SUNRISE ASSISTED LIVING OF BOULDER

A relicensure survey with complaint #CO29793 was completed on 1/5/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure its quality management program (QMP) contained all required elements, affecting 78 current residents. (Cross-reference B0514)Findings include: 1. Record ReviewReview of the residence's quality management program revealed the following: The residence's QMP was focused on the following components of service delivery: surveys and plans of correction, facilities standards, dining, pharmacy consultation audits, falls with or without injuries, and residents with three or more falls in 30 days. However, the QMP contained no documentation/information regarding: the process for staff to report service delivery errors and potential for errors within a prescribed period of time and a plan for how staff would be trained regarding such reporting; the methods used to collect and analyze data in order to find patterns and trends; how the administrator would be informed of such patterns and trends; the methods used to select quality management projects; nor the method for selecting the service delivery practices that would be reviewed. 2. InterviewOn 1/5/23 at approximately 11:30 a.m., the administrator acknowledged the residence's QMP did not contain documentation of the above, required elements. The administrator stated the above elements were part of the QMP but had not been documented and included in the QMP.

Based on record review and interview, the residence failed to ensure its quality management program (QMP) contained the required elements, affecting 78 current residents. (Cross-reference B0512)Findings include: 1. Record ReviewReview of the residence's quality management program revealed the following: The residence's QMP was focused on the following components of service delivery: surveys and plans of correction, facilities standards, dining, pharmacy consultation audits, falls with or without injuries, and residents with three or more falls in 30 days. However, the QMP contained no documentation/information regarding: a description of the intervention design, how staff would be allocated and/or trained to implement the strategy, how the strategy would be evaluated for effectiveness, nor timelines for implementation and evaluation of the strategy and how the facility or agency was tracking the meeting of those milestones. 2. InterviewOn 1/5/23 at approximately 11:30 a.m., the administrator acknowledged the residence's QMP did not contain documentation of the above, required elements. The administrator stated the above elements were part of the QMP but had not been documented and included in the QMP.

Based on record review and interview, the residence failed to ensure a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI) was completed prior to hire, affecting four of five sample staff (#1, #2, #3 and #5). Findings include:1. Residence PoliciesThe residence's employment verification and background policy, dated 5/31/19, read in part, "Background checks are conducted on all applicants who have been offered employment (with the offer conditioned on their passing the background check)."It is the policy of the residence not to employ individuals with criminal histories which prohibit such employment. The residence may in its discretion deny employment to individuals based on their criminal histories." 2. Record Review The personnel file for Staff #1 contained a hire date of 12/19/22 and a name-based criminal history report, dated 12/7/22. However, the criminal history check did not include a report by the CBI.The personnel file for Staff #2 contained a hire date of 11/1/22 and a name-based criminal history report, dated 10/17/22. However, the criminal history check did not include a report by the CBI.The personnel file for Staff #3 contained a hire date of 9/28/22 and a name-based criminal history report, dated 9/27/22. However, the criminal history check did not include a report by the CBI.The personnel file for Staff #5 file contained a hire date of 11/23/22 and a name-based criminal history report, dated 11/10/22. However, the criminal history check did not include a report by the CBI.An email from the residence's background check company dated 1/4/23 stated the company offered two types of statewide criminal record searches. The criminal record search that the company had used for background checks was a statewide criminal court record search that did not include a search of the CBI. 3. InterviewOn 1/5/23 at 11:43 a.m., the administrator stated she was not aware the residence was not performing a specific CBI background check on personnel. She confirmed this was not done for Staff #1, #2, #3 and #5.

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 first aid from a nationally recognized organization, affecting 78 current residents. (Cross-reference Q0734)Findings Include:1. Reference and Residence Policya. According to VeryWell Health, "First aid is the emergency care a sick or injured person gets. In some cases, it may be the only care someone needs, while in others, it may help them until paramedics arrive or they are taken to the hospital. The best way to prepare for these events is to get official first aid training." Brouhard, R., EMT (11/30/21) First Aid, 10 Basic First Aid Procedures, retrieved from: https://www.verywellhealth.com/basic-first-aid-procedures-1298578b. The residence's first aid policy, dated 9/1/2012, read in part that prior to providing direct resident care " ... staff shall provide evidence of current first aid certification or the community will provide the staff member training on first aid and injury response. Certification of first aid training shall be maintained in the team member file. There shall be one staff member onsite at all times who has current certification in first aid specific to adults." 2. Record Reviewa. Personnel filesStaff #1-#5 were hired on 12/19/22, 11/1/22, 9/28/22, 3/3/12, and 11/23/22 respectively. On 1/4/23, the personnel files for Staff #1-#5 did not contain evidence of current first aid certification.b. Staff SchedulesReview of staff schedule from 12/9/22 to 12/12/22 revealed the residence did not have a staff member certified in first aid onsite from 6:00 a.m. to 2:00 p.m. on 12/10/22 through 12/12/22, 2:00 p.m. to 10:00 p.m. on 12/10/22, and 10:00 p.m. to 6:00 a.m. on 12/9/22, 12/10/22 and 12/12/22 for a total of eight shifts. 3. InterviewOn 1/4/23 at 7:45 a.m., Staff #11 stated she was not first aid certified. She stated the residence had scheduled a class in December 2022, however the class had been canceled. On 1/4/23 at 2:30 p.m., the administrator stated she had a binder with first aid certification documents, however she was aware that some of the certifications in the binder were expired. The administrator stated she was aware the residence was required to have at least one staff member onsite at all times that was certified in first aid. The administrator stated the residence had scheduled a CPR class in December 2022, however the class was canceled by the instructor due to a Norovirus outbreak at the residence. The administrator stated she was aware that the residence had several shifts that were not covered with at least one CPR certified staff member on the shift.

