MORNINGSTAR ASSISTED LIVING OF LITTLETON

An administrative relicensure survey was completed on 5/14/26. No deficiencies were cited.

A relicensure survey and complaint revisit was completed on 5/21/25 for all previous deficiencies cited on 10/23/24. The residence is in compliance with all regulations surveyed.

A relicensure survey and complaint revisit was completed on 5/21/25 for the previous deficiency cited on 10/23/24. The residence is in compliance with all regulations surveyed.

A relicensure survey with complaints #CO37338 and #CO37991 was completed on 10/23/24. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure applicants complied with Colorado Adult Protective Service Data System (CAPS) requirements prior to hiring staff who provided care to residents for one staff (#5), affecting 77 current residents. (Cross-reference S410)Findings include:The residence's Abuse Prevention, Investigation and Reporting policy, dated July 2021, read in part, "Team members will maintain ethical and professional behavior. All reasonable steps are taken to ensure that team members have been properly screened as required by state regulations in order to minimize the opportunity for inappropriate behaviors."Documentation of staff hire dates provided by the administrator read that Staff #5 was hired on 8/16/24. Review of Staff #5's personnel file revealed a CAPS document, dated 8/23/24, that the residence did not submit for request due to staff not including their addresses on the document. The staff schedule for October 2024 revealed that Staff #5 was scheduled to work 20 shifts. On 8/23/24 at 10:19 a.m., the administrator acknowledged that there was no follow up from residence staff to request the CAPS check after the initial attempt.

Based on record review and interview, the residence failed to report physical abuse to law enforcement within 24 hours of observation or discovery, affecting one of six sample residents (#6). (Cross-reference S1320 and B172)Findings include:1. Residence PolicyThe residence's Abuse Reporting Protocol policy, dated September 2024 read, in part, "Mandatory reporter means any public or private official who is required by state abuse statutes to report alleged abuse ... Executive director/designee report to local law enforcement. No later than next business day."2. Resident #6 was admitted to the residence on 4/5/24 and was 92 years old. A progress note in Resident #6's record, dated 9/29/24 read, in part, "Resident paged at (1:45 a.m.) and was visibly distressed, saying that she was physically assaulted the previous night around (10:00 p.m.) by a staff member in uniform. Her description of the person was a "dark man" who was semi-tall, and thin. She said the encounter started with her being stuck in her recliner and asking for assistance. She said that the person in question told her "no," and forced her up out of the chair before throwing her onto the ground. She said that her shoes were then forcibly removed, and that she was made to get into her bed. She told this story to both NOC (overnight) staff members in AL (assisted living), and was inspected for injuries or bruises, with no skin tears or bruises being present outside of a bruise on her left forearm, measuring about 1.5 x 0.75 inch. When approached by the same staff members at (5:45 a.m.) about the encounter she told the same story, except this time she was uncertain about whether she was thrown to the ground or not. All other details remained the exact same, and the resident was still distressed while telling it."The residence's physical abuse allegation investigation, dated 9/29/24, revealed that no staff contacted local law enforcement.a. InterviewsOn 10/22/24 at 12:57 p.m., the administrator said she did not think Resident #6's allegation was actual abuse because Resident #6's story had changed after she was interviewed, despite the administrator's acknowledgement that her understanding that staff were mandatory reporters whenever there was an allegation of abuse. On 10/23/24 at 10:18 a.m., the administrator said she should have notified local law enforcement within 24 hours of the abuse allegation. On 10/23/24 at approximately 11:30 a.m., the administrator acknowledged that all staff were trained on and were required to follow the residence's Abuse Reporting Protocol policy.

Based on record review and interview, the residence failed to report to the department an occurrence of physical abuse against a resident, affecting one of six sample residents (#6). (Cross-reference S410)Findings include:1. Reference and Residence Policya. The department's occurrence reporting manual, revised May 2018, read in part, "Two elements were needed for physical abuse: intent, or knowingly or recklessly; and, bodily injury and/or serious bodily injury. This means physical pain, illness, or any impairment of physical or mental condition. After an assessment is done, there is no visible injury found. If the consumer was involved in a physical altercation and indicates by action or interview that he or she experiences pain without any noticeable marks, is this injury? Yes. Pain is considered an injury. Even if a consumer with dementia cannot express pain, any action that would normally be considered painful by a reasonable person should be considered an injury. For example, a slap that leaves no mark would normally be painful and should be considered reportable as an injury even if the consumer cannot express the pain."b. The residence's Reportable Incident/Event Protocol policy, dated July 2021 read in part, "Initial occurrence reports are due to the division no later than the end of the next division business day."2. Resident #6 was admitted to the residence on 4/5/24 and was 92 years old. A progress note in Resident #6's record, dated 9/29/24 read in part, "Resident paged at (1:45 a.m.) and was visibly distressed, saying that she was physically assaulted the previous night around (10:00 p.m.) by a staff member in uniform. Her description of the person was a "dark man" who was semi-tall, and thin. She said the encounter started with her being stuck in her recliner and asking for assistance. She said that the person in question told her "no," and forced her up out of the chair before throwing her onto the ground. She said that her shoes were then forcibly removed, and that she was made to get into her bed. She told this story to both NOC (overnight) staff members in AL (assisted living), and was inspected for injuries or bruises, with no skin tears or bruises being present outside of a bruise on her left forearm, measuring about 1.5 x 0.75 inch. When approached by the same staff members at (5:45 a.m.) about the encounter she told the same story, except this time she was uncertain about whether she was thrown to the ground or not. All other details remained the exact same, and the resident was still distressed while telling it."The department occurrence database revealed the residence reported the 9/29/24 physical abuse occurrence on 10/15/24, 16 days after the initial report was made.a. InterviewOn 10/22/24 at 12:57 p.m., the administrator said she did not report the occurrence to the department because after she interviewed Resident #6 the resident's story changed and it did not meet the three criteria: knowingly, with intent or bodily injury.

