RESIDENCE AT GRAND MESA

A recertification survey and complaint revisit was completed on 12/17/24 for the previous deficiency cited on 8/7/24. The facility is in compliance with all regulations surveyed. The deficiency cited for Event SOUO12 was cited prior to the regulation revision that was implemented 3/16/24.

A complaint revisit was completed on 12/17/24 for all previous deficiencies cited on 8/7/24. The residence is in compliance with all regulations surveyed.

A complaint revisit was completed on 12/17/24 for all previous deficiencies cited on 8/7/24. The residence is in compliance with all regulations surveyed.

A relicensure survey and complaint revisit was completed on 12/17/24 for all previous deficiencies cited on 8/7/24. The residence is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO38442 was completed on 12/17/24. No deficiencies were cited.

A relicensure and complaint revisit was completed on 8/7/24 for the previous deficiencies cited on 12/14/22. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Tag S2110 was not cited in the previous event; however, the deficiency was included in the previous event's informational 9999 tag.

Based on observation, record review, and interview, the residence failed to make a physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population affecting 53 current residents .This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident AgreementThe residence's resident agreement, dated 2/16/24, read in part that the residence provided basic weekly housekeeping services for all residents. 2. Exterior Environmenta. Observations On 8/7/24 at 9:00 a.m., a walk through tour of the courtyard was conducted at the residence; slopes and hazards were identified as follows:The concrete paved pathways of the porch and sidewalks dropped off more than four inches to the garden beds, which posed a fall risk for residents who used this area as there were no barriers or guard rails to prevent a resident from stepping off the ledge. On 08/7/24 from 7:00 a.m. to 1:00 p.m., several residents utilized the courtyard, including Resident #20.b. Interviews On 08/7/24 at 12:49 p.m., the resident care coordinator (RCC) stated that no one had fallen in the courtyard in the three years she had been with the facility. She stated Resident #20 frequently went into the courtyard and had an unsteady gait. On 08/7/24 at 1:53 p.m., the administrator acknowledged that the drop off in the courtyard posed a fall risk for residents who used the areas due to them having an unsteady gait while walking or the use of durable medical equipment that could roll off the side. 3. Interior Environmenta. ObservationsOn 8/6/24 from approximately 7:30 a.m. to 4:00 p.m:The residence housekeeper was not present at the residence and routine cleaning tasks were not completed. The residence hallway by Resident #20 and #22's rooms smelled strongly of urine and body odor. Resident #22's room and bathroom smelled strongly of urine. The common bathroom had a black hair on the side of the toilet along with a dried brown, pinky-sized smudge line on the lower right side of the toilet, near the brim. There were also four small droplets of a yellow-gray substance on the top right portion of the toilet seat. A plate with uneaten food was on the floor outside of Resident #20's room.b. Record ReviewThe residence failed to develop and implement a checklist of housekeeping tasks for staff to follow when housekeeping staff was not available.c. InterviewsOn 8/7/24 at approximately 1:00 p.m., the RCC reported that when the housekeeper called in, staff were expected to take initiative on housekeeping duties; however, the residence did not provide a list of housekeeping tasks that staff were required to complete in the absence of the housekeeper resulting in the staff not completing all housekeeping duties. On 8/7/24 at approximately 1:45 p.m., the administrator reported that housekeeping was not available on 8/6/24 and they completed the missed tasks the next day they came in. The administrator reported that Resident #20 and #22's rooms had an odor of urine which flowed into the hallway due to commonly leaving the room doors open.

Based on observation, record review, and interview, the residence failed to ensure that each resident received proper monitoring of medications for two of the seven sample residents (#8, #21). This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 2.36, defines "medication monitoring" as (A) Reminding the resident to take medication(s) at the time ordered by the authorized practitioner; (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; (D) Making a written record of the resident's compliance with regard to each medication, including the time taken; and (E) Notifying the authorized practitioner if the resident refuses or is unable to comply with the practitioner's instructions regarding the medication. The residence's undated Medication Administration policy read in part that each qualified medication administration person (QMAP) monitored medication administration of each resident for whom the residence administered medications. 2. ObservationDuring medication administration on 8/6/24 at 7:46 a.m, Staff #23 attached a disposable needle on an insulin pen and handed it to Resident #21 who independently dialed insulin to an unknown dosage then administered the injection himself. Staff #23 did not check the dosage dial on the insulin pen to ensure the resident injected the dosage ordered by the resident's practitioner. 3. Record ReviewResident #21 was admitted to the residence on 3/31/23, with a diagnosis of type II diabetes mellitus. A practitioner's order, dated 6/24/24, directed the residence to administer Lantus Solostar 100 unit/mL by injecting 15 units subcutaneously once daily. 4. InterviewsOn 8/6/24 at approximately 10:45 a.m., Resident #21 reported he was independent with checking his own blood glucose levels and dialing the insulin pen to the ordered dosage. On 8/6/24 at approximately 11:00 a.m., Staff #23 reported staff gave the insulin pen to Resident #21 who independently dialed a dosage. Staff #23 reported she counted the number of clicks of the pen to determine whether the resident dialed the correct dosage, but she did not visually check the number after the resident dialed the pen to confirm the accuracy of the dosage prior to Resident #21 administering the injection to himself. On 8/7/24 at approximately 1:15 p.m., the resident care coordinator (RCC) reported they expected staff to check the dialed number on the insulin pen prior to allowing Resident #21 to administer the medication. 5. Additionally, the residence did not ensure that each resident received proper monitoring of medications for Resident #8.

