. LamotrigineA written practitioner's order, dated 2/4/23, directed the residence to administer lamotrigine 50 mg daily. However, the March MAR revealed a blank space for the administration of the medication on 3/11/23. e. LisinoprilA written practitioner's order, dated 2/4/23, directed the residence to administer lisinopril 10 mg daily. However, the March 2023 MAR revealed blank spaces for the administration of the medication on 3/6 and 3/16/23.f. MethimazoleA written practitioner's order, dated 2/4/23, directed the residence to administer methimazole 5 mg at bedtime. However, the March 2023 MAR revealed blank spaces for the administration of the medication on 3/11 and 3/19/23.g. OmeprazoleA written practitioner's order, dated 2/4/23, directed the residence to administer omeprazole 20 mg daily. However, the March 2023 MAR revealed a blank space for the administration of the medication on 3/16/23.h. OxybutyninA written practitioner's order, dated 2/4/23, directed the residence to administer oxybutynin 5 mg twice daily. However, the March 2023 MAR revealed a blank space for the administration of the medication on 3/16/23.i. Sertraline A written practitioner's order, dated 2/4/23, directed the residence to administer sertraline 150 mg daily. However, the March 2023 MAR revealed blank spaces for the administration of the medication on 3/6, 3/7, and 3/16/23. j. Vitamin D3A written practitioner's order, dated 2/4/23, directed the residence to administer vitamin D3 25 mcg daily. However, the March and April 2023 MARs revealed blank spaces for the administration of the medication on 3/25 and 4/1/23.k. ClopidogrelA written practitioner's order, dated 2/4/23, directed the residence to administer clopidogrel 75 mg daily. However, the March 2023 MAR revealed blank spaces for the administration of the medication on 3/6 and 3/16/23.l. AtorvastatinA written practitioner's order, dated 2/4/23, directed the residence to administer atorvastatin 80 mg at bedtime. However, the March 2023 MAR revealed a blank space for the administration of the medication on 3/11/23.m. BiotinA written practitioner's order, dated 2/4/23, directed the residence to administer biotin 10 mg daily. However, the March 2023 MAR revealed blank spaces for the administration of the medication on 3/6, 3/7, and 3/16/23.n. MeloxicamA written practitioner's order, dated 2/4/23, directed the residence to administer Meloxicam 7.5 mg daily. However, the March 2023 MAR revealed blank spaces for the administration of the medication on 3/5, 3/6, 3/14-3/18, 3/20-3/24, 3/26, 3/28, and 3/30/23.6. No Legible List of QMAP names and initialsThe March and April 2023 MARs for Residents #3, #9, #10 and Former Resident #12 revealed the residence failed to have a legible list of the names of the persons utilizing the record for medication administration along with each of their signatures and initials. 7. InterviewsOn 5/16/23 at approximately 3:39 p.m., the acting administrator (AA) stated she was not aware of the requirement that a legible list of the names of QMAPs along with their corresponding initials, were included as part of the residents' MARs. She stated staff looked at a separate staff roster to determine whose initials belonged to whom. The AA stated that she would not know, just by looking at a MAR, to which QMAP each of the the initials on the MAR belonged. She stated the blank spaces on the MARs were documentation errors, adding that the QMAP failed to document that the medications were administered. The AA acknowledged that there were no reasons listed on the back of the MAR as to why the staff's initials were circled. The AA stated staff were not required, nor were they trained, to document on the back of the MAR the reason they did not administer medications. The AA stated that the administrator of record did not train or expect the staff to complete accurate documentation. On 5/16/23 at 4:36 p.m., the resident care coordinator stated the blank spaces on Residents #3, #9, #10 and Former Resident #12's MARs were due to the QMAPs' failure to accurately document each medication administration event, as required.

Plan of correction · submitted by the facility

Resident #3, #9, #10: residents MAR’s will be audited, by date of compliance, to ensure information is being documented appropriately. Resident #12: no longer resides in facilityAdministrator/designee will complete an audit, by date of compliance, of current residents’ medication administration records for accuracy and completeness, including that each has a legible list of the names of the persons utilizing the record for medication administration, their signatures and initials, and resolve any issues identified. QMAP's will be re-educated by date of compliance on medication administration and appropriate documentation in resident MAR.Administrator/designee will complete an audit, at least quarterly, of resident medication administration records for accuracy and completeness, and will resolve any issues identified. Results of audits will be included in QMP process for next 3 months for review and/or recommendations for improvement, if necessary.