Based on record review and interview the assisted living residence failed to have at least one staff member onsite at all times who had a 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 78 current residents. Specifically, the residence failed to have at least one staff member onsite at all times who had current certification in obstructed airway techniques from a nationally recognized organization, affecting 78 current residents in the event of an obstructed airway emergency for eight shifts from 12/9/22 to 12/12/22. This failure created an immediate jeopardy risk to 78 current residents in the event of an emergency. On 1/4/23, the department directed the residence to provide written evidence that the risk had been removed. Specifically, the residence failed to have at least one staff member onsite at all times who had a current CPR certification from a nationally recognized organization for eight shifts from 12/9/22 to 12/12/22. Only two staff (#9, #10) had current certifications, all other staffs' certifications were expired. This failure created an immediate jeopardy risk to two of 13 sample residents (#3, #4) who required CPR in the event of an emergency. On 1/4/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Residence Policya. The residence's CPR policy dated 6/25/05, read in part, "It is the policy of the residence that a resident, who is found unresponsive, without a pulse and does not have a Do Not Resuscitate Order (DNR), will have CPR initiated by a team member certified in CPR unless it is determined by a healthcare professional acting within established scope of practice that obvious clinical signs of irreversible death are present."b. 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 (5/1/21) Cardiopulmonary Resuscitation. retrieved from: https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600c. 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." Skill Sheet: Obstructed Airway Care for Adults and Children (2019), 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.pdfd. According to Nolo Legal Encyclopedia, "A MOST (Medical Orders for Scope of Treatment) form is a doctor's order that helps you keep control over medical care at the end of life. Like a Colorado CPR Directive, the form tells emergency medical personnel and other health care providers whether or not to administer cardiopulmonary resuscitation (CPR) in the event of a medical emergency. A MOST form may be used in addition to -- or instead of -- a CPR Directive. The MOST form may also provide other information about your wishes for end-of-life health care." Irving, S., J.D., Colorado's Medical Orders for Scope of Treatment (MOST) Form, retrieved from: https://www.nolo.com/legal-encyclopedia/colorados-medical-orders-scope-treatment-most-form.htmle. According to Very Well Health, "For employees required to have CPR training, OSHA (Occupational Safety and Health Association) standards specify that OSHA online-only certifications are not acceptable. Many employers, especially healthcare organizations, only accept certification from the American Red Cross or the American Heart Association. Those cannot be obtained online." Brouhard, R. EMT (4/20/22) Are Online Certifications Valid, retrieved from: https://www.verywellhealth.com/are-online-cpr-certifications-valid-12984232. Record ReviewsOn 1/4/23 at approximately 12:25 p.m., documentation of certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques was requested. The only current certification provided was for Staff #9 and #10; all other staffs' certifications were expired. The residence's staff schedule revealed that Staff #9 and #10 had not worked eight shifts from 12/9/22 to 12/12/22. The staff who worked those shifts had expired certifications. Therefore, there were no staff on duty with current CPR and obstructed airway techniques certification through a nationally recognized organization such the American Red Cross, the American Heart Association, the National Safety Council or the American Safety and Health Institute for eight shifts. The record for Resident #3 contained a MOST form, dated 11/25/22, that read the resident wished to receive CPR in the event of an emergency. The record for Resident #4 contained a MOST form, dated 12/5/22, that read the resident wished to receive CPR in the event of an emergency. 3. InterviewOn 1/4/23 at 2:30 p.m., the administrator stated that she had a binder that contained staff CPR certifications, however she was aware that all but two staff's (#9, #10) certifications in the binder were expired. The administrator stated she was aware the residence was required to have at least one staff member onsite at all times with certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques. She confirmed that Staff #9 and #10 did not work the above shifts and those that did work had expired certifications. 4. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe survey established that the findings above placed 78 current residents at immediate jeopardy risk for the failure to ensure at least one staff member was on site at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 1/4/23 at 3:40 p.m., the administrator submitted written evidence that read in pertinent part that all current staff would complete a CPR course through the American Red Cross on 1/5/23. Additionally, the residence would ensure that Staff #9 or Staff #10 were onsite at all times until the residence could send staff to CPR classes. However, the written evidence did not indicate the risk had been removed because it did not include an acceptable monitoring element. On 1/4/23 at 3:56 p.m., the administrator submitted additional written evidence that read in pertinent part that the administrator and the business office coordinator would monitor for ongoing compliance with CPR certifications and the residence would schedule and offer regular classes throughout the year.

Based on observation and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation), so that the information was readily available to staff at all times, affecting 78 current residents. Findings include: Throughout the on-site visit, on 1/4/23 from 7:00 a.m. to 6:00 p.m. and on 1/5/23 from 7:00 a.m. to 3:00 p.m., no list of staff who had current certification in first aid or CPR was posted in a visible location. On 1/4/23, at 7:45 a.m., Staff #8 stated he did not know how to decipher which staff had current certifications in first aid or CPR. He stated he was not currently certified, adding that when a resident required first aid or CPR, he called someone from the management team or he called 911. Staff #8 stated there was no list of current staff who had current certification in first aid or CPR posted in a visible location. On 1/4/23 at 1:40 p.m., Staff #6 and Staff #7 stated there was no list of staff who had current certification in first aid or CPR currently posted in a visible location, adding that they did not recall there ever being one. On 1/5/23 at 11:50 a.m., the administrator stated she was not aware of the requirement to post a list of staff with current first aid and CPR certification in a visible location, and she confirmed that it was not posted.