Based on interview and record review, the residence failed to ensure residents were treated with dignity and respect, affecting two of two sample residents (#12, #13). (Cross-reference S1410)Specifically, Resident #12 said she did not want Staff #5 to work with her anymore because she had made Resident #12 "feel like such a burden," miserable, and disrespected. Resident #13 said Staff #5 was careless when she assisted her in putting on her shoes, said she caused her pain, and was "mindless" regarding the edema in her legs. Findings include:1. Resident #13 was admitted to the residence on 6/9/23. On 10/22/24 at 11:30 a.m., Resident #13 said that on an unknown date, months prior to the onsite visit, Staff #5 was assisting her with putting on her shoes. She added Staff #5 was not conscious of Resident #13's limitations and wrenched Resident #13's shoe on, which caused her pain. She added she did not get a response from Staff #5 when Resident #13 said, "ouch." She added that after that experience, she did not want Staff #5 to assist her. Resident #13 said she had edema in her right leg and her legs were often in pain. 2. Resident #12 was admitted to the residence on 3/28/24. On 10/22/24 at 1:53 p.m., Resident #12 said that one week prior to the onsite visit Staff #5 told her to "be quiet" because she was in the dining room discussing her upset stomach with other residents at the dining room table. Resident #12 said Staff #5 made her feel like she was a burden adding, "She makes me so miserable," "she is mean to me," and "I feel very disrespected and (Staff #5) is so unhappy here."3. InterviewsOn 10/22/24 at approximately 8:30 a.m., Staff #8 said she heard from other staff that Staff #5 was rough when she worked with residents and Resident #13 did not want Staff #5 in her room. On 10/22/24 at 12:15 p.m., Staff #7 said Residents #12 and #13 told her Staff #5 was rough and rude to them and neither of them wanted Staff #5 to assist them. On 10/22/24 at 2:07 p.m., Staff #9 said Staff #5 was too quick when she provided services to residents and needed to slow down. On 10/22/24 at 2:36 p.m., the assisted living coordinator said Resident #13 told her Staff #5 was too fast and rushed through cares with her and she no longer wanted Staff #5 to help her.

Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and identification of injuries of unknown origin, affecting one of six sample residents (#6). Findings include:1. Residence PolicyThe residence's Abuse Prevention, Investigation and Reporting policy, dated July 2021, read in part, "Reports of abuse or suspected abuse will be promptly and thoroughly investigated. The investigation will begin immediately - conducted and documented as follows: Interview process. Include a (second) person for all interviews. Select someone who is not associated with the alleged abuse. A department head is preferable. Interview individuals involved and document each individually."2. Resident #6 was admitted to the residence on 4/5/24. A progress note in Resident #6's record, dated 9/29/24 read, in part, "Resident paged at (1:45 a.m.) and was visibly distressed, saying that she was physically assaulted the previous night around (10:00 p.m.) by a staff member in uniform. Her description of the person was a "dark man" who was semi-tall, and thin. She said the encounter started with her being stuck in her recliner and asking for assistance. She said that the person in question told her "no", and forced her up out of the chair before throwing her onto the ground. She said that her shoes were then forcibly removed, and that she was made to get into her bed. She told this story to both NOC (overnight) staff members in AL (assisted living), and was inspected for injuries or bruises, with no skin tears or bruises being present outside of a bruise on her left forearm, measuring about 1.5 x 0.75 inch. When approached by the same staff members at (5:45 a.m.) about the encounter she told the same story, except this time she was uncertain about whether she was thrown to the ground or not. All other details remained the exact same, and the resident was still distressed while telling it."The residence's physical abuse allegation investigation, dated 9/29/24, did not include interview questions or answers with other residents or staff and the investigation reported on 9/29/24 by Former Staff #10. The employee schedule was reviewed, door entry key fob records, and text messages from the original reporter, Former Staff #10, was attached. However, no interviews were documented that included Resident #6 or staff members who worked on the date of the alleged abuse. One typed note read in part that Staff #5 worked the shift in question and read in part, "(Staff #5) was working that hallways that night and the key fob report that was pulled showed the key that (Staff #5) was using. (The assisted living coordinator) pulled (Staff #5) to the care office and had a conversation with (Staff #5) regarding her roughness when she is helping a resident with any ADL's (activities of daily living)." The report indicated that staff notified adult protective services (APS). 3. InterviewsOn 10/22/24 at approximately 1:00 p.m., the administrator said, "I asked around. Nobody wanted to say anything. I asked evening shift on who put her (Resident #6) to bed. No one said anything." On 10/23/24 at 10:18 a.m., the administrator said she should have interviewed more staff and residents and then documented the interviews. She added she did not follow up to see if APS was notified after an anonymous person notified local law enforcement about the allegation approximately one week prior to the onsite v

Based on interview and record review, the residence failed to provide steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury was not suspected abuse, neglect, or exploitation affecting two of six sample residents (#6, #9). Findings include:Resident #9 was admitted to the residence on 9/30/24 with diagnoses of frontal lobe and executive function deficit post cerebral infarction, muscle weakness, mobility impairment, and trigeminal neuralgia. A progress note, dated 10/9/24, read that staff, while changing Resident #9, found "a considerable amount of dried blood on her bed sheets, beneath the middle part of her left leg. No discernible injuries or old wounds could be found from which the blood might have come, and resident (#9) reported no pain or discomfort."A progress note, dated 10/16/24, read that staff found multiple bruises on Resident #9 ' s legs. On 10/23/24 at approximately 10:00 a.m., the wellness nurse stated that Resident #9 had recently returned from the hospital and that the residence did not complete an investigation following the observations of injuries made on 10/9/24 and 10/16/24. Similar deficient practice was found for Resident #6.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration affecting three of six sample residents (#6, #10, #11). Findings include:1. Record ReviewResident #11 was admitted to the residence on 10/24/23 with diagnoses of hypertension, hyperlipidemia, glaucoma, and depression. Practitioner orders, dated 10/24/23, directed the residence to administer acetaminophen 1000 mg twice daily. Practitioner orders, dated 4/10/24, directed the residence to discontinue administering docusate sodium. The October 2024 medication administration record (MAR) revealed that the residence administered acetaminophen 500 mg twice daily from 10/1 to 10/22/24. The October 2024 MAR read that the residence administered docusate sodium daily from 10/1 to 10/22/24. 2. InterviewsOn 10/23/24 at 8:45 a.m., the administrator stated that the wellness nurse (WN) was responsible for updating MARs to match practitioner orders. On 10/23/24 at 9:44 a.m., the WN stated that staff sometimes added duplicate practitioner orders to the MAR and overlooked it, and this was possibly what caused staff to administer the incorrect dose of acetaminophen. Similar deficient practice was found for Residents #6 and #10.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.10 Each resident care plan shall: (B) Reflect the most current assessment information; (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 17.14 Staff who assist feeding a resident shall be trained in the proper techniques for supporting nutrition and hydration by a licensed or registered professional qualified by education and training to assess choking risks, such as a registered nurse, speech language pathologist, or registered dietitian. 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident ' s condition changes from baseline status. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following:(A) A description of the resident ' s wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact;(B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR ' s plan to protect the resident from unwanted visitation by other residents;(C) Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and(D) Documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents.

