CASTLE PEAK ASSISTED LIVING

A revisit survey was completed on 7/18/23 for all previous deficiencies cited on 1/19/23. The facility is in compliance with all deficiencies 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 relicensure survey was completed on 1/19/23. Deficiencies were cited.

Based on interview 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 18 current residents On 1/19/23, at 8:00 a.m., the administrator provided two resident rosters. Both resident rosters did not list the residents' emergency contact information or have a residence diagram attached. On 1/19/23 at 8:30 a.m., the administrator stated the two resident rosters provided were the only resident rosters. He added he did not know the requirement for a resident roster without referencing the regulations. On 1/19/23 at approximately 11:10 a.m., the administrator confirmed the resident roster provided did not include emergency contact information or a diagram that showed room locations. He stated he was not aware of the elements required to be included in the resident roster.

Based on observation, record review and interview, the residence failed to ensure all over-the-counter (OTC) medications prescribed for administration were labeled or marked with residents' full names, affecting two of four sample residents (#1, #2). Findings include: 1. Residence PolicyThe residence's Medication Administration policy, dated 4/29/21, read in part that the residence was required to label OTC medications with the resident's first and last name. 2. Resident #1 was admitted to the residence on 12/23/20. Review of the residence's record for Resident #1 and an audit of the residence's medication cart revealed the following OTC medications were not labeled with the resident's full name, as follows: A written practitioner order, dated 12/15/22, directed the residence to administer Tylenol 500 mg two tablets at bedtime and every six hours as needed for pain. A written practitioner order, dated 12/15/22, directed the residence to administer Refresh Tears 0.5%, one drop per eye, four times a day as needed for dryness. A written practitioner order, dated 12/15/22, directed the residence to administer Miralax 17 gm with water daily in the morning. However, the Tylenol, Refresh Tears, and Miralax bottles were labeled with only the resident's first name. 3. Resident #2 was admitted to the residence on 10/25/22Review of the residence's record for Resident #2 and an audit of the residence's medication cart revealed that the following OTC medication was not labeled with the resident's full name: A written practitioner order, dated 12/29/22, directed the residence to administer Metamucil .36 gm one cap daily. However, the Metamucil bottle was not labeled with the resident's first or last name. 4. Interviews On 1/19/22 at 9:18 a.m., Staff #4 stated that the OTC medications for Residents #1 and #2 were not labeled with the residents' first and last names. She added that she was unaware of the requirement. On 1/19/23 at 10:24 a.m., the health services director stated that the residence should have labeled the OTC medications for Residents #1 and #2 with their first and last names, and the residence had not. She added that she was unaware that the OTC medications were not labeled appropriately until the onsite visit. On 1/19/23 at approximately 11:20 a.m., the administrator stated that the residence was required to label OTC medications with the residents' first and last names per the regulation. He added that he was unaware that the OTC medications for Residents #1 and #2 were not labeled. However, the residence should have labeled the OTC medications with the residents' first and last names.

Based on record review and interview, the administrator failed to, along with the qualified medication administration personnel (QMAP) supervisor, audit and document the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, and any irregularities shall be investigated and resolved, affecting four of four sample residents (#1-#4). Findings include:On 1/19/23 at 8:30 a.m., the residence's policy for quarterly medication audits was requested from the administrator. However, a policy that addressed medication audits was not provided. On 1/19/23 at 8:30 a.m., documentation of completed quarterly medication audits was requested from the administrator. However, documentation of quarterly medication audits completed by the administrator and QMAP supervisor were not provided. On 1/19/23 at 9:18 a.m., Staff #4 stated that the residence had not conducted documented medication audits by the administrator and the QMAP supervisor. On 1/19/23 at 10:24 a.m., the health services director stated that the residence had not conducted quarterly medication audits. She added that she was unaware of the requirement for quarterly medication audits. On 1/19/23 at approximately 11:23 a.m., the administrator stated that he was unaware the residence was required to conduct quarterly medication audits prior to the onsite visit. He added that the residence did not yet have a specific audit tool.

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 7.14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner.(A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.(B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials.(C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.(D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.