Based on record review and interview, the residence failed to develop policies and procedures regarding the investigation of injuries of known or unknown source/origin; fall management; the provision of lift assistance; and unanticipated illness, injury, significant change of status from baseline, or death of resident, affecting 78 current residents. Findings include: 1. ReferenceChapter VII regulations governing assisted living residences, part 12.15, requires that the residence develop policies and procedures to establish a fall management program. The program shall include the following:(A) Providing fall management education and materials to residents and family members;(B) Detailing in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment;(C) Providing resident engagement activities to improve strength and balance as specified in Part 12.22(C);(D) Routinely inspecting and maintaining a safe exterior and interior environment as specified in Parts 21 and 22; and(E) Providing staff training related to fall prevention as specified in Part 7.8(B)(6). 2. Record ReviewsOn 1/4/22 at approximately 9:00 a.m.,the administrator was asked to provide the residence's policies regarding the investigation of injuries of known or unknown source/origin; fall management, the provision of lift assistance, and unanticipated illness, injury, significant change of status from baseline, or death of resident. However, no policy regarding the investigation of injuries of known/unknown source or origin was provided. The administrator provided the residence's Safe Resident Movement Program policy, dated 12/4/19, which the administrator stated was the residence's fall management policy. However, the policy did not include information regarding the provision of fall management education and materials to residents and family members; a requirement to detail in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment; the provision of resident engagement activities to improve strength and balance; a requirement to routinely inspect and maintain a safe exterior and interior environment, nor the provision of staff training related to fall prevention. The administrator provided the residence's undated Assessment & (and) Care Planning policy, which she said was the unanticipated illness, injury, significant change of status from baseline, or death. However, the Assessment & Care Planning policy only contained information regarding resident assessments at admission and upon a significant change of condition but did not contain information about injury or death of a resident. 2. InterviewOn 1/5/23 at 1:35 p.m., the administrator acknowledged the residence did not have a fall management policy that contained the required elements; she said she was not aware of the requirements for this policy. The administrator also acknowledged the residence had no policy regarding the investigation of injuries of known/unknown source or origin. The administrator said she believed the residence had a lift assistance policy; however, no additional policy was provided. The administrator also acknowledged the residence did not have a policy regarding unanticipated illness, injury, significant change of status from baseline, or death; she said she had not been aware there was no such policy.

Based on record review and interview, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises including, but not limited to, fire, gas explosion, power outages, tornado, flooding and threatened or actual acts of violence, affecting 78 current residents. Findings include: 1. Record ReviewOn 1/4/23 at approximately 9:00 a.m., a risk assessment of all hazards and preparedness measures to address natural and human-caused crises was requested. However, no such risk assessment was provided. 2. InterviewOn 1/5/23 at 1:44 p.m., the administrator stated she was not able to locate an assessment of all hazards and preparedness measures to address natural and human-caused crises. The administrator stated she had not known the assessment was required. The administrator stated the residence's highest risks were flood and fire, though she could not provide any documentation of that assessment.

Based on observation and interview, the residence failed to make available 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 78 current residents. Findings include:1. References a. According to Senior Safety Advice, "To keep the elderly from slipping and falling on ice, do the following: Don't wait to shovel until after the snow, as you might prevent the formation of ice if you're quick. Add gravel or sand to your driveway or other icy surfaces, as this breaks ice up." Senior Safety Advice (9/30/22) How to Keep Elderly From Slipping on Ice, retrieved from: https://seniorsafetyadvice.com/how-to-keep-elderly-from-slipping-on-ice/ b. According to Timeanddate.com, on 12/28/22 and 1/2/23, the county in which the residence was located received light snow and/or icy conditions. Past Weather in Boulder, Colorado, USA (2023). Retrieved from https://www.timeanddate.com/weather/usa/boulder/historic 2. Exterior EnvironmentOn 1/4/23 at approximately 10:30 a.m., an environmental tour of the residence's exterior grounds revealed the following: The doors leading to the assisted living residence's perimeter were open to residents wanting to go outside. The residence perimeter had a walkway encircling the outside area of the residence. However, approximately 60 percent of the walkway was covered with snow and/or ice, up to two inches in depth. There was ice melt on the exterior walkways, however the ice remained present in spots and slick when walked upon. 3. Secure Environment CourtyardOn 1/4/23 at approximately 10:00 a.m., an environmental tour of the residence's secure environment outdoor courtyard revealed the following: The doors leading to the secure environment's courtyard were unlocked. The courtyard had a walkway that encircled the area. However, approximately 80 percent of the walkway was covered with snow and/or ice, up to two inches in depth. There was no visible product to melt the ice on the ground. 4. Interior EnvironmentOn 1/4/23 at approximately 10:00 a.m., an environmental tour of the residence's interior environment revealed the following: A wooden handrail on the wall adjacent to Room #322 had a corner where the paint was missing; the wood beneath was broken and splintered, which created a risk of injury. A common area toilet adjacent to the private dining room had a toilet lid with enamel worn away so that the material beneath was exposed, which prevented cleaning. 5. InterviewsOn 1/4/23 at 8:35 a.m., Staff #12 stated two or three residents in the secure environment did sometimes want to walk around the secure environment's outdoor area. She said snow and ice were only sometimes removed from the secure environment courtyard walkway. On 1/4/23 at 1:48 a.m., the administrator stated the residence used an external vendor to shovel snow and put down a product to melt ice, when needed. The administrator also said the residence's maintenance coordinator (MC) was responsible for snow/ice removal, as needed. The administrator stated she had not noticed that the secure environment's outdoor courtyard had snow/ice on the walkway. On 1/4/23 at 2:06 p.m., the MC confirmed the residence relied on an external vendor for snow/ice removal. He said he also made sure there was a snow melting product on ice, so that it would melt. He stated that due to a snow storm around 12/29/22, he was unable to get to the residence to ensure snow/ice was removed. The MC said he did not know why no one else had applied an ice melting product to the secure environment's courtyard walkways.

