GARDENS CARE SADDLE ROCK

A licensure revisit was completed on 8/16/23 for all previous deficiencies cited on 2/28/23. A deficiency was cited

Based on observation, record review and interview, the residence failed to comply with authorized practitioners orders associated with medication administration, affecting two of five sample residents (#4, #5). Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated 4/1/23 read, in part, "Medications placed on "HOLD" will be held from use by the resident as instructed by the physician ... The designated staff person obtains a written order from the physician to HOLD the medication."2. Resident #5 was admitted to the residence on 12/8/22 with diagnoses including dementia.a. Ferrous SulfateA written practitioner's order, dated 6/6/23, directed the residence to administer ferrous sulfate 325 mg every other day. However, the July and August electronic medication administration record (eMAR) for Resident #5 read ferrous sulfate 325 mg was administered once daily. The ferrous sulfate was administered daily and not every other day, as required. On 8/15/23 at approximately 3:30 p.m., the wellness director (WD) said the eMAR for Resident #5 was incorrect and staff should administer the medication, per the practitioner order.b. Duloxetine A written practitioner's order, dated 6/6/23, directed the residence to administer duloxetine 20 mg daily. However, the August eMAR for Resident #5 read the medication was held and not administered from 8/6 to 8/15/23, for a total of 10 missed doses. On 8/15/23 at approximately 1:30 p.m., the WD said she placed the medication on hold because they were waiting on the family to deliver the medication. The WD stated the residence had not received a hold order from the practitioner, as required. c. TrazodoneA written practitioner's order, dated 6/6/23, directed the residence to administer trazodone 50 mg once daily. However, the July 2023 eMAR for Resident #5 read the medication was not available and not administered on 7/2-7/6 and 7/8/23, for a total of six missed doses. On 8/15/23 at approximately 1:30 p.m., the WD stated the medication was not available and not administered because the family member of Resident #5 provided the medication and had not yet delivered the medication to the residence. d. DonepezilA written practitioner's order, dated 6/6/23, directed the residence to administer donepezil 5 mg once daily. However, the July 2023 eMAR for Resident #5 read the medication was not available and not in stock from 7/2-7/5/23, for a total of four missed doses. On 8/15/23 at approximately 1:30 p.m., the WD stated the medication was not available and not administered because the family member of Resident #5 provided the medication and had not yet delivered the medication to the residence. e. Vitamin C (Ascorbic Acid)A written practitioner's order, dated 6/6/23, directed the residence to administer ascorbic acid 500 mg once daily. However, the July 2023 eMAR for Resident #5 read the medication was not available and not administered on 7/16/23. On 8/15/23 at approximately 1:30 p.m., the WD acknowledged the medication was not administered. 3. Resident #4 was admitted to the residence on 5/5/23 with diagnoses including Parkinson's disease and gait abnormality.a. Preservision AredsA written practitioner's order, dated 5/12/23, directed the residence to administer Areds one tablet daily. However, the July and August 2023 eMARs read the residence administered two tablets daily from 7/1-8/15/23, for a total of 46 additional doses administered. On 8/15/23 at approximately 1:00 p.m., the WD said staff should have administered one tablet instead of two tablets of the medication, as ordered. b. Lidocaine PatchA written practitioner's order, dated 5/12/23, directed the residence to administer Lidocaine patch 5% once daily. However, the July 2023 eMAR for Resident #4 read the medication was not available and not administered on 7/14-7/15/23, for a total of two patches not applied ro Resident #4. On 8/15/23 at approximately 1:00 p.m., the WD stated a family member of Resident #4 had notbrought in the Lidocaine patches and as a result Resident #4 was not administered the medication, as ordered.

A licensure complaint, prompted by #CO33115 was completed on 8/16/23 deficiencies were cited.