A complaint revisit was completed on 10/23/24 for all previous deficiencies cited on 4/26/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration affecting three of six sample residents (#6, #10, #11). This deficiency was cited previously during a complaint survey 4/26/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record ReviewResident #11 was admitted to the residence on 10/24/23 with diagnoses of hypertension, hyperlipidemia, glaucoma, and depression. Practitioner orders, dated 10/24/23, directed the residence to administer acetaminophen 1000 mg twice daily. Practitioner orders, dated 4/10/24, directed the residence to discontinue administering docusate sodium. The October 2024 medication administration record (MAR) revealed that the residence administered acetaminophen 500 mg twice daily from 10/1 to 10/22/24. The October 2024 MAR read that the residence administered docusate sodium daily from 10/1 to 10/22/24. 2. InterviewsOn 10/23/24 at 8:45 a.m., the administrator stated that the wellness nurse (WN) was responsible for updating MARs to match practitioner orders. On 10/23/24 at 9:44 a.m., the WN stated that staff sometimes added duplicate practitioner orders to the MAR and overlooked it, and this was possibly what caused staff to administer the incorrect dose of acetaminophen. On 10/23/24 at 10:18 a.m., the administrator stated that this citation was being recited because staff did not ensure that the medications were in stock. Similar deficient practice was found for Residents #6 and #10.

A licensure complaint prompted by #CO31644, was completed on 4/26/23. Deficiences were cited.