Based on observations, record review, and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting eight of 10 sample residents (#1-#4, #6, #9-#11) and one former resident (#16 ). (Cross-reference Q1510, Q1514) Findings include: 1. Residence Policya. The residence's medication policy, dated 7/1/19, read in part: "The community follows all applicable State ... laws and regulations and accepted standards of practice related to medications and medication administration."2. Resident #4 was admitted to the residence on 12/5/22 with diagnoses including acute kidney failure and hyperlipidemia. a. Polyethylene GlycolA written practitioner order, dated 12/1/22, directed the residence to administer polyethylene glycol 3350, 17 gm/scoop daily. However, the December 2022 electronic medication administration record (eMAR) for Resident #4 read the medication was not available on 12/6-12/29/22, for 24 missed doses.b. AllopurinolA written practitioner order, dated 12/1/22, directed the residence to administer allopurinol 100 mg daily. However, the December 2022 eMAR for Resident #4 read the medication was not available on 12/11-12/17/22, for seven missed doses. c. Atorvastatin CalciumA written practitioner order, dated 12/1/22, directed the residence to administer atorvastatin calcium 10 mg daily. However, the December 2022 eMAR for Resident #4 read the medication was not available on 12/13-12/22/22, for 10 missed doses. d. Aspirin A written practitioner order, dated 12/1/22, directed the residence to administer aspirin 81 mg daily. However, the December 2022 eMAR for Resident #4 read the medication was not available on 12/10-12/17/22, for eight missed doses. e. Desloratadine DisintegrateA written practitioner order, dated 12/1/22, directed the residence to administer desloratadine disintegrate 2.5 mg daily. However, the December 2022 eMAR for Resident #4 read the medication was not available on 12/14-12/19/22, for six missed doses. f. Montelukast SodiumA written practitioner order, dated 12/1/22, directed the residence to administer montelukast sodium 10 mg daily. However, the December 2022 eMAR for Resident #4 read the medication was not available on 12/11-12/22/22, for 12 missed doses.g. Interview On 1/5/23 at 9:12 a.m., the resident care director (RCD) stated the resident had been admitted with the above medications, which ran out before the residence had obtained refills. She added, "That shouldn't happen." 3. Resident #11 was admitted to the residence on 3/7/22 with diagnoses including type two diabetes mellitus with other skin ulcer and benign prostatic hyperplasia without lower urinary tract symptoms.a. GabapentinA written practitioner's order, dated 10/13/22, directed the residence to administer gabapentin 300 mg three times a day, however the December 2022 eMAR read the residence failed to administer the medication from 12/16/22 to 12/17/22 for a total of five missed doses. b. Divalproex SodiumA written practitioner's order, dated 11/5/22, directed the residence to administer divalproex sodium 250 mg at bedtime, however the December 2022 eMAR read the residence failed to administer the medication from 12/6/22 to 12/8/22 because the medication was pending delivery, for a total of three missed doses. c. Tamsulosin A written practitioner's order, dated 5/10/2022, directed the residence to administer tamsulosin two 0.4 mg capsules once daily, however the December 2022 eMAR read the residence failed to administer the medication on 12/12/22, 12/23/22 and 12/24/22 for a total of three missed doses.d. AugmentinA written practitioner's order, dated 10/25/22, directed the residence to administer 1 tablet of augmentin three times daily, however the December 2022 eMAR read the residence failed to administer the medication on 12/1/22, 12/2/22, 12/30/22 and 12/31/22 for all three doses, 12/3/22 for two doses, 12/5/22 for two doses, 12/8/22 for one dose, 12/27/22 through 12/29/22 for three doses for a total of 23 missed doses. 4. Resident #3 was admitted to the residence on 12/4/22. a. Preservision AREDSA written practitioner order, dated 11/25/22, directed the residence to administer PreserVision AREDS-2-250-90-40-1 mg twice daily. However, the December 2022 eMAR for Resident #3 read the medication was unavailable on 12/10-12/15 and 12/23/22-1/3/23, for 37 missed doses. On 1/4/23 at 3:24 p.m., the RCD confirmed the medication had not been available to administer on the above dates. The RCD could not explain the failure.b. Latanoprost Ophthalmic SolutionA written practitioner order, dated 11/25/22, directed the residence to administer latanoprost ophthalmic solution 0.005 %, one drop in both eyes daily. However, the December 2022 and January 2023 eMARs for Resident #3 read the medication was not available on 12/30, 12/31/22, 1/1 and 1/2/23, for four missed administrations. On 1/4/23 at 3:24 p.m., the RCD confirmed the medication had not been available to administer on the above dates. The RCD could not explain the failure.c. Multivitamin-MineralsA written practitioner order, dated 11/25/22, directed the residence to administer multivitamin minerals daily. However, the December 2022 eMAR for Resident #3 read the medication had been held on 12/16-12/22/22, for seven missed doses. The record for Resident #3 did not contain any hold orders for this medication. On 1/4/23 at 3:24 p.m., the RCD confirmed the medication had been held due to the resident undergoing treatment for a medical condition. On 1/5/23 at 12:33 p.m., the RCD confirmed there were no signed practitioner orders to hold the medication. The RCD said, "I think ... I took a verbal order." The RCD added she had not obtained a countersigned order from the practitioner. 5. Former Resident #16 was admitted to the residence on 11/4/21 with diagnoses including gastroesophageal reflux disease, restlessness and agitation. a. FamotidineWritten practitioner orders, dated 8/18/20 and 12/6/22, directed the residence to administer famotidine 20 mg twice daily. However, the November and December 2022 eMARs for Former Resident #16 read the medication was not available 11/22-12/6/22, for 30 missed doses. On 1/4/23 at 12:43 p.m., the RCD confirmed the medication had not been available to administer. She stated a family member had reordered the medication. She added, "We probably should have contacted (the family member)," about the medication. b. SeroquelA written practitioner order, dated 12/6/22, directed the residence to administer seroquel 25 mg daily. However, the December 2022 eMAR for Former Resident #16 read the medication was not available 12/10-12/17/22, for eight missed doses. On 1/4/23 at 1:07 p.m., the administrator confirmed the medication had not been available to administer. She stated she believed the residence had been waiting for the medication to be provided by a family member. 6. Resident #2a. Miralax PowderA written practitioner order, dated 12/17/22, directed the residence to administer Miralax Powder 17 gm/scoop daily. However, the January 2023 eMAR for Resident #2 read the medication was not available on 1/1-1/3/23, for three missed doses. On 1/5/23 at 10:09 a.m., the RCD stated the resident's family member provided the medication. The RCD added that staff must not have informed the family member in a timely way, so as to obtain the medication before it ran out. b. Docusate SodiumA written practitioner order, dated 12/17/22, directed the residence to administer docusate sodium 100 mg daily. However, the December 2022 eMAR for Resident #2 read the medication was not administered on 12/18,12/20, 12/22, 12/24, 12/25, 12/27, 12/29/22, 1/1 and 1/3/23, for nine missed doses. On 1/5/23 at 10:13 a.m., the RCD stated the order had changed from Monday, Wednesday and Friday only, to daily administration. She said she had reached out to the practitioner for more information but had not followed up with the response. The RCD acknowledged the medication should have been administered daily. 7. Resident #10 was admitted to the residence on 4/5/22 with diagnoses including depression and pain.a. AcidophilusA written practitioner's order, dated 12/6/22, directed the residence to administer acidophilus one capsule daily. However the December 2022 eMAR read the residence failed to administer the medication on 12/22/22 because the medication was out of stock and pending delivery.b. Citalopram HydrobromideA written practitioner's order, dated 12/6/22, directed the residence to administer citalopram hydrobromide 20 mg daily. However, the December 2022 eMAR read the residence failed to administer the medication on 12/15/22 because the medication was out of stock and pending delivery.c. AcetaminophenA written practitioner's order, dated 12/6/22, directed the residence to administer acetaminophen 500 mg two tablets daily. However, the December 2022 eMAR read the residence failed to administer the medication for one dose on 12/20/22 and two doses on 12/26/22 because the medication was out of stock and pending delivery. 8. Resident #1 was admitted to the residence on 12/21/21 with diagnoses including constipation. a. Mannose CranberryA written practitioner's order, dated 12/4/23, directed the residence to administer mannose cranberry twice daily. However, the December 2022 and January 2023 electronic medication administration records (eMARs) read the residence failed to administer the medication from 12/4-12/13/22, 12/15/22, and 12/17/22 to 1/5/23 because the medication was out of stock and pending delivery, for a total of 61 doses. On 1/5/23 at approximately 2:00 p.m., an audit of Resident #1's medications revealed the medication was not in stock.b. Metamucil A written practitioner's order, dated 12/4/22, directed the residence to administer Metamucil 3.4 gm/5.8 gm one scoop in water or juice daily. However, the December 2022 and January 2023 eMARs read the residence failed to administer the medication from 12/4/22 to 1/5/23 because the medication was out of stock and pending delivery, for a total of 32 missed doses. On 1/5/23 at approximately 2:00 p.m., an audit of Resident #1's medications revealed the medication was not in stock. On 1/5/23 at 11:58 a.m., the administrator stated Resident #1's two medications that were out of stock should have been caught by herself, the resident care director (RCD), or the qualified medication administration persons (QMAPs). On 1/5/23 at 12:35 p.m., the RCD stated that a QMAP had informed her that these medications were out of stock. She stated she had not notified the resident's family nor the preferred pharmacy because she had not had the time to do so. On 1/5/23 at approximately 3:00 p.m., Staff #13 acknowledged the residence was currently out of stock on Resident #1's mannose cranberry capsules and Metamucil. She stated the residence had been out of stock of both of these medications since before December 2022.9. Resident #9 was admitted to the residence on 12/21/22 with diagnoses including vitamin D deficiency and pain. a. CholecalciferolA written practitioner's order, dated 12/19/22, directed the residence to administer cholecalciferol 1000 units daily. However, the December 2022 eMAR read the residence failed to administer the medication on 12/30/22 because it was out of stock and pending delivery. b. AcetaminophenA written practitioner's order, dated 12/19/22, directed the residence to administer acetaminophen 975 mg every six hours. However, the December 2022 eMAR read the residence failed to administer two doses of the medication on 12/22/22 because the medication label read 500 mg which did not match the directions on the eMAR.10. Resident #6 was admitted to the residence on 5/25/20 with diagnoses to include Actinic keratosis, essential hypertension, myopia, Parkinson's disease, pure hyperglycemia, schizophrenia, type two diabetes mellitus with diabetic neuropathy and vitamin D deficiency. a. GabapentinA written practitioner's order,dated 7/18/22, directed the residence to administer Gabapentin 100 mg two capsules by mouth twice daily. However, the December 2022 eMAR read the residence failed to administer the medication on 12/1/22, 12/3/22 through 12/5/22, 12/6/22, 12/7/22, 12/9/22, and 12/18/22 for the evening dose and 12/11/22 through 12/14/22 for both doses because the medication was pending delivery, for a total of 15 missed doses. b. FiberconA written practitioner's order, dated 11/21/22, directed the residence to administer Fibercon 625 mg twice daily. However, the December 2022 eMAR read the residence failed to administer the medication 12/1/22, 12/7/22, 12/11/22 and 12/22/22 for one daily dose and 12/2/22 through 12/9/22 as well as 12/12/22 through 12/21/22 for both daily doses for a total of 38 missed doses. On 1/5/23 at 11:57 a.m., the administrator stated when a resident was out of medications it was the responsibility of the QMAP or the resident care director to order medications from the pharmacy. The administrator stated there was no back up plan if a family member did not bring in a medication. The administrator stated families were encouraged to order medications through the residence's designated pharmacy. 11. Interviews On 1/5/23 at approximately 9:14 a.m., the RCD stated when a medication was not administered for one day, the medication was likely ordered that day and delivered in time for the next dose. She stated the expectation was that the residence had at least a three day supply of each medication when they ordered them through a pharmacy and at least a seven day supply when the resident families provided medications. On 1/5/23 at 11:57 a.m., the administrator stated residence staff should place an order with the pharmacy any time residents' family members did not bring in medications in a timely way. She acknowledged that the residence failed to administer all medications as ordered by practitioners for Residents #1-#4, #6, #9-#11, and #16. The administrator stated residence nurses and QMAPs should have ensured their medications were in stock.