Based on observation, record review, and interview, the residence failed to be responsible for complying with authorized practitioner's orders associated with medication administration, affecting two of seven sample residents (#3 and #21). (Cross-reference S1510)This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence administered medications per the practitioner's order. 2. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of urinary tract infections.a. Cephalexin On 8/7/24 at 11:57 a.m., the residence's medication cart contained a medication bottle with a pharmacy label that directed the residence to administer cephalexin 500 mg three times a day, with a total of 30 pills to Resident #3. The bottle contained four pills that the residence did not administer to the resident. A written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 medication administration record (MAR) for Resident #3 read that the residence failed to administer two doses on 8/1/24 and two doses on 8/3/24, for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. 3. InterviewOn 8/7/24 at 1:19 p.m., the resident care coordinator (RCC) stated that if the residence left cephalexin in the bottle for Resident #3, the residence failed to comply with the practitioner's orders as it had no practitioner's order to discontinue the medication and did not document any resident refusals. She added that the residence should have administered the entire course of medication or documented the refusals, but it did not. 4. Additionally, the residence failed to be responsible for complying with the authorized practitioner's orders associated with medication administration for Resident #21

Based on interview and record review, the residence failed to ensure that the medication administration record (MAR) accurately reflected the frequency of each medication administration and that each qualified medication administration person (QMAP) accurately documented the reason and outcome for each as needed medication at the time the residence administered the medication, affecting two of seven sample residents (#3 and #20). (Cross-reference S1568)This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence staff documented medications accurately on a MAR. The documentation included the name of the medication, the correct dose of the medication, and the correct date and time of administration of the medication. 2. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of atrial fibrillation. a. WarfarinA written practitioner's order, dated 7/31/24, directed the residence to administer warfarin 2.5 mg every Sunday and Wednesday. However, the August 2024 MAR directed the residence staff to administer the warfarin on Sundays and Wednesdays, and contrary to the aforementioned direction the MAR directed the residence to administer the medication on Sundays only b. CephalexinA written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 MAR for Resident #3 read the residence failed to administer two doses on 8/1/24, and two doses on 8/3/24 for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. 3. InterviewOn 8/7/24 at 1:19 p.m., the resident care coordinator (RCC) stated she was responsible for overseeing QMAPs, medication administration, and the MARs. She stated that the the MAR for Resident #3 did not match the practitioner orders. She added that the residence did not ensure the MAR was accurate and reflected the warfarin frequency ordered by the practitioner, including a weekly administration on Wednesdays. She added that she did not ensure the MAR reflected the ordered ten day course of cephalexin instead of a seven day course. She affirmed the MAR was confusing. 4. Additionally, the residence did not ensure the QMAP accurately documented the reason and outcome for each as needed medication at the time the residence administered the medication for Resident #20.

Based on record review, observation, and interview, the residence failed to provide nourishing meal substitutes and between-meal snacks, affecting 53 current residents. This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence AgreementThe residence's resident agreement, dated 2/16/24, read in part that the residence included in the basic service rate: three nutritionally balanced meals per day with snacks, fruit or baked goods available as needed. 2. ObservationOn 8/6/24 from 7:00 a.m. to 4:15 p.m., there were no snacks readily available to residents. On 8/7/24 from 7:30 a.m. to 2:30 p.m. there were no snacks readily available to residents. Snacks were not observed in any of the common areas except in the community room refrigerator. 3. InterviewsOn 8/7/24 at 8:45 a.m., the activities coordinator stated that the residence only gave out snacks once daily at 7:00 p.m. On 8/7/24 at 12:40 p.m. Staff #23 stated that the residents purchased the food in the community refrigerator to share, adding that the residence did not provide readily available snacks for the residents. On 8/7/24 at 1:30 p.m., the resident care coordinator stated that the staff handed out snacks nightly at 7:00 p.m. On 8/7/24 at 1:58 p.m., the administrator stated that other than a daily snack, the residents were required to find staff to ask them for a snack when they wanted one.

A licensure complaint, prompted by #CO35251, was completed on 8/7/24. Deficiencies were cited.

Based on observation, record review, and interview, the residence failed to ensure that each resident received proper monitoring of medications for two of the seven sample residents (#8, #21). Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 2.36, defines "medication monitoring" as (A) Reminding the resident to take medication(s) at the time ordered by the authorized practitioner; (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; (D) Making a written record of the resident's compliance with regard to each medication, including the time taken; and (E) Notifying the authorized practitioner if the resident refuses or is unable to comply with the practitioner's instructions regarding the medication. The residence's undated Medication Administration policy read in part that each qualified medication administration person (QMAP) monitored medication administration of each resident for whom the residence administered medications. 2. ObservationDuring medication administration on 8/6/24 at 7:46 a.m, Staff #23 attached a disposable needle on an insulin pen and handed it to Resident #21 who independently dialed insulin to an unknown dosage then administered the injection himself. Staff #23 did not check the dosage dial on the insulin pen to ensure the resident injected the dosage ordered by the resident's practitioner. 3. Record ReviewResident #21 was admitted to the residence on 3/31/23, with a diagnosis of type II diabetes mellitus. A practitioner's order, dated 6/24/24, directed the residence to administer Lantus Solostar 100 unit/mL by injecting 15 units subcutaneously once daily. 4. InterviewsOn 8/6/24 at approximately 10:45 a.m., Resident #21 reported he was independent with checking his own blood glucose levels and dialing the insulin pen to the ordered dosage. On 8/6/24 at approximately 11:00 a.m., Staff #23 reported staff gave the insulin pen to Resident #21 who independently dialed a dosage. Staff #23 reported she counted the number of clicks of the pen to determine whether the resident dialed the correct dosage, but she did not visually check the number after the resident dialed the pen to confirm the accuracy of the dosage prior to Resident #21 administering the injection to himself. On 8/7/24 at approximately 1:15 p.m., the resident care coordinator (RCC) reported they expected staff to check the dialed number on the insulin pen prior to allowing Resident #21 to administer the medication. 5. Additionally, the residence did not ensure that each resident received proper monitoring of medications for Resident #8.

Based on interview and record review, the residence failed to contact the authorized practitioner to clarify orders that were unclear and obtain new orders in writing for one of the seven sample residents (#18). Resident #18 was admitted to the residence on 7/1/21. A written practitioner's order, dated 6/16/24, directed the residence to administer levothyroxine sodium 175 mcg once a day. However, the July 2024 medication administration order (MAR) read that levothyroxine sodium was discontinued on 7/11/24. No practitioner's order was provided to discontinue this medication. The July 2024 MAR revealed that from 7/22/24 to 7/31/21, the residence administered levothyroxine 150 mcg. The residence did not have a practitioner's order to administer the medication at a different dose. On 8/7/24 at 9:54 a.m., the resident care coordinator (RCC) stated that the residence did not contact the resident's practitioner to clarify which dosage of levothyroxine to administer to Resident #18.

Based on observation, record review, and interview, the residence failed to be responsible for complying with authorized practitioner's orders associated with medication administration, affecting two of seven sample residents (#3 and #21). (Cross-reference S1510)Findings include: 1. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence administered medications per the practitioner's order. 2. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of urinary tract infections.a. Cephalexin On 8/7/24 at 11:57 a.m., the residence's medication cart contained a medication bottle with a pharmacy label that directed the residence to administer cephalexin 500 mg three times a day, with a total of 30 pills to Resident #3. The bottle contained four pills that the residence did not administer to the resident. A written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 medication administration record (MAR) for Resident #3 read that the residence failed to administer two doses on 8/1/24 and two doses on 8/3/24, for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. 3. InterviewOn 8/7/24 at 1:19 p.m., the resident care coordinator (RCC) stated that if the residence left cephalexin in the bottle for Resident #3, the residence failed to comply with the practitioner's orders as it had no practitioner's order to discontinue the medication and did not document any resident refusals. She added that the residence should have administered the entire course of medication or documented the refusals, but it did not. 4. Additionally, the residence failed to be responsible for complying with the authorized practitioner's orders associated with medication administration for Resident #21.

A complaint revisit was completed on 8/7/24 for the previous deficiencies cited on 12/14/22. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Tag S2110 was not cited in the previous event; however, the deficiency was included in the previous event's informational 9999 tag.

Based on observation, record review, and interview, the residence failed to make a physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population affecting 53 current residents .This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident AgreementThe residence's resident agreement, dated 2/16/24, read in part that the residence provided basic weekly housekeeping services for all residents. 2. Exterior Environmenta. Observations On 8/7/24 at 9:00 a.m., a walk through tour of the courtyard was conducted at the residence; slopes and hazards were identified as follows:The concrete paved pathways of the porch and sidewalks dropped off more than four inches to the garden beds, which posed a fall risk for residents who used this area as there were no barriers or guard rails to prevent a resident from stepping off the ledge. On 08/7/24 from 7:00 a.m. to 1:00 p.m., several residents utilized the courtyard, including Resident #20.b. Interviews On 08/7/24 at 12:49 p.m., the resident care coordinator (RCC) stated that no one had fallen in the courtyard in the three years she had been with the facility. She stated Resident #20 frequently went into the courtyard and had an unsteady gait. On 08/7/24 at 1:53 p.m., the administrator acknowledged that the drop off in the courtyard posed a fall risk for residents who used the areas due to them having an unsteady gait while walking or the use of durable medical equipment that could roll off the side. 3. Interior Environmenta. ObservationsOn 8/6/24 from approximately 7:30 a.m. to 4:00 p.m:The residence housekeeper was not present at the residence and routine cleaning tasks were not completed. The residence hallway by Resident #20 and #22's rooms smelled strongly of urine and body odor. Resident #22's room and bathroom smelled strongly of urine. The common bathroom had a black hair on the side of the toilet along with a dried brown, pinky-sized smudge line on the lower right side of the toilet, near the brim. There were also four small droplets of a yellow-gray substance on the top right portion of the toilet seat. A plate with uneaten food was on the floor outside of Resident #20's room.b. Record ReviewThe residence failed to develop and implement a checklist of housekeeping tasks for staff to follow when housekeeping staff was not available.c. InterviewsOn 8/7/24 at approximately 1:00 p.m., the RCC reported that when the housekeeper called in, staff were expected to take initiative on housekeeping duties; however, the residence did not provide a list of housekeeping tasks that staff were required to complete in the absence of the housekeeper resulting in the staff not completing all housekeeping duties. On 8/7/24 at approximately 1:45 p.m., the administrator reported that housekeeping was not available on 8/6/24 and they completed the missed tasks the next day they came in. The administrator reported that Resident #20 and #22's rooms had an odor of urine which flowed into the hallway due to commonly leaving the room doors open.

Based on observation, record review, and interview, the residence failed to ensure that each resident received proper monitoring of medications for two of the seven sample residents (#8, #21). This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 2.36, defines "medication monitoring" as (A) Reminding the resident to take medication(s) at the time ordered by the authorized practitioner; (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; (D) Making a written record of the resident ' s compliance with regard to each medication, including the time taken; and (E) Notifying the authorized practitioner if the resident refuses or is unable to comply with the practitioner ' s instructions regarding the medication. The residence's undated Medication Administration policy read in part that each qualified medication administration person (QMAP) monitored medication administration of each resident for whom the residence administered medications. 2. ObservationDuring medication administration on 8/6/24 at 7:46 a.m, Staff #23 attached a disposable needle on an insulin pen and handed it to Resident #21 who independently dialed insulin to an unknown dosage then administered the injection himself. Staff #23 did not check the dosage dial on the insulin pen to ensure the resident injected the dosage ordered by the resident's practitioner. 3. Record ReviewResident #21 was admitted to the residence on 3/31/23, with a diagnosis of type II diabetes mellitus. A practitioner's order, dated 6/24/24, directed the residence to administer Lantus Solostar 100 unit/mL by injecting 15 units subcutaneously once daily. 4. InterviewsOn 8/6/24 at approximately 10:45 a.m., Resident #21 reported he was independent with checking his own blood glucose levels and dialing the insulin pen to the ordered dosage. On 8/6/24 at approximately 11:00 a.m., Staff #23 reported staff gave the insulin pen to Resident #21 who independently dialed a dosage. Staff #23 reported she counted the number of clicks of the pen to determine whether the resident dialed the correct dosage, but she did not visually check the number after the resident dialed the pen to confirm the accuracy of the dosage prior to Resident #21 administering the injection to himself. On 8/7/24 at approximately 1:15 p.m., the resident care coordinator (RCC) reported they expected staff to check the dialed number on the insulin pen prior to allowing Resident #21 to administer the medication. 5. Additionally, the residence did not ensure that each resident received proper monitoring of medications for Resident #8.

Based on observation, record review, and interview, the residence failed to be responsible for complying with authorized practitioner's orders associated with medication administration, affecting two of seven sample residents (#3 and #21). (Cross-reference S1510)This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence administered medications per the practitioner's order. 2. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of urinary tract infections.a. Cephalexin On 8/7/24 at 11:57 a.m., the residence's medication cart contained a medication bottle with a pharmacy label that directed the residence to administer cephalexin 500 mg three times a day, with a total of 30 pills to Resident #3. The bottle contained four pills that the residence did not administer to the resident. A written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 medication administration record (MAR) for Resident #3 read that the residence failed to administer two doses on 8/1/24 and two doses on 8/3/24, for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. 3. InterviewOn 8/7/24 at 1:19 p.m., the resident care coordinator (RCC) stated that if the residence left cephalexin in the bottle for Resident #3, the residence failed to comply with the practitioner's orders as it had no practitioner's order to discontinue the medication and did not document any resident refusals. She added that the residence should have administered the entire course of medication or documented the refusals, but it did not. 4. Additionally, the residence failed to be responsible for complying with the authorized practitioner's orders associated with medication administration for Resident #21.

Based on interview and record review, the residence failed to ensure that the medication administration record (MAR) accurately reflected the frequency of each medication administration and that each qualified medication administration person (QMAP) accurately documented the reason and outcome for each as needed medication at the time the residence administered the medication, affecting two of seven sample residents (#3 and #20). (Cross-reference S1568)This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence staff documented medications accurately on a MAR. The documentation included the name of the medication, the correct dose of the medication, and the correct date and time of administration of the medication. 2. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of atrial fibrillation. a. WarfarinA written practitioner's order, dated 7/31/24, directed the residence to administer warfarin 2.5 mg every Sunday and Wednesday. However, the August 2024 MAR directed the residence staff to administer the warfarin on Sundays and Wednesdays, and contrary to the aforementioned direction the MAR directed the residence to administer the medication on Sundays only b. CephalexinA written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 MAR for Resident #3 read the residence failed to administer two doses on 8/1/24, and two doses on 8/3/24 for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. 3. InterviewOn 8/7/24 at 1:19 p.m., the resident care coordinator (RCC) stated she was responsible for overseeing QMAPs, medication administration, and the MARs. She stated that the the MAR for Resident #3 did not match the practitioner orders. She added that the residence did not ensure the MAR was accurate and reflected the warfarin frequency ordered by the practitioner, including a weekly administration on Wednesdays. She added that she did not ensure the MAR reflected the ordered ten day course of cephalexin instead of a seven day course. She affirmed the MAR was confusing. 4. Additionally, the residence did not ensure the QMAP accurately documented the reason and outcome for each as needed medication at the time the residence administered the medication for Resident #20.

Based on record review, observation, and interview, the residence failed to provide nourishing meal substitutes and between-meal snacks, affecting 53 current residents. This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Residence AgreementThe residence's resident agreement, dated 2/16/24, read in part that the residence included in the basic service rate: three nutritionally balanced meals per day with snacks, fruit or baked goods available as needed. 2. ObservationOn 8/6/24 from 7:00 a.m. to 4:15 p.m., there were no snacks readily available to residents. On 8/7/24 from 7:30 a.m. to 2:30 p.m. there were no snacks readily available to residents. Snacks were not observed in any of the common areas except in the community room refrigerator. 3. InterviewsOn 8/7/24 at 8:45 a.m., the activities coordinator stated that the residence only gave out snacks once daily at 7:00 p.m. On 8/7/24 at 12:40 p.m. Staff #23 stated that the residents purchased the food in the community refrigerator to share, adding that the residence did not provide readily available snacks for the residents. On 8/7/24 at 1:30 p.m., the resident care coordinator stated that the staff handed out snacks nightly at 7:00 p.m. On 8/7/24 at 1:58 p.m., the administrator stated that other than a daily snack, the residents were required to find staff to ask them for a snack when they wanted one.

A complaint revisit was completed on 8/7/24 for the previous deficiencies cited on 12/14/22. A deficiency was cited. The regulations governing Alternative Care Facilities were revised and the new regulations were implemented on 11/15/23.

Based on observation, interview, and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting four of five sample participants (residents) (#3, #8, #18, #20) and one former resident (#21). This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Chapter VII regulations governing assisted living residences, part 14.20, requires that 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.a. Resident #18 was admitted to the residence on 7/1/21. A written practitioner's order, dated 6/16/24, directed the residence to administer levothyroxine sodium 175 mcg once daily. However, the July 2024 medication administration order (MAR) read that levothyroxine sodium was discontinued on 7/11/24. No practitioner's order was provided to discontinue this medication. The July 2024 MAR revealed that from 7/22/24 to 7/31/21, the residence administered levothyroxine 150 mcg. The residence did not have a practitioner's order to administer the medication at a different dose.b. InterviewOn 8/7/24 at 9:54 a.m., the resident care coordinator (RCC) stated that the residence did not contact the resident's practitioner to clarify which dosage of levothyroxine to administer to Resident #18.2. Chapter VII regulations governing assisted living residences, part 14.28, requires that the assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. On 8/6/24 at 7:40 a.m., while Staff #24 administered medication to Resident #18; a liquid medication spilled, and Staff #24 left to grab a napkin to clean the medication, then allowed Resident #18 to spit the oral rinse medication back into the cup and dispose of it. Staff #24 then removed gloves and updated the MAR, touching the computer keyboard, grabbed her phone and went to an office to fill out the missed medication form. At 7:46 a.m., Staff #24 filled out a missed medication alert form touching a pen, the other documents in the room, and her cell phone. She sent the form to the practitioner, touching the form, fax machine, and the buttons on the machine. She left the room and realized she left her phone on the table and went back to retrieve it and went back to the medication cart at 7:50 a.m. Without sanitizing or washing her hands, she separated the medication cups on top of the medication cart, placing her middle finger inside each cup. After counting the eight cups, Staff #24 used fingers on both of her hands touching the tops of each medication cup to restack them. Staff #24 did not sanitize her hands again until approximately 7:52 a.m. 3. Chapter VII regulations governing assisted living residences, part 14.29, requires that 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.(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.a. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence administered medications per the practitioner's order. b. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of urinary tract infections. Cephalexin On 8/7/24 at 11:57 a.m., the residence's medication cart contained a medication bottle with a pharmacy label that directed the residence to administer cephalexin 500 mg three times a day, with a total of 30 pills to Resident #3. The bottle contained four pills that the residence did not administer to the resident. A written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 medication administration record (MAR) for Resident #3 read that the residence failed to administer two doses on 8/1/24 and two doses on 8/3/24, for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. c. InterviewOn 8/7/24 at 1:19 p.m., the RCC stated that if the residence left cephalexin in the bottle for Resident #3, the residence failed to comply with the practitioner's orders as it had no practitioner's order to discontinue the medication and did not document any resident refusals. She added that the residence should have administered the entire course of medication or documented the refusals, but it did not. d. Additionally, the residence failed to be responsible for complying with the authorized practitioner's orders associated with medication administration for Resident #21.4. Chapter VII regulations governing assisted living residences, part 14.21, requires that 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.a. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence staff documented medications accurately on aMAR. The documentation included the name of the medication, the correct dose of the medication, and the correct date and time of administration of the medication. b. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of atrial fibrillation. WarfarinA written practitioner's order, dated 7/31/24, directed the residence to administer warfarin 2.5 mg every Sunday and Wednesday. However, the August 2024 MAR directed the residence staff to administer the warfarin on Sundays and Wednesdays, and contrary to the aforementioned direction the MAR directed the residence to administer the medication on Sundays only. CephalexinA written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 MAR for Resident #3 read the residence failed to administer two doses on 8/1/24, and two doses on 8/3/24 for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. c. InterviewOn 8/7/24 at 1:19 p.m., the RCC stated she was responsible for overseeing QMAPs, medication administration, and the MARs. She stated that the the MAR for Resident #3 did not match the practitioner orders. She added that the residence did not ensure the MAR was accurate and reflected the warfarin frequency ordered by the practitioner, including a weekly administration on Wednesdays. She added that she did not ensure the MAR reflected the ordered ten day course of cephalexin instead of a seven day course. She affirmed the MAR was confusing. d. Additionally, the residence did not ensure the QMAP accurately documented the reason and outcome for each as needed medication at the time the residence administered the medication for Resident #20.5. Chapter VII regulations governing assisted living residences, part 14.7, requires residences to ensure that each resident receives proper administration and/or monitoring of medications.a. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 2.36, defines "medication monitoring" as (A) Reminding the resident to take medication(s) at the time ordered by the authorized practitioner; (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; (D) Making a written record of the resident's compliance with regard to each medication, including the time taken; and (E) Notifying the authorized practitioner if the resident refuses or is unable to comply with the practitioner's instructions regarding the medication. The residence's undated Medication Administration policy read in part that each qualified medication administration person (QMAP) monitored medication administration of each resident for whom the residence administered medications.b. ObservationDuring medication administration on 8/6/24 at 7:46 a.m, Staff #23 attached a disposable needle on an insulin pen and handed it to Resident #21 who independently dialed insulin to an unknown dosage then administered the injection himself. Staff #23 did not check the dosage dial on the insulin pen to ensure the resident injected the dosage ordered by the resident's practitioner.c. Record ReviewResident #21 was admitted to the residence on 3/31/23, with a diagnosis of type II diabetes mellitus. A practitioner's order, dated 6/24/24, directed the residence to administer Lantus Solostar 100 unit/mL by injecting 15 units subcutaneously once daily.d. InterviewsOn 8/6/24 at approximately 10:45 a.m., Resident #21 reported he was independent with checking his own blood glucose levels and dialing the insulin pen to the ordered dosage. On 8/6/24 at approximately 11:00 a.m., Staff #23 reported staff gave the insulin pen to Resident #21 who independently dialed a dosage. Staff #23 reported she counted the number of clicks of the pen to determine whether the resident dialed the correct dosage, but she did not visually check the number after the resident dialed the pen to confirm the accuracy of the dosage prior to Resident #23 administering the injection to himself. On 8/7/24 at approximately 1:15 p.m., the RCC reported they expected staff to check the dialed number on the insulin pen prior to allowing Resident #21 to administer the medication.e. Additionally, the residence did not ensure that each resident received proper monitoring of medications for Resident #8.

A recertification and complaint revisit was completed on 8/7/24 for the previous deficiencies cited on 12/14/22. A deficiency was cited. The regulations governing Alternative Care Facilities were revised and the new regulations were implemented on 11/15/23.

Based on observation, interview, and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting four of five sample participants (residents) (#3, #8, #18, #20) and one former resident (#21). This deficiency was cited previously during a state license survey on 12/14/2022. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Chapter VII regulations governing assisted living residences, part 14.20, requires that 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.a. Resident #18 was admitted to the residence on 7/1/21. A written practitioner's order, dated 6/16/24, directed the residence to administer levothyroxine sodium 175 mcg once daily. However, the July 2024 medication administration order (MAR) read that levothyroxine sodium was discontinued on 7/11/24. No practitioner's order was provided to discontinue this medication. The July 2024 MAR revealed that from 7/22/24 to 7/31/21, the residence administered levothyroxine 150 mcg. The residence did not have a practitioner's order to administer the medication at a different dose.b. InterviewOn 8/7/24 at 9:54 a.m., the resident care coordinator (RCC) stated that the residence did not contact the resident's practitioner to clarify which dosage of levothyroxine to administer to Resident #18.2. Chapter VII regulations governing assisted living residences, part 14.28, requires that the assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. On 8/6/24 at 7:40 a.m., while Staff #24 administered medication to Resident #18; a liquid medication spilled, and Staff #24 left to grab a napkin to clean the medication, then allowed Resident #18 to spit the oral rinse medication back into the cup and dispose of it. Staff #24 then removed gloves and updated the MAR, touching the computer keyboard, grabbed her phone and went to an office to fill out the missed medication form. At 7:46 a.m., Staff #24 filled out a missed medication alert form touching a pen, the other documents in the room, and her cell phone. She sent the form to the practitioner, touching the form, fax machine, and the buttons on the machine. She left the room and realized she left her phone on the table and went back to retrieve it and went back to the medication cart at 7:50 a.m. Without sanitizing or washing her hands, she separated the medication cups on top of the medication cart, placing her middle finger inside each cup. After counting the eight cups, Staff #24 used fingers on both of her hands touching the tops of each medication cup to restack them. Staff #24 did not sanitize her hands again until approximately 7:52 a.m. 3. Chapter VII regulations governing assisted living residences, part 14.29, requires that 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.(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.a. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence administered medications per the practitioner's order. b. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of urinary tract infections. Cephalexin On 8/7/24 at 11:57 a.m., the residence's medication cart contained a medication bottle with a pharmacy label that directed the residence to administer cephalexin 500 mg three times a day, with a total of 30 pills to Resident #3. The bottle contained four pills that the residence did not administer to the resident. A written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 medication administration record (MAR) for Resident #3 read that the residence failed to administer two doses on 8/1/24 and two doses on 8/3/24, for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. c. InterviewOn 8/7/24 at 1:19 p.m., the RCC stated that if the residence left cephalexin in the bottle for Resident #3, the residence failed to comply with the practitioner's orders as it had no practitioner's order to discontinue the medication and did not document any resident refusals. She added that the residence should have administered the entire course of medication or documented the refusals, but it did not. d. Additionally, the residence failed to be responsible for complying with the authorized practitioner's orders associated with medication administration for Resident #21.4. Chapter VII regulations governing assisted living residences, part 14.21, requires that 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.a. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence staff documented medications accurately on aMAR. The documentation included the name of the medication, the correct dose of the medication, and the correct date and time of administration of the medication. b. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of atrial fibrillation. WarfarinA written practitioner's order, dated 7/31/24, directed the residence to administer warfarin 2.5 mg every Sunday and Wednesday. However, the August 2024 MAR directed the residence staff to administer the warfarin on Sundays and Wednesdays, and contrary to the aforementioned direction the MAR directed the residence to administer the medication on Sundays only. CephalexinA written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 MAR for Resident #3 read the residence failed to administer two doses on 8/1/24, and two doses on 8/3/24 for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. c. InterviewOn 8/7/24 at 1:19 p.m., the RCC stated she was responsible for overseeing QMAPs, medication administration, and the MARs. She stated that the the MAR for Resident #3 did not match the practitioner orders. She added that the residence did not ensure the MAR was accurate and reflected the warfarin frequency ordered by the practitioner, including a weekly administration on Wednesdays. She added that she did not ensure the MAR reflected the ordered ten day course of cephalexin instead of a seven day course. She affirmed the MAR was confusing. d. Additionally, the residence did not ensure the QMAP accurately documented the reason and outcome for each as needed medication at the time the residence administered the medication for Resident #20. 5. Chapter VII regulations governing assisted living residences, part 14.7, requires residences to ensure that each resident receives proper administration and/or monitoring of medications.a. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 2.36, defines "medication monitoring" as (A) Reminding the resident to take medication(s) at the time ordered by the authorized practitioner; (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; (D) Making a written record of the resident's compliance with regard to each medication, including the time taken; and (E) Notifying the authorized practitioner if the resident refuses or is unable to comply with the practitioner's instructions regarding the medication. The residence's undated Medication Administration policy read in part that each qualified medication administration person (QMAP) monitored medication administration of each resident for whom the residence administered medications.b. ObservationDuring medication administration on 8/6/24 at 7:46 a.m, Staff #23 attached a disposable needle on an insulin pen and handed it to Resident #21 who independently dialed insulin to an unknown dosage then administered the injection himself. Staff #23 did not check the dosage dial on the insulin pen to ensure the resident injected the dosage ordered by the resident's practitioner.c. Record ReviewResident #21 was admitted to the residence on 3/31/23, with a diagnosis of type II diabetes mellitus. A practitioner's order, dated 6/24/24, directed the residence to administer Lantus Solostar 100 unit/mL by injecting 15 units subcutaneously once daily.d. InterviewsOn 8/6/24 at approximately 10:45 a.m., Resident #21 reported he was independent with checking his own blood glucose levels and dialing the insulin pen to the ordered dosage. On 8/6/24 at approximately 11:00 a.m., Staff #23 reported staff gave the insulin pen to Resident #21 who independently dialed a dosage. Staff #23 reported she counted the number of clicks of the pen to determine whether the resident dialed the correct dosage, but she did not visually check the number after the resident dialed the pen to confirm the accuracy of the dosage prior to Resident #23 administering the injection to himself. On 8/7/24 at approximately 1:15 p.m., the RCC reported they expected staff to check the dialed number on the insulin pen prior to allowing Resident #21 to administer the medication.e. Additionally, the residence did not ensure that each resident received proper monitoring of medications for Resident #8.

A certification complaint, prompted by #CO35252, was completed on 8/7/24. A deficiency was cited.

Based on observation, interview, and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting four of five sample participants (residents) (#3, #8, #18, #20) and one former resident (#21). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.20, requires that 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.a. Resident #18 was admitted to the residence on 7/1/21. A written practitioner's order, dated 6/16/24, directed the residence to administer levothyroxine sodium 175 mcg once daily. However, the July 2024 medication administration order (MAR) read that levothyroxine sodium was discontinued on 7/11/24. No practitioner's order was provided to discontinue this medication. The July 2024 MAR revealed that from 7/22/24 to 7/31/21, the residence administered levothyroxine 150 mcg. The residence did not have a practitioner's order to administer the medication at a different dose.b. InterviewOn 8/7/24 at 9:54 a.m., the resident care coordinator (RCC) stated that the residence did not contact the resident's practitioner to clarify which dosage of levothyroxine to administer to Resident #18.2. Chapter VII regulations governing assisted living residences, part 14.28, requires that the assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. On 8/6/24 at 7:40 a.m., while Staff #24 administered medication to Resident #18; a liquid medication spilled, and Staff #24 left to grab a napkin to clean the medication, then allowed Resident #18 to spit the oral rinse medication back into the cup and dispose of it. Staff #24 then removed gloves and updated the MAR, touching the computer keyboard, grabbed her phone and went to an office to fill out the missed medication form. At 7:46 a.m., Staff #24 filled out a missed medication alert form touching a pen, the other documents in the room, and her cell phone. She sent the form to the practitioner, touching the form, fax machine, and the buttons on the machine. She left the room and realized she left her phone on the table and went back to retrieve it. and went back to the medication cart at 7:50 a.m. Without sanitizing or washing her hands, she separated the medication cups on top of the medication cart, placing her middle finger inside each cup. After counting the eight cups, Staff #24 used fingers on both of her hands touching the tops of each medication cup to restack them. Staff #24 did not sanitize her hands again until approximately 7:52 a.m. 3. Chapter VII regulations governing assisted living residences, part 14.29, requires that 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.(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.a. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence administered medications per the practitioner's order. b. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of urinary tract infections. Cephalexin On 8/7/24 at 11:57 a.m., the residence's medication cart contained a medication bottle with a pharmacy label that directed the residence to administer cephalexin 500 mg three times a day, with a total of 30 pills to Resident #3. The bottle contained four pills that the residence did not administer to the resident. A written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 medication administration record (MAR) for Resident #3 read that the residence failed to administer two doses on 8/1/24 and two doses on 8/3/24, for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. c. InterviewOn 8/7/24 at 1:19 p.m., the RCC stated that if the residence left cephalexin in the bottle for Resident #3, the residence failed to comply with the practitioner's orders as it had no practitioner's order to discontinue the medication and did not document any resident refusals. She added that the residence should have administered the entire course of medication or documented the refusals, but it did not. d. Additionally, the residence failed to be responsible for complying with the authorized practitioner's orders associated with medication administration for Resident #21.4. Chapter VII regulations governing assisted living residences, part 14.21, requires that 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.a. Residence PolicyThe residence's undated Medication Administration policy read in part that the residence staff documented medications accurately on a MAR. The documentation included the name of the medication, the correct dose of the medication, and the correct date and time of administration of the medication. b. Resident #3 was admitted to the residence on 4/20/15 with a diagnosis of atrial fibrillation. WarfarinA written practitioner's order, dated 7/31/24, directed the residence to administer warfarin 2.5 mg every Sunday and Wednesday. However, the August 2024 MAR directed the residence staff to administer the warfarin on Sundays and Wednesdays, and contrary to the aforementioned direction the MAR directed the residence to administer the medication on Sundays only. CephalexinA written practitioner's order, dated 7/25/24, directed the residence to administer cephalexin 500 mg three times daily for ten days. However, the August 2024 MAR for Resident #3 read the residence failed to administer two doses on 8/1/24, and two doses on 8/3/24 for a total of four missed doses. Further, the August MAR directed the residence staff to administer the medication for seven days. c. InterviewOn 8/7/24 at 1:19 p.m., the RCC stated she was responsible for overseeing QMAPs, medication administration, and the MARs. She stated that the the MAR for Resident #3 did not match the practitioner orders. She added that the residence did not ensure the MAR was accurate and reflected the warfarin frequency ordered by the practitioner, including a weekly administration on Wednesdays. She added that she did not ensure the MAR reflected the ordered ten day course of cephalexin instead of a seven day course. She affirmed the MAR was confusing. d. Additionally, the residence did not ensure the QMAP accurately documented the reason and outcome for each as needed medication at the time the residence administered the medication for Resident #20.5. Chapter VII regulations governing assisted living residences, part 14.7, requires residences to ensure that each resident receives proper administration and/or monitoring of medications.a. Reference and Residence PolicyChapter VII regulations governing assisted living residences, part 2.36, defines "medication monitoring" as (A) Reminding the resident to take medication(s) at the time ordered by the authorized practitioner; (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; (D) Making a written record of the resident ' s compliance with regard to each medication, including the time taken; and (E) Notifying the authorized practitioner if the resident refuses or is unable to comply with the practitioner ' s instructions regarding the medication. The residence's undated Medication Administration policy read in part that each qualified medication administration person (QMAP) monitored medication administration of each resident for whom the residence administered medications.b. ObservationDuring medication administration on 8/6/24 at 7:46 a.m, Staff #23 attached a disposable needle on an insulin pen and handed it to Resident #21 who independently dialed insulin to an unknown dosage then administered the injection himself. Staff #23 did not check the dosage dial on the insulin pen to ensure the resident injected the dosage ordered by the resident's practitioner.c. Record ReviewResident #21 was admitted to the residence on 3/31/23, with a diagnosis of type II diabetes mellitus. A practitioner's order, dated 6/24/24, directed the residence to administer Lantus Solostar 100 unit/mL by injecting 15 units subcutaneously once daily.d. InterviewsOn 8/6/24 at approximately 10:45 a.m., Resident #21 reported he was independent with checking his own blood glucose levels and dialing the insulin pen to the ordered dosage. On 8/6/24 at approximately 11:00 a.m., Staff #23 reported staff gave the insulin pen to Resident #21 who independently dialed a dosage. Staff #23 reported she counted the number of clicks of the pen to determine whether the resident dialed the correct dosage, but she did not visually check the number after the resident dialed the pen to confirm the accuracy of the dosage prior to Resident #23 administering the injection to himself. On 8/7/24 at approximately 1:15 p.m., the RCC reported they expected staff to check the dialed number on the insulin pen prior to allowing Resident #21 to administer the medication.e. Additionally, the residence did not ensure that each resident received proper monitoring of medications for Resident #8.