Based on observation, record review and interview, the residence failed to admit a resident whose needs could be fully met by the existing staff and services already being provided, affecting one of two sample residents (#1) and one former resident (#5). Findings include: 1. Residence PolicyThe residence's admission policy, dated July 2021, read in part: Residents must be able to minimally transfer with one care staff, residents could not be admitted if they required medical or nursing services 24 hours a day seven days a week, or had stage three or four pressure sores would only be admitted on a case-by-case basis. 2. Resident #1 was admitted to the residence on 3/4/23 with diagnoses including parkinson's disease, venous insufficiency, cardiomegaly, osteoarthritis, blindness left eye, anemia and chronic kidney disease. On 4/26/23 at 2:56 p.m., the room for Resident #1 smelled of feces and urine and there were urine stains on the carpet and soiled incontinence pads on the furniture. A preadmission assessment dated 3/4/23 read in part: Resident #1 required assistance with decision making due to poor judgment, skin and wound care monitoring, and assitance with bathing. The assessment further read that Resident #1 was independent with toileting. A care plan, dated 3/4/23, read in part: Resident #1 required wound care from an external service provider, had occasional urinary incontinence, and required assistance with judgment. A progress note, dated 3/7/23, read the Former Health and Wellness Nurse (HWN) reported that Resident #1 required wound care services from an external service provider, for venous stasis wounds. A progress note, dated 3/13/23, read Resident #1 urinated in his bed at night and his linens needed to be changed daily. A progress note, dated 3/14/23, read Resident #1 was leaking from his incontinence underwear it was so saturated with urine when care staff came to get Resident #1 out of his chair. A progress note, dated 4/4/23 read an external service provider came to the residence to complete wound care on Resident #1. The external service provider instructed the residence to ensure that Resident #1 had pressure sore boots applied and wore them until his next shower. A progress note, dated 4/10/23 read Resident #1 had his urinal on his walker, he was told by care staff to leave it in his room during breakfast. However; Resident #1 subsequently urinated on himself then continued to eat in front of another resident who was upset by this during meal time in the residence dining area. Resident #1 told the care staff if they had let him take his urinal to the dining area this would not have occurred. A progress note, dated 4/13/23 read Resident #1 intentionally urinated in front of his door going back to his room and argued with care staff about changing his clothes because the resident claimed his clothes were not wet. Resident #1 was wearing his family member's incontinence underwear who was another resident, and refused to wear the incontinence underwear provided by the residence. Resident #1 was advised to follow the house rules. On 4/26/23 at 1:24 p.m., Resident #1 stated that he required staff to assist him with toileting; however, he stated staff were frequently busy and unable to provide assistance. On 4/26/23 at 1:57 p.m., the family member for Resident #1 stated before Resident #1 was admitted to the residence he had poor mobility and poor decision making capability. Resident #1's family member stated that Resident #1 required assistance transferring out of bed and would urinate in the urinal without staff assistance and intentionally dump his urine everywhere since staff would not empty his urinal. The family member further stated Resident #1 required skilled nursing assistance as he required incontinence care and was unable to push the call button. The family member for Resident #1 stated his care needs had not changed since before admission to the residence. The family member stated he tried to set up a care conference with the administrator for the two weeks prior to the onsite investigation and was supposed to meet with her on 4/24/23 in regard to the services Resident #1 required that the residence was unable to provide. However, he stated the administrator was not at the residence and he had not heard anything back. On 4/26/23 at approximately 2:00 p.m., Staff #4 stated Resident #1 was a difficult resident to care for, and would urinate on t-shirts. Staff #4 further stated Resident #1 would bring his urinal to the dining room and urinate in front of other residents instead of leaving the urinal in the privacy of his own room. She further stated Resident #1 would intentionally urinate in his brief when instructed not to bring the urinal to the dining area and to go to his room when he had to urinate. Staff #4 added Resident #1 had these behavioral expressions since admission to the residence. On 4/26/23 at 2:31 p.m., a nurse at Resident #1's practitioner's office stated Resident #1 was last seen on 3/6/23 due to cellulitis and was started on a diuretic for high blood pressure from stage four kidney disease. The nurse stated that he had been with his current practitioner since 2/17/23, and was admitted to the residence with venus stasis dermatitis which meant he has an open wound with swelling at the site. The nurse stated Resident #1 was seen by the practitioner on 3/6/23 and it was noted that the resident no longer had any wounds. However, during the visit on 4/19/23 Resident #1 was diagnosed with an additional wound which included a pressure wound on the foot. The nurse further stated the family member for Resident #1 requested an order for a skilled nursing facility on 4/13/23 as the resident required more care than the assisted living was able to provide. On 4/26/23 at 4:07 p.m., the vice president of wellness (VPW) stated Resident #1 continued to bring his urinal into the dining room at meal times which was not sanitary. She confirmed that Resident #1 was not an average admission for the residence due to his high medical acuity. 2. Former Resident #5 was admitted to the residence on 3/9/23, with diagnoses including striatonigral degeneration, dependence on supplemental oxygen, essential hypertension, depression, insomnia, chronic ischemic heart disease and gastro-esophageal reflux disease. A preadmission assessment dated 2/19/23 and updated 3/13/23 read former Resident #5 used a wheelchair and required two-person staff assistance with mobility and toileting. A care plan dated 2/19/23, read Former Resident #5 required two-person staff assistance with mobility and toileting. However, the pre-admission assessment and care plan for Former Resident #5 contradicted the residence's admission policy to only admit residents who required one person assistance with transfers or less. A progress note, dated 3/23/23, read Former Resident #5 required changing and repositioning in bed and did not like when staff moved her. A progress note, dated 4/3/23, read Former Resident #5 required skilled nursing and was unable to come back to the residence. A physical therapy note dated 4/4/23, read Former Resident #5 had impaired strength, was wheelchair bound at baseline, had poor mobility, and posture, and would benefit from a skilled nursing facility. On 4/26/23 at 7:34 a.m., Staff #1 stated that former Resident #5 needed to be in a skilled nursing facility because she required total assistance and needed a sit-to-stand mechanical lift, required incontinence care, and was bed bound otherwise without staff assistance. Staff #1 stated that she did not believe that residence staff were able to provide her the level of care she required since there was often not a second staff member around, so she was not able to get her up into her wheelchair as often as she would have liked, since there were other residents that required assistance and there was only so much one person could do. On 4/26/23 at 8:01 a.m., Staff #2 stated Former Resident #5 required total care and two-person transfer assistance. On 4/26/23 at 8:12 a.m., Staff #3 stated Former Resident #5 required two-person assistance with all transfers and it was difficult to coordinate a time with a second staff member to get her into her wheelchair. On 4/26/23 at 8:42 a.m., Staff #4 stated Former Resident #5 required two-person transfer assistance, required help with dressing, was in a wheelchair and bedbound, and stated that former Resident #5 required a higher level of care to ensure that there was always a staff member available to provided incontinence care and transfer her out of the bed into the wheelchair and to require two-person transfer assistance was not a service the residence normally provided. On 4/26/23 at 12:45 p.m., the administrator designee stated Former Resident #5 was initially assessed on 2/19/23, which was why her admission assessment was updated on 3/13/23 and was deferred ineligible for admission. The administrator designee stated the family member of Former Resident #5 convinced the residence staff that she would only require one-person assistance with transfers since they would not admit a resident who was two-person assistance with transfers. The administrator designee further stated when they admitted Former Resident #5 they realized she did in fact require two-person assistance with transfers. On 4/26/23 at 1:41 p.m., contrary to what the administrator designee stated, Former Resident #5's family member stated the residence accepted her after initially denying her due to the high level of care she required and then changed their mind and thought they could care for her in her condition, so they agreed to admit her. Former Resident #5's family member stated Former Resident #5 could not stand on her own, required feeding assistance and bathroom assistance. On 4/26/23 at 4:07 p.m., the VPW stated that the assisted living tried to ensure resident recieved placement so they were not waiting extended periods of time for a place to live and added that she believed that to be the case with Former Resident #5. The VPW stated she was unable to say for sure whether or not Former Resident #5 was an appropriate admission, since the administrator was on vacation and she was the one who did Former Resident #5's admission assessment. The VPW stated that she was unaware former Resident #5's physical therapist recommended to send her to a skilled nursing facility.

Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of four sample residents (#1-#4) and one former resident (#5) whose medications were reviewed. Specifically, Resident #1 was admitted to the residence on 3/4/23 with a diagnosis of Parkinson's disease. The record for the resident contained a written practitioner's order, dated 2/8/23, which directed the residence to administer carbidopa-levodopa 25-250 mg three times daily. A second written practitioner's order, dated 4/14/23, directed the practitioner to administer carbidopa-levodopa 25-100 mg four times daily to be taken with 25-250 mg. However, the April 2023 electronic medication administration record (eMAR) read carbidopa-levodopa 25-250 mg was discontinued from 4/16 a.m. to 4/26/23 for a total of 41 missed doses. On 4/26/23, the neurologist for Resident #1 stated that Resident #1 was at immediate risk for harm due to increased tremors and freezing episodes related to not receiving the medication for 41 doses and subsequently stated the medication needed to be restarted right away. This failure created an immediate jeopardy risk for Resident #1. On 4/26/23, the department directed the residence to submit written evidence that the risk had been removedFindings include: 1. References and Residence Policya. According to Mayo clinic, "carpidopa levodopa is used to treat motor fluctuations for people with advanced Parkinson's disease. The medication must be given on a strict schedule and if a dose is missed a practitioner must be contacted immediately. Withdrawal from carbidopa-levodopa can include convulsions and muscle stiffness." Mayo clinic (February 2023) Carbidopa and Levodopa (Route Not Applicable), retrieved from: https://www.mayoclinic.org/drugs-supplements/carbidopa-and-levodopa-route-not-applicable/proper-use/drg-20137316b. According to Mayo clinic, "do not stop taking ropinirole suddenly without consulting a practitioner. Withdrawal from ropinirole can cause fever, confusion, and severe muscle stiffness." Mayo clinc (Febraury 2023) Ropinirole (Oral Route), retrieved from: https://www.mayoclinic.org/drugs-supplements/ropinirole-oral-route/precautions/drg-20066810c. According to Drugs.com, "do not stop taking amantadine if you have been taking for more than four weeks. Rapid withdrawal can occur and includes delirium, anxiety, agitation, parkinsonian crisis, hallucinations, slurred speech and low levels of consciousness. Why Should You Not Discontinue Amantadine (Medically reviewed in 2022), retrieved from: https://www.drugs.com/medical-answers/you-discontinue-amantadine-3546645/#:~:text=Symptoms%20of%20rapid%20withdrawal%20can,deliriumd. According to Mayo clinic "Mycophenolate is used after organ transplants. Do not stop taking mycophenolate suddenly since doing so can cause rejection of the transplanted organ." Mayo clinic (May 2023) Mycophenolate (Oral Route), retrieved from: https://www.mayoclinic.org/drugs-supplements/mycophenolate-mofetil-oral-route/proper-use/drg-20073191e. The residence's medication administration policy, dated July 2021, read in part: "routine medications are administered to residents in compliance with state regulations ... all medications will be (administered) in accordance with the directions of a resident's practitioner."2. Resident #1 was admitted to the residence on 3/4/23, with diagnoses including Parkinson's disease, venous insufficiency, cardiomegaly, osteoarthritis, blindness left eye, anemia and chronic kidney disease. A preadmission assessment dated 3/4/23 read that Resident #1 did not self administer medications,. would have cycle filled medications and required assistance from staff with medication management that would be monitored by a licensed nurse. The community would assist the resident to take medications, order medications from the pharmacy, store medications per pharmacy directions, monitor for side effects and communicate with the practitioner as needed for issues and concerns. a. Carbidopa-LevodopaA written practitioner's order, dated 2/8/23, directed the residence to administer carbidopa-levodopa 25-250 mg three times daily. An occurrence report, dated 3/4/23, read the medication was not administered on 3/4/23 (add which doses were missed a.m., noon, p.m.) Additionally, the March 2023 (eMAR) revealed no evidence of documentation on 3/5 and 3/6/23. A second written practitioner's order, dated 4/3/23, directed the residence to administer carbidopa-levodopa 25-250 mg four times daily. A third written practitioner's order dated 4/14/23, directed the residence to administer carbidopa-levodopa 25-100 mg four times daily to be taken with 25-250 mg four times daily. However, the April 2023 eMAR read carbidopa-levodopa 25-250 mg four times daily was discontinued from 4/16 a.m., to 4/26/23 for a total of 41 missed doses. On 4/26/23 at approximately 2:45 p.m., a medication cart audit was conducted and revealed that Resident #1's carbidopa-levodopa 25-250 mg was not in the medication cart.b. Ropinirole HCLA written practitioner's order, dated 2/8/23, directed the residence to administer ropinirole 0.25 mg three times daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, ropinirole was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of eight missed doses. c. AmantadineA written practitioner's order, dated 2/8/23, directed the residence to administer amantadine 100 mg twice daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, amantadine was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of six missed doses. d. GabapentinA written practitioner's order, dated 2/8/23, directed the residence to administer gabapentin 100 mg twice daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, gabapentin was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of six missed doses. e. FurosemideA written practitioner's order, dated 2/8/23, directed the residence to administer furosemide 20 mg twice daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, furosemide was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of six missed doses. f. LisinoprilA written practitioner's order, dated 2/8/23, directed the residence to administer lisinopril 10 mg twice daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, lisinopril was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of six missed doses. g. Metoprolol tartrateA written practitioner's order, dated 2/8/23, directed the residence to administer metropolol tartrate 25 mg twice daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, metropolol tartrate was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of six missed doses. h. Ferrous sulfateA written practitioner's order, dated 2/8/23, directed the residence to administer ferrous sulfate 325 mg once daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, ferrous sulfate was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of three missed doses. i. MultivitaminA written practitioner's order, dated 2/8/23, directed the residence to administer multivitamin once daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, multivitamin was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of three missed doses. j. Polyethylene GlycolA written practitioner's order, dated 2/8/23, directed the residence to administer polyethylene glycol once daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, polythylene glycol was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of three missed doses. k. Potassium ChlorideA written practitioner's order, dated 2/8/23, directed the residence to administer potassium chloride 20 meq once daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, potassium chloride was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of three missed doses. l. Stimulant laxativeA written practitioner's order, dated 2/8/23, directed the residence to administer two tablets of stimulant laxative 8.6-50 once daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, stimulant laxative was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of three missed doses. m. XareltoA written practitioner's order, dated 2/8/23, directed the residence to administer Xarelto 10 mg once daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/5 and 3/6/23. Further, Xarelto was revealed to have not been administered on the residence's 3/4/23 occurrence report, for a total of three missed doses. n. Triamcinolone acetonideA written practitioner's order, dated 2/8/23, directed the residence to administer triamcinolone acetonide 0.1% cream twice daily. However, the March 2023 eMAR read the medication was not administered 3/10 and 3/15/23 in the evening due to waiting on the pharmacy, for a total of two missed doses. o. Nystop powderA written practitioner's order, dated 2/8/23, directed the residence to administer nystatin powder 1000 grams twice daily. However, the March 2023 eMAR read the medication was not administered 3/10 and 3/15/23 in the evening due to waiting on the pharmacy, for a total of two missed doses. The residence's internal grievance occurrence report, dated 3/6/23, read that the former health and wellness director (HWD), instructed Resident #1 to self-medicate until his medications arrived from the pharmacy. However on 3/5/23, Resident #1 was unable to get his amantadine, carbidopa-levodopa, ferrous sulfate, furosemide, gabapentin, lisinopril, metoprolol tartrate, multivitamin, polyethylene glycol, potassium chloride, ropinirole, stimulant laxative and Xarelto. On 3/5/23, no medications had arrived from the pharmacy. It was reported that Resident #1's family member stated that he could not keep coming to the residence to put Resident #1's medications in his medication reminder box. An email communication dated 3/7/23, read that the former HWD obtained Resident #1's medications the morning of 3/7/23, and the former health and wellness nurse (HWN) and was also unable to get the medications filled for Resident #1 on 3/6/23. An email communication dated 3/7/23 by the administrator, read that the Former HWD changed the