A HAVEN OF CARE LLC

An administrative relicensure survey was completed on 6/4/26. No deficiencies were cited.

A revisit survey was completed on 3/12/24 for all previous deficiencies cited on 11/17/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 3/12/24 for all previous deficiencies cited on 11/17/23. The facility is in compliance with all deficiencies that were cited.

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

A recertification survey was completed on 11/17/23. A deficiency was cited.

Based on interview and observation the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, Medication Administration Regulations, affecting two of four sample participants (residents) (#1, #2). Findings include:1. Chapter VII regulations governing assisted living residence, part 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks:(H) Pre-pouring of medication.a. ReferenceRegulations governing assisted living residences, part 2.27, defines "Medication monitoring" as:(B) Handing to a resident a container or package of medication that was lawfully labeled previously by an authorized practitioner for the individual resident;(C) Visual observation of the resident to ensure compliance.b. Observations and InterviewsOn 11/17/23 at approximately 10:00 a.m., two medication cups were labeled with resident's names, one for Resident #1 and one for Resident #2. Each cup contained medications and were observed on the kitchen counter of the residence. On 11/17/23 at approximately 10:15 a.m., Staff #1 confirmed that the medications in the cups on the kitchen counter were for Resident #1 and Resident #2. She stated she pre-poured medications at 8:00 a.m. for Resident #1 and Resident #2 when she prepared medications for all residents. She explained that she prepared Resident #1 and Resident #2's medication at this time because Resident #1 and Resident #2 did not like to wake up early. She confirmed that she pre-poured medications for Resident #1 and Resident #2 every morning while administering medications for other residents. On 11/17/23 at 11:04 a.m., Resident #1 was observed taking her medications that had been pre-poured and placed on the counter of the kitchen. Resident #1 took her medications in the kitchen with Staff #1 watching the ingestion of the medications. On 11/17/23 at 11:04 a.m., Resident #1 stated that she received her medications in the cup that staff pre-poured and placed on the counter for her every morning. She stated the medications were available to her to take when she woke up around 11:00 a.m. On 11/17/23 at 1:54 p.m., Staff #1 stated she always labeled each resident name on the medication cups prior to pouring medications for each resident. On 11/17/23 at 2:14 p.m., the administrator designee stated that she was aware QMAPs were not permitted to pre-pour medications and she was unaware that Staff #1 had been pre-pouring medications. 2. Chapter VII regulations governing assisted living residence, part 14.27, requires that no stock medications shall be stored or administered by qualified medication administration persons. A) All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident's full name. On 11/17/23 at 2:38 p.m., observations made during a medication cart audit revealed a bottle of aspirin purchased as an over-the-counter medication was not labeled with Resident #2's first and last name. On 11/17/23 at 2:40 p.m., observations made during a medication cart audit revealed a bottle of acetaminophen purchased as an over-the-counter medication was not labeled with Resident #1's first and last name. On 11/17/23 at approximately 2:45 p.m., the administrator designee stated that she was aware over-the-counter medication needed to be labeled with first and last names. She was unaware that the over-the-counter medications currently in the medication cart were not labeled with the resident's first and last name.

A relicensure survey was completed on 11/17/23. A deficiency was cited. A change of ownership occurred on 8/3/22.

Based on observation and interview, the residence failed to ensure the qualified medication administration persons (QMAPs) did not perform pre-pouring of medication, affecting two of four residents (#1, #2) whose medication administration was observed in the morning. Findings include:1. ReferenceRegulations governing assisted living residences, part 2.27, defines "Medication monitoring" as:(B) Handing to a resident a container or package of medication that was lawfully labeled previously by an authorized practitioner for the individual resident;(C) Visual observation of the resident to ensure compliance. 2. Observations and InterviewsOn 11/17/23 at approximately 10:00 a.m., two medication cups were labeled with resident's names, one for Resident #1 and one for Resident #2. Each cup contained medications and were observed on the kitchen counter of the residence. On 11/17/23 at approximately 10:15 a.m., Staff #1 confirmed that the medications in the cups on the kitchen counter were for Resident #1 and Resident #2. She stated she pre-poured medications at 8:00 a.m. for Resident #1 and Resident #2 when she prepared medications for all residents. She explained that she prepared Resident #1 and Resident #2's medication at this time because Resident #1 and Resident #2 did not like to wake up early. She confirmed that she pre-poured medications for Resident #1 and Resident #2 every morning while administering medications for other residents. On 11/17/23 at 11:04 a.m., Resident #1 was observed taking her medications that had been pre-poured and placed on the counter of the kitchen. Resident #1 took her medications in the kitchen with Staff #1 watching the ingestion of the medications. On 11/17/23 at 11:04 a.m., Resident #1 stated that she received her medications in the cup that staff pre-poured and placed on the counter for her every morning. She stated the medications were available to her to take when she woke up around 11:00 a.m. On 11/17/23 at 1:54 p.m., Staff #1 stated she always labeled each resident name on the medication cups prior to pouring medications for each resident. On 11/17/23 at 2:14 p.m., the administrator designee stated that she was aware QMAPs were not permitted to pre-pour medications and she was unaware that Staff #1 had been pre-pouring medications.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.27 No stock medications shall be stored or administered by qualified medication administration persons. A) All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident's full name. 22.4 Designated areas where smoking is allowed shall be equipped with fire resistant wastebaskets. Resident rooms occupied by smokers, even when house rules prohibit smoking in resident rooms, shall have fire resistant wastebaskets. 22.37 Designated outdoor smoking areas shall have fire resistant waste disposal containers. Resident rooms occupied by smokers, even when house rules prohibit smoking in resident rooms, shall have fire resistant wastebaskets.