Based on record review and interview, the residence personnel failed to report suspected caretaker abuse of an at-risk resident to law enforcement within 24 hours of observation or discovery, affecting one of six sample residents (#4). (Cross-reference Q1360)Findings include:1. References and Residence Policiesa. Chapter VII regulations governing assisted living residences, part 2.7, defines At-risk person as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), Colorado Revised Statutes (C.R.S.).b. Chapter VII regulations governing assisted living residences, part 2.28, defines mistreatment as abuse, caretaker neglect, or exploitation.c. Chapter II regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein."d. CRS 27-65-102 (14) reads, "Person with a mental illness" means a person with one or more substantial disorders of the cognitive, volitional, or emotional processes that grossly impairs judgment or capacity to recognize reality or to control behavior.e. The residence's Reportable Events policy, dated 4/1/23 read, in part, "Should any of the following occur ... The Department of Health will be notified as per above requirements ... All alleged or suspected serious crimes committed by or against residents and have been reported at the time of occurrence to the local police department ... Any occurrence involving ... verbal abuse of a resident by another resident, employee, or visitor of a resident ... The following are the Colorado State Reportable Events that required notification within one business day ... Verbal abuse ... Any major occurrence or incident as outlined above shall be reported promptly by telephone and confirmed in writing as soon as possible thereafter ... Documentation regarding investigation, including the appropriate measure to be instituted and appropriate measure to prevent similar future situations shall be made available to the department as required. The assisted living residences' final investigation report shall be submitted to the department within three business days after the initial report of the occurrence.f. The residence's Reporting Suspected Abuse policy, dated 41/23 read, in part, "All allegations of abuse, neglect or exploitation of residents shall be appropriately reported. Appropriate agencies as noted below and the legal representative of the resident will be made aware of the allegation within 24 hours. These agencies will also investigate and follow-up as needed (sic) ensure the safety of our residents ... Call the adult protection services ... Notify the department of health as per reportable events policy ... Executive director shall conduct interviews with all related staff members and obtain signed, written statements ... Executive director is to make available all of the above agencies findings of the investigations. A copy of the report with the investigation findings shall be retained by the facility and available for department review."2. Resident #4 was admitted to the residence on 5/5/23 with diagnoses including Parkinson's disease, anxiety, hard of hearing and Parkinson's dementia. Resident #4 was 76 years old. A communication sent by the wellness director (WD) to an outside staffing agency, dated 7/24/23 read, in part, "This morning I received reports regarding an interaction between (Former Staff #10 and a resident (Resident #4) in our community from a family member ... (Family member) came to my office at 9:15 a.m. on 7/24/23. She stated that (Former Staff #10) we had here last night (sic) threatened (Resident #4). I asked (family member) what was said, and she stated, '(Resident#4) told me that the guy told him he will kill him.' I asked (family member) what (Resident #4's exact words were and she stated 'That guy was not nice to me. He told me he will kill me.' (Family member) also mentioned that (Resident #4) stated he was using (Resident #4's) wheelchair for another resident, and this upset (Resident #4) as well. (Family member) reported that she asked this (Former Staff #10) what his name was, and he snapped back at her, 'You do not need to know anything about me!' (Family member) reported she attempted to discuss with this staff member (Resident #4's) diagnosis of Parkinson's, and he yelled at her 'He does not have Parkinson's, he is just crazy! I have years of medical experience and I know.' (Family member) then went on to ask what we will be doing about this. I explained to her that we have blocked him from our community, and he will not be back. I also explained to her that I will be reporting this incident to the (staffing) agency."a. InterviewsOn 8/15/23 at 9:42 a.m., an outside agency representative stated on 8/14/23 she spoke to the WD. She said, "She (WD) admitted ... they did not call the police (after Resident #4 felt threatened by the agency staff member) and they left it to the agency staff (to make a mandatory report). They admitted they did not do that."On 8/15/23 at 12:52 p.m., the WD said the family member of Resident #4 notified her on 7/24/23 that Former Staff #10 told Resident #4 he was going to kill him and that he was crazy and did not have Parkinson's disease. The WD stated her and the administrator did not report the incident to local law enforcement and said, "The (staffing) agency would be best to report it because he's employed under them. If he was our employee we would have. We would have ... made a report to the police." The WD said on 7/23/23 Resident #4 was worried after the incident. On 8/15/23 at 2:35 p.m., the family member of Resident #4 stated on 7/23/23 Resident #4 told her that Former Staff #10 was mean and not nice to him and told him he was crazy and going to kill him. The family member added that evening Resident #4 was not his normal self, did not eat dinner and was scared. She added she notified the WD the next day on 7/24/23. On 8/16/23 at 8:23 a.m., the administrator said she was notified of the incident between Resident #4 and Former Staff #10 on 7/24/23. She added she had a care conference with Resident #4 and his family where they discussed that Former Staff #10 told Resident #4 that he was crazy and did not have Parkinson's disease. The administrator said she spoke with Resident #4 and said the incident made Resident #4 feel unsafe in his home. The administrator said she left it to the agency to report to local law enforcement because she did not consider Former Staff #10 a residence staff member. The administrator acknowledged she should have reported the suspected caretaker abuse of an at-risk resident to law enforcement within 24 hours of discovery, however, she did not..