paperwork to independent with medication administration upon admission for Resident #1 and had the family for Resident #1 provide assistance with medication. The incident was reported as neglect since the resident had ended up missing doses of medication and experienced discomfort due to these actions. The email further read that the resident's external private caregiver had taken the prescriptions to a alternate pharmacy prior to move-in and failed to pick up the medications upon admission to the residence. Therefore when the residence attempted to fill the medications they were unable to for insurance reasons. A termination summary dated 3/8/23 read the Former HWD was terminated due to failing to ensure Resident #1 had his medications prior to admission to the residence. On 4/26/23 at 1:24 p.m., Resident #1 stated that staff had been inconsistentwith his medications and staff were not aware what medications he had missed. On 4/26/23 at 1:57 p.m., the family member for Resident #1 stated that he had only administered Resident #1's medications one time when he first moved into the residence, the family member stated it took two days to deliver the resident's medications from the pharmacy, since he was unaware he needed to pick it up. The family member stated that Resident #1 missed his medications for two days while waiting for the medication to be picked up. The family member further stated Resident #1 did not have the ability to self-administer his medications. He stated Resident #1 had previously overdosed on his medications when he self-administered in the past. Additionally, the family member stated the residence had told him upon move-in, he was required to bring prefilled medication reminder boxes for Resident #1 to self-administer. However, the family member stated it that it was not possible because not all of his medications were available. The family member for Resident #1 stated the reason that Resident #1 was not capable of self-administration, was because he was ordered to take carbidopa levodopa three times daily, however, prior to when Resident #1 moved in to the residence, he had taken carbidopa-levodopa four times daily even though he was never ordered to take that extra dose. The family member stated when the resident moved into the residence and the residence complied with the three times daily order, Resident #1 experienced increased weakness due to the change in medication that was administered. On 4/26/23 at 2:31 p.m., a nurse at Resident #1's practitioner's office stated that she was able to see he had an order for carbidopa-levodopa 25-250 four times daily, and had never been informed that the medication was not being administered. The nurse at Resident #1's practitioner's office stated that Resident #1's medication should have been picked up in March 2023. The nurse also stated that she had not received any faxes or communication from the residence about any other missed medications. On 4/26/23 at 3:32 p.m., the Health and Wellness Director (HWD) stated that she had only worked at the residence two weeks and would check medication orders and input them into the medication administration record, however, had never worked with the pharmacy, nor did she discontinue the carbidopa-levodopa 25-250 mg. On 4/26/23 at 3:40 p.m., a nurse at the neurologist office for Resident #1, stated carbidopa-levodopa 25-250 four times daily should not have been discontinued as it could make his Parkinson's disease worse, including increased tremors and directed the department reinstate the medication right away. The nurse at the neurologist office for Resident #1 stated the neurologist would need to examine the resident sooner than 5/5/23 when his next appointment was, since he had not been receiving his medication. On 4/26/23 at 4:07 p.m., contrary to what the HWD stated, the Vice President of Wellness (VPW) stated that she discovered that the HWD had discontinued Resident #1's carbidopa-levodopa 25-250 mg four times daily, and was unsure why she discontinued it on the April 2023 eMAR. The VPW also stated that when Resident #1 was out of his medication in early March 2023 upon admission, he had experienced more freezing episodes, and the Former HWD and HWN were terminated since they did not ensure Resident #1 had medication in stock prior to admission. On 4/26/23 at 4:56 p.m., the nurse at the neurologist office for Resident #1 stated he had spoken with the prescribing neurologist who stated that stopping Resident #1's carbidopa levodopa 25-250 mg four times daily meant the resident was at risk for serious harm as was receiving less than half his original dose and was at risk for increased tremors, bounds and slow movement. The neurologist stated the medication needed to be restarted right away. 3. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed Resident #1 at immediate jeopardy risk for harm, injury or death. The residence was directed to provide the department with written evidence that the risk had been removed. Part 13.11 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 4/26/23 at 5:28 p.m., the VPW submitted written evidence that read in pertinent part: "with respect to how the facility (residence) will correct the problem identified: the Carbidopa-Levodopa 25-250 mg that was missing was immediately found on the medication cart. The order was immediately reinstated on resident's MAR, and the primary care provider was notified for instructions on how to reinstate the order. The nurse at the primary care practitioner's office would call the practitioner and an executive with the practitioner's office would request escalation to the resident's practitioner. Medication will be administered as soon as orders are received to resume."However, the written evidence did not contain that the medications were ever discontinued and therefore needed to be resumed immediately per the prescribing practitioner. The written evidence also did not include a monitoring element to ensure this would not happen again, and did not reflect any follow up appointments as necessary, and re-training of staff who discontinued the order. On 4/26/23 at 5:42 p.m., the VPW submitted a second and final attempt of written evidence that read in pertinent part: "with respect to how the facility will prevent this problem in the future: the new HWD that discontinued the order will complete QuickMar education with mentor on 4/27/23. The administrator or administrator designee will review medications discontinued in nursing 24-hour binder. Documentation of review will be kept in the administrator's office. A complete root cause analysis to be completed as to whether pharmacy initiated the discontinue order or the community initiated the discontinue order. All missing medications and/or medication exceptions to be reviewed daily at clinical standup for continued compliance."On 4/26/23 at 5:46 p.m., the VPW submitted additional documentation of an order prescribed by Resident #1's neurologist, and signed by Resident #1's practitioner the day of the onsite survey to resume carbidopa-levodopa 25-250 mg four times daily. 4. Former Resident #5 was admitted to the residence on 3/9/23, with diagnoses including striatonigral degeneration, dependence on supplemental oxygen, essential hypertension, depression, insomnia, chronic ischemic heart disease and gastro-esophageal reflux disease. A preadmission assessment dated, 3/13/23, read that Former Resident #5 did not self administer medications, would have cycle fill medications, required assistance from staff with medication management with oversight by a licensed nurse, store medications per pharmacy directions, monitor for side effects, and communicate with the practitioner as needed for issues and concerns. a. AlbuterolA written practitioner's order, dated 2/27/23, directed the residence to administer albuterol 2.5 mg-3ml four times daily. However, the March 2023 eMAR read the medication was not administered on 3/9 two times, 3/10 four times, 3/11 three times as the family administered the medications and due to waiting on the pharmacy on 3/14 four times, 3/15 two times, 3/16 three times, 3/17 three times and 3/18/23 four times, for a total of 25 missed doses. b. NystatinA written practitioner's order, dated 2/27/23, directed the residence to administer nystatin cream 1000 units topically twice daily. However, the March 2023 eMAR read the medication was not administered 3/9 once, 3/10 twice, and 3/11/23 once due to family administering the medications. Additionally, nystatin was unavailable 3/15-3/18/23 in the evening, for a total of eight missed doses.c. PregabalinA written practitioner's order, dated 2/27/23, directed the residence to administer pregabalin 100 mg twice daily. However, the March 2023 eMAR read the medication was not administered 3/9 once, 3/10 twice and 3/11 once due to family administering the medications. Additionally the March 2023 eMAR read the medication was unavailable once on 3/13, 3/24, 3/30 and 3/31/23, for a total of eight missed doses.d. Calcium-Vitamin D3A written practitioner's order, dated 2/27/23, directed the residence to administer calcium vitamin D3 600 mg three times daily. However, the March 2023 eMAR read the medication was not administered 3/9 once, 3/10 three times, and 3/11/23 twice due to family administering the medications, for a total of six missed doses.e. Carbidopa-LevodopaA written practitioner's order, dated 2/27/23, directed the residence to administer carbidopa-levodopa 25-100 mg three times daily. However, the March 2023 eMAR read the medication was not administered 3/9 once, 3/10 three times and 3/11/23 twice due to family administering the medications, for a total of six missed doses.f. LevothyroxineA written practitioner's order, dated 2/27/23, directed the residence to administer levothyroxine 88 mcg once daily. However, the March 2023 eMAR read the medication was not administered on 3/10-3/11/23 due to family administering the medications. Additionally the