Based on observation, record review and interview, the residence failed to ensure all over-the-counter (OTC) medication prescribed for administration was labeled or marked with residents' full names, affecting two of two sample residents (#2, #3) who were administered medications from the medication cart on the south side of the residence. Findings include: 1. Residence PolicyThe residence's medication policy, dated 7/1/19, read in part: "Over-the (sic) counter medications are stored as follows: ... All medications are kept in ... properly labeled containers." 2. Resident #2Resident #2's medications were administered from the medication cart on the south side of the residence building. The medication cart contained the following OTC medications, which were not labeled with the resident's full name nor any other identifying information: A bottle of calcium 600 mgA bottle of docusate sodium 100 mgA bottle of PreserVision AREDSA bottle of One-A-Day Men's 50 PlusA bottle of vitamin C 500 mgA bottle of slow release ironThe record for Resident #2 contained written practitioner orders, dated 12/9/22, that directed the residence to administer the following medications:Calcium 600 mg dailyDocusate sodium 100 mg daily on Monday, Wednesday and FridayPreserVision AREDS dailyOne-A-Day Men's 50 Plus dailyVitamin C 500 mg Monday, Wednesday and FridaySlow Fe Extended Release 143/45/FE mg every Monday, Wednesday and Friday 3. Resident #3Resident #3's medications were administered from the medication cart on the south side of the residence building. The medication cart contained the following OTC medications, which were not labeled with the resident's full name: A bottle of multivitamin-mineralsA bottle of timolol maleate ophthalmic 0.5% solutionThe record for Resident #3 contained written practitioner orders, dated 11/25/22, that directed the residence to administer the following medications: Multivitamin-minerals dailyTimolol maleate 0-5% ophthalmic solution one drop into both eyes, daily. 4. InterviewsOn 1/5/23 at approximately 10:50 a.m., Staff #4 stated the OTC medications should have been labeled with resident's full names. Staff #4 said she had not had time to write Resident #2 and #3's names on their OTC medications. On 1/5/23 at approximately 12:00 p.m., the administrator stated the cart on the south side of the residence was Staff #4's responsibility. The administrator stated OTC medications should be labeled with residents' full names. The administrator could not explain why that had not been the case, as documented above.

