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An involuntary discharge appeal survey, prompted by #CO41463, was completed on 2/9/26. No deficiencies were cited.

A complaint survey, prompted by #CO40249, was completed on 2/9/2026. 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 relicensure survey with complaint #CO33796 was completed on 12/11/24. No deficiencies were cited.

A revisit survey was completed on 11/21/23 for all previous deficiencies cited on 7/17/23. No deficiencies were cited.

A revisit survey was completed on 11/21/23 for all previous deficiencies cited on 7/17/23. No deficiencies were cited.

A licensure complaint, prompted by #CO32157, was completed on 7/17/23. Deficiencies were cited.

Based on record review and interviews, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting 27 current residents and one former Resident (#6). Findings include:1. Referencea. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(I) Completing, maintaining, and submitting all reports and records required by the Department. 2. Record ReviewOn 7/17/23 at 7:30 a.m. the following items were requested:a. Current resident rosterb. Current staff list with phone numbersc. December 2022 and June-July 2023 staff schedulesd. Blank resident agreemente. Resident rights and house rulesf. Medication administration policyOn 7/17/23 at 8:56 a.m. the following items were requested:a. Last three quarters of medication auditsb. Personnel files for Staff #4 and the resident care and wellness director (RCWD)c. December 2022 electronic medication administration record (eMAR), orders, face sheet and progress notes for former Resident #6d. June-July 2023 eMARs, orders, face sheet, and progress notes for Residents #3-#5On 7/17/23 at 9:05 a.m., a current resident roster was provided, approximately one and a half hours after first requested. On 7/17/23 at 9:30 a.m., electronic health record access was provided to the surveyor, however, the access was restricted and would not allow the surveyor to view or save the requested resident records. On 7/17/23 at 9:40 a.m., the above documentation was requested a second time, and resident records were requested to be printed by the administrator. On 7/17/23 at 10:13 a.m., the December 2022 eMAR, face sheet and progress notes were provided for former Resident #6. However, no signed practitioner's orders were provided. On 7/17/23 at 11:20 a.m. a blank resident agreement, resident rights, house rules, June-July 2023 staff schedules and a medication administration policy were provided, approximately three and a half hours after first requested. Additionally signed practitioner's orders for former Resident #6 were provided, approximately two hours after first requested. On 7/17/23 at 11:33 a.m., the last three quarters of medication audits was requested a third time, resident records for Residents #3-#5, and staff files for Staff #4 and the RCWD were requested a second time. On 7/17/23 at 11:45 a.m., staff files for Staff #4 and the RCWD were provided, approximately 2 and a half hours after first requested. On 7/17/23 at 12:00 p.m., face sheets, June-July 2023 eMARs and orders and progress notes were provided for Resident #3, three hours after first requested and an hour and a half after requested the second time. On 7/17/23 at 12:35 p.m., face sheets, June-July 2023 eMARs and orders and progress notes were provided for Resident #4, three and a half hours after first requested and two hours after requested the second time. On 7/17/23 at 12:58 p.m., a December 2022 staff schedule was provided five hours after first requested and medication audits were provided, approximately four hours after requested the first time, two and a half hours after requested the second time, and over an hour after requested the third time. On 7/17/23 at 1:20 p.m., face sheets, June-July 2023 eMARs and orders and progress notes were provided for Resident #5, four and a half hours after first requested and two and a half hours after requested the second time. On 7/17/23 at 3:58 p.m., a current staff list with phone numbers was provided by the RCWD, approximately eight hours after requested. 3. InterviewsOn 7/17/23 at 7:25 a.m., Staff #4 stated she would do her best to provide me with requested documentation until the administrator and RCWD arrived, since they were both over an hour away from the residence. On 7/17/23 at 4:27 p.m., the administrator stated that he was aware of the requirementto provide timely documentation or designate a staff member to provide documents. However, stated that both himself and RCWD who knew where documentation was located, were unable to get to the residence after 9:00 a.m. The administrator further stated he had issues finding all the requested documentation and had issues with the computer system and electronic access.

Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#3-#5). Findings include:1. Residence PolicyThe residence's Medication Management Policy, updated 3/23/22, read in part: "the residence shall administer medications upon the written order of a practitioner."2. Resident #4 was admitted to the residence on 8/24/22, with a diagnosis of Alzheimer's Disease.a. Lidocaine patch 5%A written practitioner's order, dated 5/18/23, directed the residence to administer lidocaine patch 5% once daily. However, the June 2023 electronic medication administration record (eMAR), read the residence did not administer the medication on 6/10-6/12/23, 6/14/23 and 6/16/23 for a total of five missed doses, due to the medication being out of stock. b. Citalopram hydrobromideA written practitioner's order, dated 5/18/23, directed the residence to administer citalopram hydrobromide 20 mg once daily. However, the June and July 2023 eMARs read the residence did not administer the medication on 6/12 and 7/13/23 for a total of two missed doses, due to the medication being out of stock.c. AriceptA written practitioner's order, dated 7/2/23, directed the residence to administer Aricept 5 mg once daily. However, the July 2023 eMAR read the residence did not administer the medication on 7/3/23 for a total of one missed dose, due to the medication being out of stock. d. BupropionA written practitioner's order, dated 5/18/23, directed the residence to administer bupropion 150 mg once daily. However, the July 2023 eMAR read the residence did not administer the medication on 7/5/23 for a total of one missed dose, due to the medication being out of stock. e. IbuprofenA written practitioner's order, dated 5/22/23, directed the residence to administer ibuprofen 200 mg three times daily. However, the June 2023 eMAR read the residence did not administer the medication on 6/4/23 for a total of one missed dose, due to the medication being out of stock. On 7/17/23 at 4:25 p.m., the administrator stated that the external hospice provider for Resident #4 had changed his orders throughout June and July which contributed to missed medications. 3. Resident #5 was admitted to the residence on 9/26/22 with diagnoses including Parkinson's disease and major depressive disorder.a. SeroquelA written practitioner's order, dated 6/7/23, directed the residence to administer seroquel 50 mg twice daily. However, the June 2023 eMAR read the residence did not administer the medication on 6/26/23 for a total of two missed doses, due to the medication being out of stock. b. TylenolA written practitioner's order, dated 4/27/23, directed the residence to administer tylenol 325 mg two tablets three times daily. However, the June 2023 eMAR read the residence did not administer the medication once on 6/19/23, due to the medication being out of stock. On 7/17/23 at 4:24 p.m., the resident care and wellness director (RCWD) stated she was responsible for transcribing practitioner's orders onto the eMAR4. Resident #3 was admitted to the residence on 4/18/22, with a diagnosis of dementia. A written practitioner's order, dated 4/12/22, directed the residence to administer carvedilol 3.125 mg twice daily, and hold for systolic blood pressure less than 105, or heart rate less than 50. However, the June and July 2023 eMARs read the residence administered the medication to Resident #3 once on 6/5, 6/12, 6/15, 6/17, 6/26 and 7/2/23, although her heart rate was less than 50. Additionally, the residence held the medication on 7/14 and 7/15/23 in the evening, although the systolic blood pressure was above 105 and the heart rate was over 50. On 7/17/23 at 4:24 p.m., the RCWD stated that she was unaware that staff were not complying with the order to hold Resident #3's carvedilol if her systolic blood pressure was below 105 and her heart rate below 50, and to administer the medication if her systolic blood pressure was above 105 and heart rate above 50.5. InterviewsOn 7/17/23 at 4:24 p.m., the RCWD stated that herself and qualified medication administration persons (QMAPs) were responsible for ordering medications from the pharmacy, and further stated she was responsible for transcribing the eMAR. The RCWD stated that some of the medications missed for one dose were due to staff not having looked hard enough in the medication carts. The RCWD stated she had identified this issue previously and confirmed it was still an issue. On 7/17/23 at approximately 4:25 p.m., the administrator stated that he expected the residence to comply with the practitioner's orders and was unsure the reason medications were not administered as ordered for Residents #3-#5.

Based on record review and interviews, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event is completed for each resident along with each of their signatures and, if used, their initials, and failed to document accurate information in the medication administration record (MAR), affecting one of four sample residents (#4) and one former resident (#6). Findings include:1. Residence PolicyThe residence's Medication Management Policy, updated 3/23/22, read in part: "The administration of medication shall be documented at the time of administration."2. Resident #4 was admitted to the residence on 8/24/22, with a diagnosis of Alzheimer's Disease. A written practitioner's order, dated 5/23/23, directed the residence to administer ondansetron 4 mg once daily. The July 2023 electronic medication administration record (eMAR) read that on 7/9/23 ondansetron was administered; however, eMAR documentation notes read that on 7/9/23 the medication was not administered. Further, on 7/11/23, the eMAR read an exception code to "see progress notes",however, there was no progress note as to why ondansetron was not administered on 7/11/23. On 7/17/23 at 4:27 p.m., the administrator stated he would have expected what was documented in the eMAR to correspond with a progress note accurately. 3. Former Resident #6 was admitted to the residence on 10/31/22. A written practitioner's order, dated 12/17/22, directed the residence to administer clindamycin 300 mg every six hours for seven days. However, the December 2022 eMAR contained no evidence of documentation for one dose on 12/23 and 12/24/22. On 7/17/23 at 4:27 p.m., the administrator stated that blanks in the eMAR meant the medication administration was not recorded, and stated he would expect there to be documentation of staff initials or an exception code if former Resident #6's clindamycin was not administered.