Based on record review and interview, the residence failed to ensure each staff member completed an overview of state regulatory oversight applicable to the assisted living residence, person-centered care, the role and communication with external service providers, recognizing behavioral expressions and management techniques, how to effectively communicate with residents that have hearing loss and limited English proficiency, training related to fall prevention, maintenance of a clean, safe and sanitary environment, food safety, and understanding the staff's role in end of life care including hospice, affecting eight of eight sample residents (#1, #2, #4-#9) and one former sample resident (#3). Findings include: 1. Reference and Residence Policy a. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" means employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.b. The residence's Employee Orientation Policy, dated 4/1/23, read in part: "all new employees will be thoroughly oriented to all the residents in the community BEFORE participating in their care ... all new employees are to be oriented to residents' personal care plans, specific needs, medications, allergies, food requirements, medical history, social history ... within 3 days of employment, orientation to include emergency plan and policy and evacuation procedures ...within 30 days of employment, orientation to include the following: assessment and competency skills, as indicated; infection control, dealing with difficult situations and behaviors, residents' rights and health emergency response." 2. Record ReviewOn 8/15/23 at approximately 8:55 a.m., the residence's personnel file for (Contracted) Staff #6 was provided and revealed Staff #6 had an unknown hire date. On 8/15/23 at 9:09 a.m., the residence's personnel file for Former (Contracted) Staff #10 was provided and revealed Former Staff #10 was hired on 7/23/23. Review of Staff #6 and Former Staff #10 personnel files revealed no training documentation on the following required topics: Overview of state regulatory oversight applicable to the assisted living residence; Person-centered care; The role and communication with external service providers; Recognizing behavioral expressions and management techniques; How to effectively communicate with residents that have hearing loss and limited English proficiency; Training related to fall prevention; Maintenance of a clean, safe and sanitary environment; Food safety; and Understanding the staff's role in end of life care including hospice. The July 2023 and August 2023 staff schedule read the following:Staff #6 worked at the residence on 7/7-7/8/23, 7/22/23, and 8/2/23. Former Staff #10 worked at the residence on 7/23/23. 3. Interviews On 8/16/23 at approximately 8:23 a.m., the administrator confirmed Staff #6 and Former Staff #10 were contracted staff who provided care to all residents. She stated the residence considered contracted staff as contracted third party vendors and all required training was conducted through the vendor. She acknowledged the residence does not provide all the required training to contracted staff.