March 2023 eMAR read that levothyroxine was not administered as it was unavailable from 3/14-3/17/23 for a total of six missed doses.g. RopiniroleA written practitioner's order, dated 2/27/23, directed the residence to administer ropinirole 1 mg three times daily. However, the March 2023 eMAR read the medication was not administered 3/9 once, 3/10 three times and on 3/11/23 twice due to the family administering the medications, for a total of six missed doses.h. Diclofenac sodiumA written practitioner's order, dated 2/27/23, directed the residence to administer diclofenac sodium 1% twice daily. However, the March 2023 eMAR read the medication was not administered 3/9 once, 3/10 twice and 3/11/23 once due to family administering the medications, for a total of four missed doses.i. HydroxyzineA written practitioner's order, dated 2/27/23, directed the residence to administer hydroxyzine 25 mg twice daily. However, the March 2023 eMAR revealed the medication was not transcribed until 3/11/23. As a result, Former Resident #5 was not administered her medication 3/9 once, 3/10 twice, and 3/11 once, for a total of four missed doses.j. SennaA written practitioner's order, dated 2/27/23, directed the residence to administer senna 8.6 mg once daily. However, the March 2023 eMAR read the medication was not administered on 3/10 and 3/11/23 due to family administering the medications, for a total of two missed doses.k. SertralineA written practitioner's order, dated 2/27/23, directed the residence to administer sertraline 100 mg once daily. However, the March 2023 eMAR read the medication was not administered on 3/10 and 3/11/23 due to family administering the medications, for a total of two missed doses.l. Vitamin D3A written practitioner's order, dated 2/27/23, directed the residence to administer vitamin D3 50 mcg once daily. However, the March 2023 eMAR read the medication was not administered on 3/10 and 3/11/23 due to family administering the medications, for a total of two missed doses.m. ProbioticA written practitioner's order, dated 2/27/23, directed the residence to administer a probiotic once daily. However, the March 2023 eMAR read the medication was not administered on 3/10 and 3/11/23 due to family administering the medications, for a total of two missed doses.n. Losartan potassiumA written practitioner's order, dated 2/27/23, directed the residence to administer losartan potassium 25 mg once daily. However, the March 2023 eMAR read the medication was not administered on 3/10 and 3/11/23 due to family administering the medications, for a total of two missed doses.o. Magnesium OxideA written practitioner's order, dated 2/27/23, directed the residence to administer magnesium oxide 400 mg once daily. However, the March 2023 eMAR read the medication was not administered on 3/10 and 3/11/23 due to family administering the medications, for a total of two missed doses.p. OmeprazoleA written practitioner's order, dated 2/27/23, directed the residence to administer omeprazole 20 mg once daily. However, the March 2023 eMAR read the medication was not administered on 3/10 and 3/11/23 due to family administering the medications, for a total of two missed doses.q. FluticasoneA written practitioner's order, dated 2/27/23, directed the residence to administer fluticasone spray 50 mcg in each nostril once daily. However, the March 2023 eMAR read the medication was not administered on 3/10 and 3/11/23 due to family administering the medications, for a total of two missed doses.r. Folic acidA written practitioner's order, dated 2/27/23, directed the residence to administer folic acid 1 mg once daily. However, the March 2023 eMAR read the medication was not administered on 3/10 and 3/11/23 due to family administering the medications, for a total of two missed doses.s. AspirinA written practitioner's order, dated 2/27/23, directed the residence to administer aspirin 81 mg once daily. However, the March 2023 eMAR read the medication was not administered on 3/10 and 3/11/23 due to family administering the medications, for a total of two missed doses. The residence's internal grievance occurrence report, dated 4/1/23, read that former Resident #5's family member and the administrator were in communication regarding former Resident #5's missing doses of medication in March 2023, including levothyroxine, tramadol, and pregabalin. Former Resident #5 was sent to the hospital on 4/1/23 and had a heart attack. On 4/26/23 at 8:42 a.m., Staff #4 stated that Former Resident #5 was out of quite a few of her medications in March 2023 due to issues with the pharmacy. On 4/26/23 at 12:10 p.m., the administrator designee stated that Former Resident #5 had moved in with a medication reminder box a family member would come in and administer her medications while the residence was waiting on the pharmacy. She added the former resident was not able to self-administer medications when she was assessed. On 4/26/23 at 1:05 p.m., the administrator designee stated at that the medication reminder box for former Resident #5 was under her sink and family had the key to open it. On 4/26/23 at 1:41 p.m., contrary to what the administrator designee stated, the family member for Former Resident #5 stated that the former resident had run out of medication due to issues with the residence's preferred pharmacy not accept the electronic prescriptions from Former Resident #5's practitioner. The family member stated that the residence requested a medication box that was previously used for Former Resident #5 when she lived at home so the residence could ensure the contents were what was prescribed by the practitioner; However the family member for Former Resident #5 stated they did not administer any medications, so Former Resident #5 went without her medications. On 4/26/23 at 4:23 p.m., the VPW stated that the administrator would have done Former Resident #5's admission with her medications since the former HWD had left on 3/8/23 which was prior to Former Resident #5's admission date of 3/9/23. On 4/26/23 at 4:47 p.m., the administrator designee acknowledged that if the family member for Former Resident #5's family stated that they did not administer any of her medications and the residence did not, then the Former resident did not receive any of her medications from 3/9-3/11/23 in the afternoon. 5. Resident #2 was admitted to the residence on 3/4/23, with a diagnosis of dementia.a. MycophenolateA written practitioner's order, dated 3/11/23, directed the residence to administer mycophenolate 250 mg twice daily. However the April 2023 eMAR read the medication was not administered on 4/12-4/25/23 twice and 4/26/23 once due to medication being unavailable, for a total of twenty-nine missed doses.b. UrsodiolA written practitioner's order, dated 3/1/23, directed the residence to administer ursodiol four 300 mg capsules once daily. However, the April 2023 eMAR read the medication was not administered on 4/9, 4/10, 4/11, 4/12 due to the medication being unavailable, for a total of four missed doses. An second written practitioner's order, dated 4/18/23, directed the residence to administer ursodiol two 300 mg capsules twice daily. However, the April 2023 eMAR read the medication was not administered on 4/20-4/25/23 twice due to medication being unavailable, for a total of ten missed doses. On 4/26/23 at 2:31 p.m., a nurse at Resident #2's practitioner's office stated the office had not been made aware that Resident #2 was out of any medications. On 4/26/23 at 3:04 p.m., a representative with the residence's preferred pharmacy for Resident #2, stated that there were insurance issues with Resident #2's mycophenolate, and stated it had been requested. However, the representative stated the medication required a prior authorization which had not been obtained. 6. Resident #4 was admitted to the residence on 4/3/23, with diagnoses including heart failure, hemorrhage of anus and rectum, pulmonary nodular amyloidosis, dysphagia and acute renal failure.a. Alendronate SodiumA written practitioner's order, dated 3/27/23, directed the residence to administer alendronate sodium 70 mg every seven days. However, the April 2023 eMAR read the medication was not administered on 4/4/23 due to medication unavailable, for a total of one missed dose.b. Miralax PowderA written practitioner's order, dated 3/27/23, directed the residence to administer miralax 17 grams once daily. However, the April 2023 eMAR read the medication was not administered on 4/4/23 due to medication unavailable, for a total of one missed dose.c. Vitamin D3A written practitioner's order, dated 3/27/23, directed the residence to administer vitamin D3 25 mcg once daily. However, the April 2023 eMAR read the medication was not administered on 4/4/23 due to medication unavailable, for a total of one missed dose.d. DigoxinA written practitioner's order, dated 3/27/23, directed the residence to administer digoxin 0.125 mg every other day. However, the April 2023 eMAR read the medication was not administered on 4/17/23 due to medication unavailable, for a total of one missed dose. 7. Resident #3 was admitted to the residence on 4/11/23, with diagnoses including type 2 diabetes, macular degeneration and urine retention.a. MetaxaloneA written practitioner's order, dated 4/10/23, directed the residence to administer metaxalone 800 mg three times daily. However, the April 2023 eMAR read the medication was not administered on 4/25 once and 4/26/23 once, for a total of two missed doses. On 4/26/23 at 4:50 p.m., the VPW stated that the residence should have complied with all practitioner's orders and ensured that none of the residents went without medications. The VPW acknowledged that there seemed to be issues when residents who were admitted in March 2023, with their medications not being transcribed onto the MAR. The VPW acknowledged it was against the residence's policy to make a resident self-administer at admission if medication were not received.