Based on record reviews and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP), on a quarterly basis, audit the accuracy and completeness of the medication administration records and ensure any irregularities were investigated and resolved, affecting 27 current residents. Findings include: The residence's Medication Management Policy, updated 3/23/22, read in part: "the administrator and wellness director will audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records at least quarterly ... audits will be documented and reviewed."On 7/17/23 at 8:56 a.m., the last three medication audits were requested from the administrator. At 12:58 p.m., two medication audits were provided and revealed the following:On 12/3/22 the resident care and wellness director (RCWD) had completed a medication audit. However, the audit provided no evidence the audit was completed to ensure the accuracy of the medication administration records (MARs) in regards to the written practitioner's orders, what was transcribed on the MARs, and when the medications were administered. There was no evidence a medication audit was completed during the first quarter. On 6/30/23 the administrator and RCWD had completed a medication audit. However, the audit provided no evidence the audit was completed to ensure the accuracy of the MARs in regards to the written practitioner's orders, what was transcribed on the MARs, and when the medications were administered. On 7/17/23 at 4:17 p.m., the administrator stated himself and the RCWD were in charge of medication audits and was aware they needed to be completed quarterly and be compared against practitioner's orders. The administrator stated there was a medication audit completed in March of 2023, however the RCWD was unable to find the medication audit sheet, so it was not documented as required.

A licensure revisit was completed on 7/17/23 for all previous deficiencies cited on 12/15/22. A deficiency was cited.

Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#3-#5). This deficiency was cited previously during a state licensure survey 12/15/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Residence PolicyThe residence's Medication Management Policy, updated 3/23/22, read in part: "the residence shall administer medications upon the written order of a practitioner."2. Resident #4 was admitted to the residence on 8/24/22, with a diagnosis of Alzheimer's Disease.a. Lidocaine patch 5%A written practitioner's order, dated 5/18/23, directed the residence to administer lidocaine patch 5% once daily. However, the June 2023 electronic medication administration record (eMAR), read the residence did not administer the medication on 6/10-6/12/23, 6/14/23 and 6/16/23 for a total of five missed doses, due to the medication being out of stock. b. Citalopram hydrobromideA written practitioner's order, dated 5/18/23, directed the residence to administer citalopram hydrobromide 20 mg once daily. However, the June and July 2023 eMARs read the residence did not administer the medication on 6/12 and 7/13/23 for a total of two missed doses, due to the medication being out of stock.c. AriceptA written practitioner's order, dated 7/2/23, directed the residence to administer Aricept 5 mg once daily. However, the July 2023 eMAR read the residence did not administer the medication on 7/3/23 for a total of one missed dose, due to the medication being out of stock. d. BupropionA written practitioner's order, dated 5/18/23, directed the residence to administer bupropion 150 mg once daily. However, the July 2023 eMAR read the residence did not administer the medication on 7/5/23 for a total of one missed dose, due to the medication being out of stock. e. IbuprofenA written practitioner's order, dated 5/22/23, directed the residence to administer ibuprofen 200 mg three times daily. However, the June 2023 eMAR read the residence did not administer the medication on 6/4/23 for a total of one missed dose, due to the medication being out of stock. On 7/17/23 at 4:25 p.m., the administrator stated that the external hospice provider for Resident #4 had changed his orders throughout June and July which contributed to missed medications. 3. Resident #5 was admitted to the residence on 9/26/22 with diagnoses including Parkinson's disease and major depressive disorder.a. SeroquelA written practitioner's order, dated 6/7/23, directed the residence to administer seroquel 50 mg twice daily. However, the June 2023 eMAR read the residence did not administer the medication on 6/26/23 for a total of two missed doses, due to the medication being out of stock. b. TylenolA written practitioner's order, dated 4/27/23, directed the residence to administer tylenol 325 mg two tablets three times daily. However, the June 2023 eMAR read the residence did not administer the medication once on 6/19/23, due to the medication being out of stock. On 7/17/23 at 4:24 p.m., the resident care and wellness director (RCWD) stated she was responsible for transcribing practitioner's orders onto the eMAR4. Resident #3 was admitted to the residence on 4/18/22, with a diagnosis of dementia. A written practitioner's order, dated 4/12/22, directed the residence to administer carvedilol 3.125 mg twice daily, and hold for systolic blood pressure less than 105, or heart rate less than 50. However, the June and July 2023 eMARs read the residence administered the medication to Resident #3 once on 6/5, 6/12, 6/15, 6/17, 6/26 and 7/2/23, although her heart rate was less than 50. Additionally, the residence held the medication on 7/14 and 7/15/23 in the evening, although the systolic blood pressure was above 105 and the heart rate was over 50. On 7/17/23 at 4:24 p.m., the RCWD stated that she was unaware that staff were not complying with the order to hold Resident #3's carvedilol if her systolic blood pressure was below 105 and her heart rate below 50, and to administer the medication if her systolic blood pressure was above 105 and heart rate above 50.5. InterviewsOn 7/17/23 at 4:24 p.m., the RCWD stated that herself and qualified medication administration persons (QMAPs) were responsible for ordering medications from the pharmacy, and further stated she was responsible for transcribing the eMAR. The RCWD stated that some of the medications missed for one dose were due to staff not having looked hard enough in the medication carts. The RCWD stated she had identified this issue previously and confirmed it was still an issue. On 7/17/23 at approximately 4:25 p.m., the administrator stated that he expected the residence to comply with the practitioner's orders and was unsure the reason medications were not administered as ordered for Residents #3-#5. He also stated he was unaware why this deficiency had not been corrected and had worked on reviewing eMARs since he assumed his role as administrator in April 2023, to ensure medications were always in stock.