Based on record review and interview, the residence failed to develop policies and procedures to establish a fall management program, affecting two sample residents who sustained recent falls (#4, #7). Findings include:1. References and Residence Policiesa. According to ParkinsonsDisease.net, "People living with Parkinson's disease (PD) are at a higher risk for falls due to the motor symptoms, including stiff muscles, freezing (temporary inability to move), and balance impairment. Research estimates that people with PD are at twice the risk of falling as often as their peers. Falls can be mild, causing only bumps and bruises, or they can result in significant damage, causing increased disability and a reduced quality of life. The fear of falling in people living with PD is real and impacts both the patient and their caregiver or care partner." ParkinsonsDisease.net (August 2020) Reducing Fall Risk with Parkinson's, retrieved from:https://parkinsonsdisease.net/living-with-pd/reduce-fall-riskb. Chapter VII regulations governing assisted living residences, part 12.22, reads examples of resident engagement include, but are not limited to, the following:(C) Physical pursuits such as games, sports, and exercise that develop and maintain strength, coordination, and range of motion.c. The residence's Fall Policy, dated 4/1/23 read, in part, "Review history of falls, contributing factors, causes, prior period assessment. Interventions, alert patient care staff of potential risks, staff accompany residents at risk where possible to avoid accidents, resident is toileted with staff assistance, resident is exercised under staff supervision ... Documentation of fall risk assessment findings will be recorded in the resident's plan of care with appropriate interventions for prevention."d. The residence's Fall Prevention policy, dated 4/1/23 read, in part, "Residents with dementia will be provided with an environment that is safe from the hazards that can lead to falls ... A fall risk assessment is to be completed upon admission, any re-admission, or for any change in condition using the fall risk assessment form as well as review of the following conditions ... Review of history of falls, contributing factors, causes, supervision, prior period assessment."2. Resident #7 was admitted to the residence on 10/12/22 with diagnoses including Alzheimer's disease. Incident reports in Resident #7's record for June, July and August 2023, revealed the following:On 6/19/23 Resident #7 had a fall in the activity room. No injuries. On 6/20/23 Resident #7 had a fall in the common area of the residence. No injuries. On 6/26/23 Resident #7 yelled for help and staff found him on the floor. No injuries. On 7/31/23 Resident #7 had an unwitnessed fall in the common area. On 8/5/23 Resident #7 was found on the floor in the common area in front of the chair he was seated on. No injuries. A care plan for Resident #7, dated 1/13/23, read Resident #7 did not have a history of falls. There were no additional individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight in the care plan for Resident #7 after he sustained multiple falls in June, July and August 2023. An assessment for Resident #7, dated 7/6/23, read Resident #7 was, "a high fall risk and needs to be monitored."There were no other care plans in Resident #7's record.a. InterviewsOn 8/15/23 at approximately 12:30 p.m., Staff #2 and #7 stated after Resident #7 fell in June, July and August 2023 they were not provided any additional training by management to help mitigate future falls. On 8/15/23 at approximately 12:45 p.m., the wellness director (WD) said staff received training on the residence's fall management program when they were hired and added no other training was provided afterwards. She added the care plan for Resident #7 was not updated after he fell, as required. 3. Resident #4 was admitted to the residence on 5/5/23 with diagnoses including Parkinson's disease and gait abnormality. Incident reports in Resident #4's record for June and July 2023 revealed the following:On 6/1/23 Resident #4 was found on the floor in his bedroom with a skin tear on his left arm. On 7/22/23 Resident #4 was found on the floor in his bedroom. Resident #4 yelled for help. No injuries. A care plan for Resident #4, dated 6/16/23, read Resident #4 experienced bouts of freezing up and stiffness. There were no other individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight after he sustained a fall on 7/22/23. There were no other care plans in Resident #4's record.a. InterviewsOn 8/15/23 at approximately 12:30 p.m., Staff #2 and #7 stated after Resident #4 fell in June and July 2023 they were not provided any additional training by management to help mitigate future falls. On 8/15/23 at 1:19 p.m., the WD said the reason the care plan was not updated after Resident #4 fell on 7/22/23 because it was determined the fall was related to his Parkinson's stiffness. On 8/16/23 at approximately 8:30 a.m., the administrator said implementing the fall management program had been a "struggle historically with the community. Our care plans could use some work in that respect." She added she expected the residence's fall management program to be implemented after a resident sustained a fall.