1514Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based on record review and interview, the administrator failed to, along with the qualified medication administration personnel (QMAP) supervisor, audit the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, affecting three of three sample residents (#3, #9, #10) and one former resident (#12) whose medications administration records (MARs) were reviewed. (Cross-reference Q1468 and Q1510)Findings include:On 5/16/23 at 2:50 p.m., documentation of the residence's medication audits from the two quarters prior to the on-site investigation was requested but was not provided. On 5/16/23 at 3:07 p.m., the resident care coordinator (RCC) stated she had just started employment at the residence approximately two weeks prior to the on-site investigation. She stated that the acting administrator (AA) had assisted her with a medication audit within this time. The RCC stated, however, that they did not document the audit. On 5/16/23 at 3:39 p.m., the AA stated she was aware that the residence was required to complete and document quarterly medication audits. She added that the RCC was the QMAP supervisor, but she was unable to find any documentation for medication audits.

Plan of correction · submitted by the facility

Resident #3, #9, #10: residents MAR’s will be audited, by date of compliance, to ensure information is being documented appropriately. Resident #12: no longer resides in facilityAdministrator/designee will complete an audit, by date of compliance, of current residents’ medication administration records for accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, and resolve any issues identified. Administrator/designee will complete an audit, at least quarterly, of resident medication administration records for accuracy and completeness, and will resolve any issues identified. Results of audits will be included in QMP process for next 3 months for review and/or recommendations for improvement, if necessary.

2130HIR-Cntnt IncldS/S B▼

Findings

Based on record review and interview, the residence failed to ensure that resident records contained individualized resident care plans and progress notes, affecting three of six sample residents (#6-#8). (Cross-reference Q1110, Q1146)Findings include:1. References and Residence PolicyRegulations governing assisted living residences, part 2.9, defines a "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual's need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual's needs. In order to deliver person-centered care, the care plan shall take into account the resident's preferences and desired outcomes. "Care plan" may also mean a service plan for those facilities which are licensed to provide services specifically for the mentally ill. Regulations governing assisted living residences, part 12.10, requires that each resident care plan shall:(B) Reflect the most current assessment information;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs. The residence's Health Information Management Policy, dated 6/17/22, read in part that each resident record contained a care plan, including any amendments or updates; progress notes documenting any accident, incident or injury; documentation of any change in the resident's behavior, physical, cognitive, or functional condition; and the action taken by staff to address the resident's changing needs. 2. Record Reviewa. Resident #6 was admitted to the residence on 8/5/21. On 5/16/23 at 8:19 a.m., a staff member who wished to remain anonymous stated s/he had reported to the acting administrator within the three months prior to the onsite investigation that s/he had seen evidence of mice in Resident #6's room likely due to clutter that accumulated in the resident's room. On 5/16/23 at 9:36 a.m., the acting administrator stated that Resident #6 complained that there were mice in her room approximately one week prior to the onsite investigation. She stated the resident did not allow staff to go through her belongings to clean out the room. On 5/16/23 at 3:13 p.m., Resident #6 stated she had seen a mouse in her room approximately one week prior to the onsite investigation. She stated she had notified staff about the mice. The record for Resident #6 did not contain a care plan at all. Additionally, the record did not include progress notes regarding Resident #6's tendency to hoard personal belongings, the resident's reports of seeing evidence of mice in her room, nor the action taken by staff to address these concerns.b. Resident #8 was admitted to the residence on 6/1/21. On 5/16/23 at 11:07 a.m., Staff #5 stated that Resident #8 was incontinent and required two hour checks because he had bowel and bladder incontinence. She stated staff sometimes had to change his clothing in the middle of the day due to incontinence. On 5/16/23 at approximately 12:30 p.m., a staff member who wished to remain anonymous stated Resident #8 had been demonstrating increased confusion and disorientation for at least two months prior to the onsite investigation. S/he added that during this time, he had more incontinence of bowel and bladder, needed reminders for all meals, and was observed using a dining room chair instead of his walker. The anonymous staff stated the residence did not update the comprehensive assessment when the resident had a change in baseline status. On 5/16/23 at 8:19 a.m., a staff who wished to remain anonymous stated Resident #8 had several bladder and bowel accidents daily for at least two months prior to the onsite investigation. S/he stated he now required full staff assistance with bathing, toileting, and getting dressed. On 5/17/23 at 8:40 a.m., Staff #6 stated Resident #8 required full assistance with showering, dressing, and toileting. She stated for approximately the nine months up to the date of the onsite investigation, the resident had steadily declined and needed more assistance with all cares. A care plan for Resident #8, dated 7/5/22, read in part that the resident required regular supervision when toileting and assistance with incontinence products. Additionally, it read that he self-managed toileting with reminders. The record for Resident #8 did not include progress notes regarding Resident #8 increased incontinence and care needs nor the actions taken by the staff to address these needs.c. Resident #7 was admitted to the residence on 7/24/21. On 5/16/23 at 11:07 a.m., Staff #5 stated that for three weeks prior to the onsite investigation, Resident #7 refused shower assistance, so she did not provide the assistance. On 5/16/23 at 8:19 a.m., a staff who wished to remain anonymous stated Resident #7 required assistance with showering and dressing. However, she consistently refused assistance with showers and changing her clothes. On 5/16/23 at approximately 12:30 p.m., a staff member who wished to remain anonymous stated that Resident #7 refused frequently refused assistance with bathing and dressing. S/he stated that only two staff were able to assist her with bathing because they attempted more than once and they used a verbal tone and approach that the resident responded to in a positive manner. On 5/17/23 at 8:40 a.m., Staff #6 stated Resident #7 had been refusing bathing assistance for three months prior to the onsite investigation. The care plan for Resident #7, dated 6/13/22, read in part that the resident required verbal reminders but was able to independently manage toileting. The record for Resident #7 did not include progress notes regarding Resident #7's refusals to bathe and change her clothes nor the actions taken by the staff to address these needs. 3. InterviewOn 5/17/23 at 10:20 a.m., the acting administrator (AA) stated a care plan should have been a part of the resident record for Resident #6, but she was unable to locate the care plan. She stated she looked for progress notes for Residents #6-#8 as well. The AA stated she was unable to find a care plan for Resident #6 and progress notes for Residents #6-#8 due to the residence's inefficient filing system. She confirmed that staff should have documented in progress notes when they saw changes in baseline status for Residents #7 and #8, but she was unable to locate progress notes in the residents' records.