Based on observation, record review and interview, the residence failed to ensure qualified medication administration persons (QMAPs) applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting four of four sample residents (#4, #13-#15), whose medication administrations were observed. Findings include: 1. Residence Policy The residence's medication policy, dated 7/1/19, read in part: "The community follows all applicable State ... laws and regulations and accepted standards of practice related to medications and medication administration ... All (QMAPs) follow all regulatory and safe medication administration requirements when passing medications." 2. ObservationOn 1/4/23 between approximately 7:30 a.m. and 8:30 a.m., Staff #4 was observed administering medications to four residents. Staff #4 donned gloves but then touched the medication cart's computer screen and keyboard, the medication cart handles and keys, as well as medication containers with the gloved hands. Staff #4 did not sanitize these touched surfaces before or during medication administration. However, as Staff #4 administered medications to Residents #13-#15, she popped pills into her gloved hand, which had touched the unsanitized items above. The medications were then administered to the three residents. While administering Resident #4's medications, Staff #4 used her finger to remove a pill from a bottle cap, before putting the medication into the cup with other medications, which were then administered to Resident #4. 3. InterviewsOn 1/4/22 at 8:29 a.m., Staff #4 stated she knew she was not supposed to put pills into her gloved hand if the gloved hand had touched other items. She added, "But it's hard to get them out of the ... package. I have to push down really hard, so I do it into my hand." On 1/4/23 at 1:53 p.m., the administrator stated QMAPs should not put pills into the palm of their gloved hands, unless the gloved hand had touched nothing unsanitary, prior.