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 one former resident (#5). Findings include:1. The residence's medication administration policy, dated July 2021, read in part: "Medication assistant or qualified medication administration personnel (QMAPS) shall document when a medication is unavailable in the electronic medication administration record (eMAR)."2. Former Resident #5 was admitted to the residence on 3/13/23, with a diagnosis of striatonigral degeneration. a. PregabalinA written practitioner's order, dated 2/27/23, directed the residence to administer 100 mg of pregabalin twice daily. However, the March 2023 eMAR revealed no evidence of documentation on 3/30/23 in the evening, or 3/31/23 in the morning. 3. Interview On 4/26/23 at 4:50 p.m., the VPW stated that the residence should have documented that former Resident #5's pregabalin and the qualified medication administration personnel (QMAP) should not have just left it blank.

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 7.11.16 The assisted living residence shall provide written notice of any discharge to the resident or legal representative 30 calendar days in advance of discharge except in cases of imminent physical harm to or by the resident or medical emergency, whereupon the assisted living residence shall notify the legal representative as soon as possible. 14.39 Controlled substances shall be kept in double lock storage.(A) Two individuals who are either qualified medication administration persons, nurses, or practitioners shall jointly count all controlled substances at the end of each shift and sign documentation regarding the results of the count at the time it occurs. Any discrepancy in the controlled substance count shall be immediately reported to the administrator. 18.8 Resident records shall contain, but not be limited to, the following items:(D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident ' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident ' s changing needs;(1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them.