Plan of correction · submitted by the facility

Residents #6, ##7 & 8: care plan will be reviewed, by date of compliance, to ensure it accurately reflects residents’ baseline statusAdministrator will be educated on ensuring that care plans are updated at least annually & after a resident change of conditionAdministrator/designee will complete an audit of current resident care plans, by date of compliance, to ensure that they accurately reflect residents’ current condition and needsResident care plans will be reviewed and updated at least annually, and with any change of condition, to accurately reflect residents’ current condition and needsAdministrator/designee will complete an audit of fifteen resident charts per month, for three months, to ensure that care plans are up to date and reflect residents’ current conditions and needs. Results of audits and reviews will be included in QMP process for three months for review and recommendations for improvement, if necessary.

2712Env Pest Cntrl CntrctS/S B▼

Findings

Based on record review and interview, the residence failed to have a contract with a licensed pest control company or an effective means for pest control using the least toxic and least flammable effective pesticides. Additionally the residence failed to ensure that pesticides were not stored in resident areas, affecting 48 current residents. (Cross-reference Q1110)Findings include:The residence's Pest Control Policy, dated 8/16/22, read in part that the administrator was assigned the responsibility of coordinating efforts to effectively control or eradicate unwanted pests. Pest management services were provided routinely and upon request through the administrator via contract with a pest control company. On 5/16/23 at 12:32 p.m., the business office manager (BOM) stated she was aware of the requirement to have a contract with a pest control company; however, she added that the residence did not currently have a contract that she was aware of. She stated she had not received a bill from a pest control company since she started as the BOM on 10/31/22. On 5/17/23 at 9:01 a.m., an external service provider (from the pest control company that was named by the resident care coordinator as the company she had called for pest control) stated he had no record of a contract with the residence to provide pest control within the residence's rooms and common areas nor on the grounds of the residence.

Plan of correction · submitted by the facility

Resident #6 & #11: Pest control company was contacted and was on-site on 5/20/23 and addressed cited pest problems in resident’s rooms, no further issues noted. Contract executed with Pest Control company to provide services to facility quarterly, and as needed in between services. Administrator/designee will complete an audit of all resident rooms, at least monthly, for three months, to ensure that resident rooms remain pest free, and will resolve any issues identified. Results of audits will be included in QMP process for 3 months for review and/or recommendations for improvement, if necessary.

9999Final ObservationsSurveyor note▼

Findings

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 7.12.10 Each resident care plan shall:(A) Be developed with input from the resident and the resident's representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers along with care coordination arrangements; and(F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident's personal choices and needs.

Plan of correction

The state did not require a plan of correction for this citation.

Provider Information

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Reportable Occurrences