SPRUCE HOUSE

An administrative relicensure survey was completed on 3/11/26. No deficiencies were cited.

A certification complaint, prompted by #CO34254 was completed on 12/11/24. No deficiencies were cited.

A licensure complaint, prompted by #CO34253 was completed on 12/11/24. No deficiencies were cited.

/A revisit survey was completed on 12/7/23 for all previous deficiencies cited on 10/25/23. No deficiencies were cited.

/A revisit survey was completed on 12/7/23 for all previous deficiencies cited on 10/25/23. No deficiencies were cited.

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

A recertification survey was completed on 10/25/23. 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 three of three sample participants (residents) (#1-#3). Findings include:1. Chapter VII regulations governing assisted living residents, part 14.29, requires 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. (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. The residence's Medication Error policy, dated 5/15/19, read in part: "a documentation error is any documentation that occurs that does not accurately reflect the medication administration that was performed ... documentation errors will be handled differently and as follows ... documentation error one and two ... a medication administration error report form will be filled out and submitted to (the residence's) management ... six documentation errors ... the employee will not be allowed to administer medications until ... (management) meets to supervise their medication administration."a. Resident #1 was admitted to the residence on 5/20/22. Atorvastatin A written practitioner's order, dated 9/1/23, directed the residence to administer atorvastatin 20 mg daily. However, the September 2023 electronic medication administration record (eMAR) revealed blanks on 9/5 and 9/14/23. Additionally, on 9/4/23, the eMAR was marked under "missed/refused," by Staff #1, and there were no corresponding eMAR documentation notes to determine whether the medication was not administered or was refused by Resident #1. QuetiapineA written practitioner's order, dated 3/25/23, directed the residence to administer quetiapine 100 mg twice daily. However, the September 2023 eMAR revealed a blank on 9/14/23 in the evening. TrazodoneA written practitioner's order, dated 3/25/23, directed the residence to administer trazodone 50 mg once daily at bedtime. However, the September 2023 eMAR revealed a blank on 9/14/23. MetforminA written practitioner's order, dated 3/25/23, directed the residence to administer metformin 1000 mg once daily. However, the September 2023 eMAR revealed a blank on 9/14/23 in the evening. AspirinA written practitioner's order, dated 3/25/23, directed the residence to administer aspirin 81 mg daily. However, the September 2023 eMAR revealed a blank on 9/14/23. MelatoninA written practitioner's order, dated 3/25/23, directed the residence to administer melatonin 3 mg once daily at bedtime. However, the September 2023 eMAR revealed a blank on 9/14/23. Omega 3 A written practitioner's order, dated 9/2/23, directed the residence to administer omega 3 1000 mg once daily. However, the October 2023 eMAR revealed a blank on 10/8/23. On 10/25/23 at 12:01 p.m., the administrator stated blank spaces on the eMAR meant that a QMAP failed to document whether a medication was administered. She stated she expected the QMAP to document whether Resident #1's medications were administered on the days there were blank spaces. The administrator further acknowledged she expected Staff #1 to make note in the eMAR for Resident #1's atorvastatin that was marked as "missed/refused" so it could be determined whether the medication was not administered or was refused. The administrator stated the residence received Resident #1's omega 3 order in early September 2023 and the medication had never been administered. The administrator acknowledged there was a blank space on 10/8/23 and stated the staff member on shift should have documented that the medication was unavailable. b. Resident #2 was admitted to the residence on 5/1/22. TerazosinA written practitioner's order, dated 6/22/23, directed the residence to administer terazosin 5 mg once daily at bedtime. However, the October 2023 eMAR revealed a blank on 10/23/23. On 10/25/23 at 12:01 p.m., the administrator stated she expected QMAPs to document each medication at the time administration was completed. The administrator further stated that for 10/23/23 the medication cart pill package showed that the medication was removed. She stated that there was a blank space on 10/23/23 since the QMAP failed to document that the medication was administered.c. InterviewOn 10/25/23 at 12:01 p.m., the administrator stated she expected all eMARs to be documented accurately and contain corresponding documentation notes if the medication was missed or refused. The administrator stated that blank spaces and failure to make a note whether a medication was missed or refused was a documentation error and should have been caught and addressed in accordance with their policy. The administrator stated the reason she was unaware of the above documentation errors was because the residence had not yet completed their quarterly medication review. 