Based on record review and interview, the residence failed to ensure staff were trained to provide lift assistance when determined appropriate, instead of relying on emergency medical responders, affecting one of six sample residents (#4). Findings include:1. Residence Policies a. The residence's Accidents and Injury Emergencies policy, dated 4/1/23 read, in part, "Any situation that results in injury, or has the potential to do so, regardless of how insignificant it may appear, must be taken care of immediately... To provide an environment that meets the special needs of people with dementia and keep them safe by addressing those needs in an appropriate and timely manner ... Procedure ... Provide immediate assistance to the resident, stay with the resident, instruct your co-worker to call 911 (if necessary). Understand that you determine the necessity for emergency assistance, and have the right to call 911 when the situation requires medical emergency or police intervention. If 911 is necessary, it is always the first call ... Remember: You are the person closest to the situation. If, in your opinion, the resident needs emergency medical care then you make the 911 call. You should first make the 911 call, then inform supervisors, doctors and family."b. The residences Falls-Lift Assistance policy, dated 4/1/23 read, in part, "Staff will be trained to evaluate residents who have fallen or are otherwise unable to independently get up off the floor and provide lift assistance when determined appropriate ... Each situation shall be evaluated to determine if the resident can be assisted in a safe manner ... Once the situation has been evaluated ... physically perform lift assistance using techniques provided in staff training and monitor the resident, or not lift and call 911 when ... the resident experiences an increase in pain when lifting is attempted."2. Resident #7 was admitted to the residence on 10/12/22 with diagnoses including Alzheimer's disease. An incident report in Resident #4's record read on 7/22/23 at 7:52 p.m., Resident #4 yelled for care staff and when they entered his room his body faced towards the window, his knees were tucked under his body, his right arm was tucked behind him and his head rested on a wicker basket. Family was notified at 8:12 p.m. Emergency medical services (EMS) were notified at 9:14 p.m. and arrived shortly after to record Resident #4's vitals.a. InterviewsOn 8/15/23 at approximately 2:35 p.m., a family member of Resident #4 said she received a telephone call from the residence on 7/22/23 and notified her Resident #4 fell and was hurt and asked her if she wanted staff to notify EMS. The family member said if he was hurt to notify EMS. The family member said the staff member told her she needed to take Resident #4 to the hospital. The family member said she was frustrated because staff had asked her what to do instead of evaluating the situation themselves and following their policies. On 8/16/23 at approximately 8:30 a.m., the administrator said normally the family member would have been notified by a supervisor when a resident fell. She added, the staff member should have simply notified the family member that Resident #4 fell and did not ask the family member what to do. She added, "If we make the wrong decision and call 911 then we are in hot water with the family because they are the decision makers."