Based on record review and interview, the residence failed to accurately document each medication administration or monitoring event at the time the event was completed for each resident, affecting four of eight sample residents (#1, #3, #4, #6) who resided in the non-secure environment and one former resident (#16) (Cross-reference Q1468, Q1514) Findings include: 1. Residence PolicyThe residence's medication policy, dated 7/1/19, read in part: "MARs (medication administration records) are checked weekly for accurate documentation practices ... In-depth audit of ... MARs assesses for ... incorrect or missing documentation." 2. Resident #3 was admitted to the residence on 12/4/22.a. Preservision AREDSA written practitioner order, dated 11/25/22, directed the residence to administer PreserVision AREDS-2-250-90-40-1 mg twice daily. It was established that the medication was not available to administer on 12/10-12/15 and 12/23/22-1/3/23. However, the December 2022 and January 2023 eMAR for Resident #3 read the medication had been administered on 12/10-12/15, 12/23, 12/24, 12/26/22, 1/1 and 1/2/23, in the morning. On 1/4/23 at 3:24 p.m., the RCD stated staff had incorrectly documented that the medication had been administered on the above dates. b. Latanoprost Ophthalmic SolutionA written practitioner order, dated 11/25/22, directed the residence to administer latanoprost ophthalmic solution 0.005 %, one drop in both eyes daily. It was established the residence had not had ensured the medication was available to administer on 12/30/22 and 1/1/23. However, the December 2022 and January 2023 eMARs for Resident #3 read the medication had been administered on those dates. On 1/4/23 at 3:24 p.m., the RCD stated staff had incorrectly documented that the medication had been administered on the above dates. 3. Resident #16 was admitted to the residence on 11/4/21.a. FamotidineWritten practitioner orders, dated 8/18/20 and 12/6/22, directed the residence to administer famotidine 20 mg twice daily. It was established the residence had not had ensured the medication was available to administer on 11/25/22. However, the November 2022 eMAR read the medication administered on 11/25/22 in the morning. On 1/4/23 at 12:43 p.m., the RCD confirmed the medication had not been available to administer and that staff had erroneously marked the medication as having been administered. 4. Resident #4 was admitted to the residence on 12/5/22. A written practitioner order, dated 12/1/22, directed the residence to administer polyethylene glycol 3350, 17 gm/scoop daily. It was established the residence had not had ensured the medication was available to administer on 12/6-12/29/22. However, the December 2022 eMAR for Resident #4 read the medication had been administered on 12/8, 12/18, 12/20 and 12/25/22. Additionally, the eMAR read the medication had been refused on 12/9-12/11, 12/21-12/24 and 12/26-12/29/22. On 1/5/23 at 12:33 p.m., the RCD confirmed staff had erroneously documented that the medication had been administered and/or refused, as documented above. 5. Resident #1 was admitted to the residence on 12/21/21 with an unrelated diagnosis. A written practitioner's order, dated 12/4/23, directed the residence to administer mannose cranberry twice daily. It was established that residence did not have this medication in stock since before December 2022. However, the December 2022 eMAR for Resident #1 read the residence administered the medication on the mornings of 12/14/22 and 12/16/22.6. Resident # 6 was admitted to the residence on 5/25/20 with diagnoses to include Actinic keratosis, essential hypertension, myopia, Parkinson's disease, pure hyperglycemia, schizophrenia, type two diabetes mellitus with diabetic neuropathy and vitamin D deficiency. A written practitioner's order, dated 11/21/22, directed the residence to administer Fibercon 625 mg twice daily. However, it was established the residence did not have the medication in stock from 12/1/22 to 12/23/22. The December 2022 eMAR read the residence administered the medication on 12/7/22, 12/10/22 and 12/11/22.

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, controlled substance list, medication error reports, and medication disposal records, affecting 11 of 15 current sample residents (#1-#4, #6, #9-#11, #13-#15) and one former resident (#16). (Cross-reference Q1468, Q1494, Q1510)Findings include:The residence's medication policy, dated 7/1/19, read in part that the resident care director retained overall responsibility for monthly medication cart checks but could delegate audits as appropriate and permitted by state regulation. The goals of the monthly medication audit included: an in-depth assessment of expired medication, poor storage practices, inaccurate or missing documentation, and general organization of the medication cart. A licensed nurse or designee performed a full audit of each medication cart once per month and documented it on the residence's monthly cart check document. On 1/4/23 at 8:29 a.m., documentation from the residence's last three quarterly medication audits was requested but not provided. On 1/4/23 at 1:20 p.m., the resident care director (RCD) stated she was the QMAP supervisor. She stated the QMAPs completed weekly medication audits, adding that the residence's preferred pharmacy completed quarterly audits. The RCD added she was not aware she was required to participate in and document quarterly medication audits and acknowledged that she had not done so. On 1/4/23 at 1:20 p.m., the administrator stated she was not aware of the requirement for her to participate in and document the residence's quarterly medication audits. She stated she recalled participating in one medication audit within the year prior to the on-site visit. On 1/5/23 at 12:15 p.m., the administrator stated the residence could have caught medication errors in real time if they completed the required quarterly medication audits.