2. Chapter VII regulations governing assisted living residents, 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 Medication Error policy, dated 5/15/19, read in part: "a documentation error is any documentation that occurs that does not accurately reflect the medication administration that was performed ... documentation errors will be handled differently and as follows ... documentation error one and two ... a medication administration error report form will be filled out and submitted to (the residence's) management ... six documentation errors ... the employee will not be allowed to administer medications until ... (management) meets to supervise their medication administration."b. Resident #1 was admitted to the residence on 5/20/22. Atorvastatin A written practitioner's order, dated 9/1/23, directed the residence to administer atorvastatin 20 mg daily. However, the September 2023 electronic medication administration record (eMAR) revealed blanks on 9/5 and 9/14/23. Additionally, on 9/4/23, the eMAR was marked under "missed/refused," by Staff #1, and there were no corresponding eMAR documentation notes to determine whether the medication was not administered or was refused by Resident #1. QuetiapineA written practitioner's order, dated 3/25/23, directed the residence to administer quetiapine 100 mg twice daily. However, the September 2023 eMAR revealed a blank on 9/14/23 in the evening. TrazodoneA written practitioner's order, dated 3/25/23, directed the residence to administer trazodone 50 mg once daily at bedtime. However, the September 2023 eMAR revealed a blank on 9/14/23. MetforminA written practitioner's order, dated 3/25/23, directed the residence to administer metformin 1000 mg once daily. However, the September 2023 eMAR revealed a blank on 9/14/23 in the evening. AspirinA written practitioner's order, dated 3/25/23, directed the residence to administer aspirin 81 mg daily. However, the September 2023 eMAR revealed a blank on 9/14/23. MelatoninA written practitioner's order, dated 3/25/23, directed the residence to administer melatonin 3 mg once daily at bedtime. However, the September 2023 eMAR revealed a blank on 9/14/23. Omega 3 A written practitioner's order, dated 9/2/23, directed the residence to administer omega 3 1000 mg once daily. However, the October 2023 eMAR revealed a blank on 10/8/23. On 10/25/23 at 12:01 p.m., the administrator stated blank spaces on the eMAR meant that a QMAP failed to document whether a medication was administered. She stated she expected the QMAP to document whether Resident #1's medications were administered on the days there were blank spaces. The administrator further acknowledged she expected Staff #1 to make note in the eMAR for Resident #1's atorvastatin that was marked as "missed/refused" so it could be determined whether the medication was not administered or was refused. The administrator stated the residence received Resident #1's omega 3 order in early September 2023 and the medication had never been administered. The administrator acknowledged there was a blank space on 10/8/23 and stated the staff member on shift should have documented that the medication was unavailable. c. Resident #2 was admitted to the residence on 5/1/22. TerazosinA written practitioner's order, dated 6/22/23, directed the residence to administer terazosin 5 mg once daily at bedtime. However, the October 2023 eMAR revealed a blank on 10/23/23. On 10/25/23 at 12:01 p.m., the administrator stated she expected QMAPs to document each medication at the time administration was completed. The administrator further stated that for 10/23/23 the medication cart pill package showed that the medication was removed. She stated that there was a blank space on 10/23/23 since the QMAP failed to document that the medication was administered.d. InterviewOn 10/25/23 at 12:01 p.m., the administrator stated she expected all eMARs to be documented accurately and contain corresponding documentation notes if the medication was missed or refused. The administrator stated that blank spaces and failure to make a note whether a medication was missed or refused was a documentation error and should have been caught and addressed in accordance with their policy. The administrator stated the reason she was unaware of the above documentation errors was because the residence had not yet completed their quarterly medication review. 3. Chapter VII regulations governing assisted living residences, part 14.11, requires only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. The residence's Medication Administration policy, dated 10/5/22, read that all orders must be written by a licensed practitioner for the purpose of medication administration. Resident #3 was admitted to the residence on 2/23/21. On 10/25/23 at approximately 8:40 a.m., the full resident record and October 2023 eMARs with corresponding orders were requested for Resident #3. However, the resident record provided did not include orders for Resident #3's olanzapine and multivitamin or Resident #3's gabapentin dated prior to 10/5/23, or fluoxetine 20 mg once daily. OlanzapineThe October 2023 eMAR read olanzapine 5 mg was administered 10/1-10/8 and 10/10-10/24/23. However, there was no written practitioner's order provided. MultivitaminThe October 2023 eMAR read multivitamin mineral was administered 10/1-10/8, 10/10-10/22, 10/24 and 10/25/23. However, there was no written practitioner's order provided. GabapentinThe October 2023 eMAR read gabapentin 400 mg three times daily, was administered 10/1-10/4/23. However, there was no written practitioner's order provided. FluoxetineThe October 2023 eMAR read fluoxetine 20 mg one capsule daily, was administered 10/1-10/6/23. However, there was no written practitioner's order provided. On 10/25/23 at 12:22 p.m., the administrator stated she provided all the orders she had for Resident #3. The administrator stated Resident #3's family member transported Resident #3 to his practitioner appointments and there were issues obtaining orders from the family member for Resident #3's medications. The administrator stated she would expect the residence to have all signed practitioner's orders prior to administering medications to Resident #3 and was aware of the requirement. 4. Chapter VII regulations governing assisted living residences, part 14.12, requires all qualified medication administration persons (QMAPs) adhere to medication administration procedures that included identification of the right resident for each medication administration, by asking for the resident's name or comparing the resident to a photograph maintained specifically for medication administration identification. The residence's Medication Administration policy, dated 4/21/23 read in part: "(the residence) will ensure that (QMAPs) are trained in and adhere to the following medication administration procedures: identification of the right resident for each medication administration or monitoring by asking for the resident's name or comparing the resident to a photograph maintained specifically for medication administration identification."a. Resident #1 was admitted to the residence on 5/20/22 with a diagnosis of a traumatic brain injury. A written practitioner's order, dated 8/6/23, directed the residence to administer levothyroxine 0.2 mg daily. The September 2023 eMAR contained a note authored by Staff #4 that read on 9/30/23, Resident #1's "medication (levothyroxine) was given to a different participant. The MOC (manager on call) and oncoming notified. An additional part of the note authored by former Staff #5, read in part: "administered with 8:00 a.m. meds, due to med error."b. Resident #2 was admitted to the residence on 5/1/22 with a diagnosis of a traumatic brain injury. Review of Resident #2's September 2023 eMAR and orders revealed Resident #2 was not prescribed levothyroxine. An incident report, dated 9/30/23, read that at 7:00 a.m., Contracted Staff #4 prepared levothyroxine for Resident #1, confused the two residents and administered the medication to Resident #2 by mistake. Contracted Staff #4 realized the mistake, called the lead QMAP who was the manager on call and reported it. The lead QMAP contacted Resident #2's practitioner and was advised by the practitioner to monitor Resident #2 throughout the day. No medical attention was required and Resident #2 experienced no side effects to being administered Resident #1's medication. A lead QMAP report, authored by the lead QMAP and dated 9/30/23, read Contracted Staff #4 administered another resident's medication to the wrong resident. A follow-up incident report note, authored by assistant director #1 (AD #1) and dated 10/2/23, read that former Staff #5 was advised to monitor Resident #2 throughout the day on 9/30/23. Resident #2 suffered no effects and remained at baseline. Contracted Staff #4 was a new staff member and would be retrained on proper medication administration. Staff #4 was advised to properly identify the resident prior to administering medications. On 10/25/23 at 11:48 a.m., the administrator stated Resident #2 was administered Resident #1's levothyroxine on 9/30/23 by Contracted Staff #4 upon shift change at 7:00 a.m. The administrator stated Former Staff #5 administered Resident #1's levothyroxine for the following day when she came on shift at 8:00 a.m. to make sure Resident #1 did not go without his levothyroxine due to the medication error. The administrator stated the lead QMAP who was the manager on-call and the practitioner were notified, and the practitioner for Resident #2 advised to monitor the resident throughout the day. The administrator stated Resident #2 had experienced no negative side effects and Contracted Staff #4 was re-trained on properly identifying residents through either verification of their name, a photograph, or a resident roster with room locations. On 10/25/23 at 12:10 p.m., the lead QMAP stated on the phone with AD #2 that retraining for Contracted Staff #4 was completed by AD #1, and Resident #2's practitioner advised that Resident #2 be monitored throughout the day on 9/30/23. The lead QMAP further stated Resident #2 experienced no negative side effects. The lead QMAP stated Resident #1 was administered his levothyroxine at 8:00 a.m. instead of 7:00 a.m. when the medication error occurred. On 10/25/23 at 12:22 p.m., the administrator acknowledged she expected Contracted Staff #4 to ensure they used one personal identifier such as verification of the resident's name prior to administering medication to ensure the correct dose of medication was administered to the right resident.

A relicensure survey was completed on 10/25/23. Deficiences were cited.

Based on observation, record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of three sample residents (#1) who was not administered two medications from one to two months. Findings include:1. Residence PolicyThe residence's Medication Administration policy, dated 10/2/19, read in part: "(The residence) strives to ensure that participant (resident) medications are ordered and received accurately ... the assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration."2. ObservationOn 10/25/23 at 8:06 a.m., Staff #1 was unable to locate the omega 3 medication for Resident #1 and had not administered the medication. 3. Resident #1 was admitted to the residence on 5/20/22 with a diagnosis of mixed hyperlipidemia. Omega 3 capsuleA written practitioner's order, dated 9/2/23, directed the residence to administer omega 3 1000 mg once daily. However, the September and October 2023 electronic medication administration records (eMARs), read omega 3 was unavailable and was not administered on 9/4-10/7 and 10/9-10/25/23, for a total of 52 missed doses. FenofibrateA written practitioner's order, dated 9/1/23, directed the residence to administer fenofibrate 40 mg once daily. However, the September 2023 eMAR, read fenofibrate 40 mg was unavailable and was not administered on 9/4-9/13/23, for a total of 10 missed doses. An additional practitioner's order, dated 9/14/23, directed the residence to discontinue fenofibrate 40 mg and administer fenofibrate 54 mg once daily. However, the September 2023 eMAR, read fenofibrate 54 mg was not administered on 9/14-9/18/23, for a total of four missed doses. 4. InterviewsOn 10/25/23 at 7:32 a.m., Staff #1 stated that Resident #1's omega 3 had never been delivered by the pharmacy to the residence. Staff #1 acknowledged the medication had been unavailable since 9/4/23. On 10/25/23 at 12:01 p.m., the administrator stated the residence received Resident #1's omega 3 order in early September 2023 and the medication had never been administered. The administrator stated the reason the medication was not administered was because the residence's preferred pharmacy required updated practitioner orders. The administrator stated there was one practitioner for this residence and the five sister residences, and had experienced "significant delays" in obtaining updated signed orders. The administrator acknowledged that the same issue occurred in September 2023 with Resident #1's fenofibrate, where the pharmacy required updated faxed orders to fill Resident #1's 40 mg dose and the 54 mg dose that was changed on 9/14/23. On 10/25/23 at 12:52 p.m., the administrator stated that all qualified medication administration persons (QMAPs) were responsible for ordering medication from the pharmacy. However, she stated the issue was with the residence's preferred pharmacy unable to fill medications due to delays from lack of correspondence on behalf of the residence's preferred practitioner. The administrator further stated she expected the residence to be responsible for complying with practitioner's orders and should have obtained discontinue orders for the fenofibrate and omega 3 until the pharmacy had received the required information to fill the prescriptions from the residence's preferred practitioner.

Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed, affecting two of three sample residents (#1, #2). 1. Residence PolicyThe residence's Medication Error policy, dated 5/15/19, read in part: "a documentation error is any documentation that occurs that does not accurately reflect the medication administration that was performed ... documentation errors will be handled differently and as follows ... documentation error one and two ... a medication administration error report form will be filled out and submitted to (the residence's) management ... six documentation errors ... the employee will not be allowed to administer medications until ... (management) meets to supervise their medication administration."2. Resident #1 was admitted to the residence on 5/20/22.a. Atorvastatin A written practitioner's order, dated 9/1/23, directed the residence to administer atorvastatin 20 mg daily. However, the September 2023 electronic medication administration record (eMAR) revealed blanks on 9/5 and 9/14/23. Additionally, on 9/4/23, the eMAR was marked under "missed/refused," by Staff #1, and there were no corresponding eMAR documentation notes to determine whether the medication was not administered or was refused by Resident #1. b. QuetiapineA written practitioner's order, dated 3/25/23, directed the residence to administer quetiapine 100 mg twice daily. However, the September 2023 eMAR revealed a blank on 9/14/23 in the evening.c. TrazodoneA written practitioner's order, dated 3/25/23, directed the residence to administer trazodone 50 mg once daily at bedtime. However, the September 2023 eMAR revealed a blank on 9/14/23.d. MetforminA written practitioner's order, dated 3/25/23, directed the residence to administer metformin 1000 mg once daily. However, the September 2023 eMAR revealed a blank on 9/14/23 in the evening.e. AspirinA written practitioner's order, dated 3/25/23, directed the residence to administer aspirin 81 mg daily. However, the September 2023 eMAR revealed a blank on 9/14/23.f. MelatoninA written practitioner's order, dated 3/25/23, directed the residence to administer melatonin 3 mg once daily at bedtime. However, the September 2023 eMAR revealed a blank on 9/14/23.g. Omega 3 A written practitioner's order, dated 9/2/23, directed the residence to administer omega 3 1000 mg once daily. However, the October 2023 eMAR revealed a blank on 10/8/23. On 10/25/23 at 12:01 p.m., the administrator stated blank spaces on the eMAR meant that a QMAP failed to document whether a medication was administered. She stated she expected the QMAP to document whether Resident #1's medications were administered on the days there were blank spaces. The administrator further acknowledged she expected Staff #1 to make note in the eMAR for Resident #1's atorvastatin that was marked as "missed/refused" so it could be determined whether the medication was not administered or was refused. The administrator stated the residence received Resident #1's omega 3 order in early September 2023 and the medication had never been administered. The administrator acknowledged there was a blank space on 10/8/23 and stated the staff member on shift should have documented that the medication was unavailable. 3. Resident #2 was admitted to the residence on 5/1/22. TerazosinA written practitioner's order, dated 6/22/23, directed the residence to administer terazosin 5 mg once daily at bedtime. However, the October 2023 eMAR revealed a blank on 10/23/23. On 10/25/23 at 12:01 p.m., the administrator stated she expected QMAPs to document each medication at the time administration was completed. The administrator further stated that for 10/23/23 the medication cart pill package showed that the medication was removed. She stated that there was a blank space on 10/23/23 since the QMAP failed to document that the medication was administered. 4. InterviewOn 10/25/23 at 12:01 p.m., the administrator stated she expected all eMARs to be documented accurately and contain corresponding documentation notes if the medication was missed or refused. The administrator stated that blank spaces and failure to make a note whether a medication was missed or refused was a documentation error and should have been caught and addressed in accordance with their policy. The administrator stated the reason she was unaware of the above documentation errors was because the residence had not yet completed their quarterly medication review.

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 7.14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 14.12 The assisted living residence shall ensure that all qualified medication administration persons are trained in and adhere to the following medication administration procedures: (A) Identification of the right resident for each medication administration or monitoring by asking for the resident ' s name or comparing the resident to a photograph maintained specifically for medication administration identification.