Based on record review and interview, the residence failed to investigate allegations of abuse of residents in accordance with Part 5.3 and its written policy, affecting one of six sample residents (#4). (Cross-reference Q410)Findings include: 1. References and Residence Policies a. Chapter VII regulations governing assisted living residences, part 13.11, requires that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (C) The process for investigating such allegations; (D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted;(E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted; (F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and (G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review.b. Chapter II regulations governing assisted living residences, part 4.2.2, the following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department:(D) Any occurrence involving physical, sexual, or verbal abuse of a client, by another client, an employee of the licensee or a visitor to the facility or agency.c. Chapter II regulations governing assisted living residences, part 1.1, defines "Abuse" as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish.d. Chapter II regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein."e. The residence's Reportable Events policy, dated 4/1/23 read, in part, "Should any of the following occur ... The Department of Health will be notified as per above requirements ... All alleged or suspected serious crimes committed by or against residents and have been reported at the time of occurrence to the local police department ... Any occurrence involving ... verbal abuse of a resident by another resident, employee, or visitor of a resident ... The following are the Colorado State Reportable Events that required notification within one business day ... Verbal abuse ... Any major occurrence or incident as outlined above shall be reported promptly by telephone and confirmed in writing as soon as possible thereafter ... Documentation regarding investigation, including the appropriate measure to be instituted and appropriate measure to prevent similar future situations shall be made available to the department as required. The assisted living residences' final investigation report shall be submitted to the department within three business days after the initial report of the occurrence.f. The residence's Reporting Suspected Abuse policy, dated 41/23 read, in part, "All allegations of abuse, neglect or exploitation of residents shall be appropriately reported. Appropriate agencies as noted below and the legal representative of the resident will be made aware of the allegation within 24 hours. These agencies will also investigate and follow-up as needed (sic) ensure the safety of our residents ... Call the adult protection services ... Notify the department of health as per reportable events policy ... Executive director shall conduct interviews with all related staff members and obtain signed, written statements ... Executive director is to make available all of the above agencies findings of the investigations. A copy of the report with the investigation findings shall be retained by the facility and available for department review."g. The residence's Resident Rights policy, dated 4/1/23 read, in part, "The community respects and adheres to the following policies. Each resident, resident's family member and resident's legal appointed guardian, if applicable, shall be informed of these resident rights, and each shall be explained to him or her ... The right to civil and religious liberties, including ... the right to be free from ... verbal, physical, or emotional abuse, humiliation, intimidation, or punishment."2. Resident #4 was admitted to the residence on 5/5/23 with diagnoses including Parkinson's disease, anxiety, hard of hearing and Parkinson's dementia. Resident #4 was 76 years old. A communication sent by the wellness director (WD) to an outside staffing agency, dated 7/24/23 read, in part, "This morning I received reports regarding an interaction between (Former Staff #10 and a resident (Resident #4) in our community from a family member ... (Family member) came to my office at 9:15 a.m. on 7/24/23. She stated that (Former Staff #10) we had here last night (sic) threatened (Resident #4). I asked (family member) what was said, and she stated, '(Resident #4) told me that the guy told him he will kill him.' I asked (family member) what (Resident #4's exact words were and she stated 'That guy was not nice to me. He told me he will kill me.' (Family member) also mentioned that (Resident #4) stated he was using (Resident #4's) wheelchair for another resident, and this upset (Resident #4) as well. (Family member) reported that she asked this (Former Staff #10) what his name was, and he snapped back at her, 'You do not need to know anything about me!' (Family member) reported she attempted to discuss with this staff member (Resident #4's) diagnosis of Parkinson's, and he yelled at her 'He does not have Parkinson's, he is just crazy! I have years of medical experience and I know.' (Family member) then went on to ask what we will be doing about this. I explained to her that we have blocked him from our community, and he will not be back. I also explained to her that I will be reporting this incident to the (staffing) agency."There were no other documents related to the incident in Resident #4's record.a. InterviewsOn 8/15/23 at 9:42 a.m., an outside agency representative stated on 8/14/23 she spoke to the WD. She said, "She (WD) admitted that she did not (file a report with the appropriate agencies) when (Resident #4)'s family reported verbal abuse of a staff member. (WD) told me that ... they did not call the police."On 8/15/23 at 12:52 p.m., the WD said the family member of Resident #4 notified her on 7/24/23 that (Former Staff #10) told Resident #4 he was going to kill him and that he was crazy and did not have Parkinson's disease. The WD stated her and the administrator did not report the incident to the appropriate agencies and said, "The (staffing) agency would be best to report (the verbal abuse) because he's employed under them. If he was our employee we would have (investigated the allegation of abuse). We would have ... done an internal investigation..." The WD said on 7/23/23 Resident #4 was worried after the incident. On 8/15/23 at 2:35 p.m., the family member of Resident #4 stated on 7/23/24 Resident #4 told her that Former Staff #10 was mean and not nice to him and told him he was crazy and going to kill him. The family member added that evening Resident #4 was not his normal self, did not eat dinner and was scared. She added she notified the WD the next day on 7/24/23. On 8/16/23 at 8:23 a.m., the administrator said she was notified of the incident between Resident #4 and Former Staff #10 on 7/24/23. She added she had a care conference with Resident #4 and his family where they discussed that Former Staff #10 told Resident #4 that he was crazy and did not have Parkinson's disease. The administrator said she spoke with Resident #4 and said the incident made Resident #4 feel unsafe in his home. The administrator said she did not complete an investigation and left it to the agency to investigate because she did not consider Former Staff #10 a residence staff member. The administrator acknowledged that she should have conducted an investigation, as required after she learned that contracted staff are considered residence staff.

Based on record review and interview, the residence failed to ensure only medication that has been ordered by an authorized practitioner was administered to residents, affecting one of six sample residents (#4). Findings include:Resident #4 was admitted to the residence on 5/5/23. The July and August electronic medication administration record (eMAR) for Resident #4 instructed staff to administer Rytary 61.25 two tablets twice daily at 10:00 p.m. Staff initials documented that the medication was administered on 7/1-8/15/23. There was no evidence of a written practitioner's order provided by the residence. On 8/16/23 at approximately 8:30 a.m., the wellness director stated she received an updated medication list from the practitioner but the list was not signed. On 8/16/23 at approximately 8:30 a.m., the administrator stated she expected the residence to obtain signed practitioner orders for the medications administered to Resident #4 in July and August 2023.

Based on observation, record review and interview, the residence failed to comply with authorized practitioners orders associated with medication administration, affecting two of five sample residents (#4, #5). Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated 4/1/23 read, in part, "Medications placed on "HOLD" will be held from use by the resident as instructed by the physician ... The designated staff person obtains a written order from the physician to HOLD the medication."2. Resident #5 was admitted to the residence on 12/8/22 with diagnoses including dementia.a. Ferrous SulfateA written practitioner's order, dated 6/6/23, directed the residence to administer ferrous sulfate 325 mg every other day. However, the July and August electronic medication administration record (eMAR) for Resident #5 read ferrous sulfate 325 mg was administered once daily. The ferrous sulfate was administered daily and not every other day, as required. On 8/15/23 at approximately 3:30 p.m., the wellness director (WD) said the eMAR for Resident #5 was incorrect and staff should administer the medication, per the practitioner order.b. Duloxetine A written practitioner's order, dated 6/6/23, directed the residence to administer duloxetine 20 mg daily. However, the August eMAR for Resident #5 read the medication was held and not administered from 8/6 to 8/15/23, for a total of 10 missed doses. On 8/15/23 at approximately 1:30 p.m., the WD said she placed the medication on hold because they were waiting on the family to deliver the medication. The WD stated the residence had not received a hold order from the practitioner, as required. c. TrazodoneA written practitioner's order, dated 6/6/23, directed the residence to administer trazodone 50 mg once daily. However, the July 2023 eMAR for Resident #5 read the medication was not available and not administered on 7/2-7/6 and 7/8/23, for a total of six missed doses. On 8/15/23 at approximately 1:30 p.m., the WD stated the medication was not available and not administered because the family member of Resident #5 provided the medication and had not yet delivered the medication to the residence. d. DonepezilA written practitioner's order, dated 6/6/23, directed the residence to administer donepezil 5 mg once daily. However, the July 2023 eMAR for Resident #5 read the medication was not available and not in stock from 7/2-7/5/23, for a total of four missed doses. On 8/15/23 at approximately 1:30 p.m., the WD stated the medication was not available and not administered because the family member of Resident #5 provided the medication and had not yet delivered the medication to the residence. e. Vitamin C (Ascorbic Acid)A written practitioner's order, dated 6/6/23, directed the residence to administer ascorbic acid 500 mg once daily. However, the July 2023 eMAR for Resident #5 read the medication was not available and not administered on 7/16/23. On 8/15/23 at approximately 1:30 p.m., the WD acknowledged the medication was not administered. 3. Resident #4 was admitted to the residence on 5/5/23 with diagnoses including Parkinson's disease and gait abnormality.a. Preservision AredsA written practitioner's order, dated 5/12/23, directed the residence to administer Areds one tablet daily. However, the July and August 2023 eMARs read the residence administered two tablets daily from 7/1-8/15/23, for a total of 46 additional doses administered. On 8/15/23 at approximately 1:00 p.m., the WD said staff should have administered one tablet instead of two tablets of the medication, as ordered. b. Lidocaine PatchA written practitioner's order, dated 5/12/23, directed the residence to administer Lidocaine patch 5% once daily. However, the July 2023 eMAR for Resident #4 read the medication was not available and not administered on 7/14-7/15/23, for a total of two patches not applied ro Resident #4. On 8/15/23 at approximately 1:00 p.m., the WD stated a family member of Resident #4 had notbrought in the Lidocaine patches and as a result Resident #4 was not administered the medication, as ordered.

Based on observation, record review, and interview, the residence failed to ensure all over-the-counter (OTC) medications prescribed were labeled or marked with the individual resident's full name, affecting two of five sample residents (#4, #5). Findings include: On 8/16/23 at approximately 9:45 a.m., a medication cart audit revealed the following OTC medications were not labeled or marked with the individual's full name, as follows:Resident #4: a bottle of eye vitamin and mineral supplement, a bottle of potassium gluconate 90 mg, and a bottle of ibuprofen 200 mg. Resident #5: a bottle of iron ferrous sulfate supplement 325 mg, and a bottle of vitamin c supplement 500 mg. On 8/16/23 at 10:21 a.m., the administrator and wellness director stated that OTC medications should be labeled with the resident's full name.

Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) documented accurate information in the medication administration records (MAR), affecting one of five sample residents (#5). Findings include: 1. Residence Policy The residence's Medication Administration policy, dated 4/1/23 read, in part, "No medication administration time is to be left blank ..." 2. Resident #5 was admitted to the residence on 12/8/22. A written practitioner's order, dated 6/6/23, directed the residence to administer alendronate 70 mg once every seven days. However, the July and August 2023 electronic medication administration record (eMAR) for Resident #5 read alendronate 70 once daily. The medication was administered every seven days. The eMAR frequency did not match the practitioner's order, as required. 3. InterviewsOn 8/15/23 at approximately 1:00 p.m., the wellness director acknowledge the eMAR for Resident #5 was incorrect. On 8/16/23 at approximately 8:30 a.m., the administrator said she expected the eMARs for residents to be accurate according to the practitioner order.

Based on record review and interview, the residence failed to ensure that the resident's legal representative was promptly notified of a resident's pattern of refusal, affecting one of five sample residents (#5). Findings include: Resident #5 was admitted to the residence on 12/8/22. A written practitioner's order, dated 6/6/23, directed the residence to administer azelastine 137 mcg two sprays in each nostril daily. However, the July and August 2023 electronic medication administration record (eMAR) for Resident #5 read she refused the medication on the morning of 7/1-7/5, 7/6, 7/15 and the evening of 7/8-7/14, 7/16-7/20/23 and 8/11-8/14/23, for a total of 78 doses refused. On 8/15/23 at 2:07 p.m., a family member of Resident #5 stated he was never notified by the residence that Resident #5 refused her nasal spray. On 8/16/23 at approximately 8:30 a.m., the administrator stated she expected the residence's practitioner and family member to be notified if the resident had a pattern of refusing medications.

A relicensure survey was completed on 3/1/23. Deficiencies were cited.

Based on record review and interviews, the licensee failed to notify the department of a change in the administrator of record, at least 30 calendar days in advance, affecting 40 current residents. Findings include:The department database revealed the administrator of record was listed as the administrator since 8/2/21. On 2/28/23 at 1:18 p.m., a department representative confirmed the residence had not nofitifed the department of a change in administrator. On 2/28/23 at 2:16 p.m., the acting administrator stated the previous administrator had notified the department of the change in administrator in April 2022. She stated she was first made aware in June 2022 that the department was not notified of the change in administrator of record. The acting administrator stated she was aware the department should have been notified of the change in the administrator. She stated she had recent correspondence with the department and was not sure who was required to notify the department of the change in administrator. She added she believed the residence's corporate office was responsible for notifying the department.

Based on interviews and record review, the residence failed to ensure there was a readily available roster that included emergency contact information and a residence diagram showing room locations, affecting 40 current residents. Findings include:On 2/28/23 at 8:30 a.m., the marketing director provided a document she stated was the residence's resident roster. However, the document did not contain emergency contact information or a diagram showing resident room locations. On 2/28/23 at 2:46 p.m., the acting administrator stated she was not aware the residence was required to include the emergency contact information on the roster. She stated she was also unaware the roster was required to contain a diagram showing room locations.

Based on observations, record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of three sample residents (#3). Findings include:1. Residence PolicyThe residence's Medication Administration Policy, dated 6/1/21, read, in part, "... The medication administration record (MAR) is to be followed and checked for accuracy with each administration of medication ..."2. Resident #3 was admitted to the residence on 10/21/21 with diagnoses including dementia and macular degeneration.a. Acetaminophen A written practitioner's order, dated 7/7/22, directed the residence to administer acetaminophen 325 mg three times a day. However, the January and February 2023 MARs for Resident #3 read the medication was not administered the evening doses on 1/20, 1/26-/27, 2/9 and 2/25/23, for a total of five missed doses.b. Astepro OTC Nasal SprayA written practitioner's order, dated 11/29/21, directed the residence to administer Astepro otc nasal spray two sprays into each nostril once daily. However, the February 2023 MAR for Resident #3 read the medication was not administered on 2/22-2/28/23, for a total of seven missed doses.c. LactaidA written practitioner's order, dated 5/11/22, directed the residence to administer lactaid three times a day . However, the January and February 2023 MARs for Resident #3 read the medication was not administered in the afternoon doses on 1/20 and 2/26/23, for a total of two missed doses. 3. InterviewsOn 2/28/23 at 12:30 p.m. the care director stated the circled initials on the MARs for residents meant the medication was not available and not administered, as required. On 2/28/23 at approximately 3:00 p.m., the acting administrator said she expected medications for residents to be in stock and administered as ordered.