Based on record review and interview, the residence failed to have policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and/or expired medications that were not returned to the resident or legal representative that included all required information, affecting 10 of 10 sample residents (#1-#10) and one former resident (#16). Findings include: 1. Record ReviewOn 1/4/23 at approximately 9:00 a.m., the residence's policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and/or expired medications that were not returned to the resident or legal representative were requested. The administrator provided the residence's Community Medication Oversight Program policy, dated 7/1/19. The policy read, in a section titled "Medication Destruction" that: "All medications are disposed of or destroyed promptly." However, the policy did not read that outdated, discontinued, and/or expired medications were destroyed in accordance with federal, state, and local regulations within thirty (30) days. The policy read that only controlled medication were to take place "in the presence of at least two authorized community Team Members," rather than that all medication was to be destroyed in the presence of two individuals, each of whom were either a qualified medication administration person, nurse, or practitioner. 2. InterviewOn 1/5/23 at 7:00 a.m., the administrator confirmed there were no additional drug disposal policies. She acknowledged the provided policy did not contain all of the required information.

Based on record review and interview, the residence failed to ensure the face sheets were updated at least annually and contained all of the required information, affecting 12 of 12 current sample residents (#1-#12). Findings include: 1. Record Reviewa. The face sheet for Resident #8 was missing the resident's marital status; former address; name, address, and contact information for family members, legal representatives, and/or other persons to be notified in case of an emergency; and the resident's primary language and religious preference. b. The face sheet for Resident #9 was missing the resident's marital status; former address; medical insurance information; name, address, and contact information for family members, legal representatives, and/or other persons to be notified in case of an emergency; primary language and religious preference. c. The face sheet for Resident #1 was missing the resident's marital status; former address; name, address, and contact information for family members, legal representatives, and/or other persons to be notified in case of an emergency; and religious preference. d. The face sheet for Resident #11 was missing the resident's marital status; former address; name, address, and contact information for family members, legal representatives, and/or other persons to be notified in case of an emergency; primary language and religious preference. e. The face sheet for Resident #4 was missing the resident's marital status; former address; name, address, and contact information for family members, legal representatives, and/or other persons to be notified in case of an emergency; primary language and religious preference. f. The face sheet for Resident #10 was missing the resident's marital status; former address; name, address, and contact information for family members, legal representatives, and/or other persons to be notified in case of an emergency; primary language and religious preference. g. The face sheet for Resident #3 was missing the resident's marital status, former address, the address and contact information for the resident's practitioner, primary language, and religious preference. h. The face sheet for Resident #5 was missing the resident's marital status, former address, medical insurance information, primary language, and religious preference. i. The face sheet for Resident #6 was missing the resident's marital status, former address, medical insurance information, and religious preference. j. The face sheet for Resident #2 was missing the resident's marital status, former address, primary language, and religious preference. k. The face sheet for Resident #12 was missing the resident's marital status, former address, and religious preference.l. The face sheet for Resident #7 was missing a former address. 2. InterviewsOn 1/5/23 at 1:09 p.m., the memory care coordinator (MCC) stated the sales team completed the initial face sheet when a resident was admitted. He stated the administrator was responsible for ensuring that all required information was included in the face sheet. The MCC stated after a resident was admitted, the administrator, resident care director, and the sales team were responsible for updating the information in each residents' face sheet. He stated he was not aware that current residents' face sheets did not contain all of the required information. On 1/5/23 at 12:16 p.m., the administrator stated face sheets were completed by the business office coordinator upon resident admission. She stated she and the resident care director, in addition to three or four others from the management team, had access to update them after the residents were admitted. The administrator stated that in the event that a resident was transferred to the emergency department, the residence sent a face sheet specifically for transfers. She added that the residents' religion and primary language was important information for emergency responders and should be provided on a face sheet.

Based on record review and interview, the residence failed to hold regular family council meetings at least quarterly, affecting 25 residents who resided in the secure environment. Findings include: On 1/4/23 at approximately 9:00 a.m., the residence's family council meeting minutes for 2022 were requested. However, no such meeting minutes were provided. On 1/4/23 at 11:38 a.m., the administrator stated there had been no family council meetings to allow residents, their family members, friends, and representatives to provide mutual support and share concerns and/or recommendations about the care and services in the residence's secure environment, since the beginning of the COVID-19 pandemic. The administrator stated that, due to COVID-19 and other outbreaks and staffing, the family council meetings had not yet been resumed.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.12 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicable;(D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable. 11.1 The assisted living residence shall accept only those persons whose needs can be fully met by the existing staff, physical environment, and services already being provided. The assisted living residence's ability to meet resident needs shall be based upon a comprehensive pre-admission assessment of a resident's physical, mental, and social needs; cultural, religious and activity needs; preferences; and capacity for self-care. 12.26 Each assisted living residence shall place notices of planned resident engagement offerings in acentral location readily accessible to residents, relatives, and the public. Copies shall be retained for at least six months. 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 14.19 Any orders received from medical staff on behalf of an authorized practitioner must be countersigned by said practitioner as soon as possible. 14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing.