BONAVENTURE OF PUEBLO

A licensure complaint, prompted by #CO32810, #CO34245, #CO34411, and #CO34576, was completed on 1/10/24. No deficiencies were cited.

A licensure revisit was completed on 6/27/23 for all previous deficiencies cited on 11/2/22. Deficiencies were cited.

Based on observation, interview and record review the residence failed to either directly or indirectly through a resident agreement provide personal services and a safe and sanitary environment affecting two of five sample residents (#11, #21). Findings include:1. Residence PolicyThe residence's resident agreement, dated February 2019, read in part: The residence agreed to provide personal services. Chapter VII regulations governing assisted living residences, defines personal services as services that an assisted living residence and its staff provide for each resident including, but not limited to: (D) Assistance with activities of daily living. 2. Resident #21 was admitted to the residence on 12/28/19 with a diagnosis of Parkinson's disease. a. Safe and Sanitary Environment On 6/27/23 at 7:41 a.m., during morning medication pass the memory care director (MCD) prepared a medication for Resident #21 and dispensed it into a cup. The MCD subsequently closed the medication cart and removed her keys. She then opened the door that led to Resident #21's room. The MCD once in the room, greeted Resident #21 and administered her medication while the resident was laying down. The medication subsequently fell out of the side of her mouth. The MCD picked up the pill with her bare hand off the resident's bedding and placed the pill back into Resident #21's mouth. The MCD had her swallow the medication with a cup of water. Progress notes read in part:On 2/2/23, Resident #11 was having difficulty getting food down at lunch. Staff assisted the resident with clearing the food object. Resident was placed on alert charting due to coughing during meals. On 2/5/23 Resident #11 was on alert charting due to coughing during meals. Since having issues swallowing, the resident has been very scared to eat any meals. Care staff have been cutting meals very small for the resident to make sure she does not cough during meals again. On 6/27/23 at 3:57 p.m., the regional nurse consultant stated Medication should have not been administered while laying down and the resident should have been upright to take the medication. The regional nurse further stated that the MCD should have not picked up the medication with her bare hand after it fell and administer it to the resident. On 6/27/23 at 4:00 p.m., the administrator stated the medication should have not been picked up with the MCD's bare hand and she should have worn a glove. b. Personal ServicesThe care plan for Resident #21, dated 4/6/23, read in part: Staff were to use caution and protect extremities during transfers to prevent bruises and lacerations. A written practitioner's order, dated 4/27/23, directed the residence to administer arm protectors each morning. However, the May 2023 MAR read they were not administered on 5/14 and 5/16/23. On 6/27/23 at 12:39 p.m., the family member for Resident #21 stated the last couple times he had visited the residence. Resident #21 was not observed to have been wearing her protective sleeves. 3. Resident #11 was admitted to the residence on 1/28/22 with a diagnosis including acute kidney failure. The care plan for Resident #11, dated 10/3/22, read in part staff were to put compression stockings on in the morning and remove them at night. The care plan further read staff were to wash the compression stockings nightly after each use and hang dry. A written practitioner's order, dated 3/28/23, directed the residence to administer compression stockings once daily in the morning and remove at night. However, the June 2023 MAR read the compression stockings were not administered from 6/10-6/26/23 as they were too small. MAR exceptions for June 2023 read in part:On 6/10/23 at 8:36 a.m., compression stockings were not administered as they were too small and needed a larger size. On 6/10/23 at 8:17 p.m., compression stockings were not administered as the wrong size came in and the residence was waiting on a new pair. On 6/11/23 at 9:32 a.m., compression stockings were not administered as they were the wrong size and the residence was awaiting a new pair. On 6/13/23 at 8:24 a.m., left compression stockings off due to staff not removing prior to bedtime. Swelling and circulation cut off was observed. On 6/15/23 at 8:28 a.m., compression stockings were too small for the resident. On 6/17/23 at 9:14 a.m., staff spoke with the family for Resident #11 and they stated they would obtain new compression stockings next week. On 6/19/23 at 8:35 a.m., compression hose were too small and not administered. On 6/21/23 at 8:57 a.m., family was ordering the compression stockings. On 6/25/23 at 10:09 a.m., the practitioner sent an order for a larger size last week. Family was buying a larger size from an online retailer. On 6/27/23 at 12:36 p.m., a family member for Resident #11 stated she has purchased compression stockings of multiple sizes in the past for the resident. She stated she was not aware that the resident needed new compression stockings. On 6/27.23 at 4:00 p.m., the administrator stated that she was notified the day of the on-site visit that Resident #11 had been without her compression stockings.

Based on interview and record review the residence failed to develop and implement a fall management program affecting 70 current residents. This deficiency was cited previously during a state licensure survey 11/2/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Failure to develop a fall management program:a. Chapter VII regulations governing assisted living residences, requires in 7.8 (B) (6), that the The assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self study courses, or on-the-job training, and shall include, but is not limited to, the following topics:Training related to fall prevention and ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobility. b. The residence's fall management policy, dated 8/27/20, read in part: The residence would provide initial and ongoing evaluations of each resident's mobility needs as well as seek to minimize risk of injury from falls while promoting resident independence and safety. Residents and their environments were evaluated to identify those at risk for falling, and interventions that might reduce that potential. After any resident fall, staff would review specific care coordination needs and seek to minimize recurrence. Health services staff would evaluate each resident to determine resident status at each of the following times: at time of move in, post occurrence, quarterly, after any change in living location within the residence. Documentation of such evaluation was maintained in the resident's record. An evaluation of the fall potential tool for data collection was available electronically as desired but not required. When an evaluation identified potential risk, staff should discuss and document the following with the resident and/or responsible party: contributing factors linked to creating the risk/trend. Explanation of the evaluation, discussion regarding the benefits of proposed interventions, outcomes, including responses about resident ability and preference related to the proposed interventions. Available resources to assist the resident in achieving mobility goals such as community exercise activities and outside agencies such as physical therapy and occupational therapy. Staff must specify in the care plan any trends, contributing factors and interventions used as well as residents preferred level of participation in interventions which could include refusal of offered increased assistance, participation in outside therapies, participation in the community exercise or activity programs. c. The residence's Caregiver Training policy, dated 9/20/22, read in part: A caregiver who sees or was in contact with a resident about to fall should immediately act as follows; Bring the resident as close to your body as possible, as quickly as possible. Wrap your arms around the resident's wait or hold them under the arms as you begin to guide them down with your feet in a firm stance, flat and wide. Bend at your hips and knees as you begin to slide the resident down your leg. Summon a supervisor immediately and decide what further assistance or care the resident requires. Complete the occurrence report process and document the resident's behavior and actions before the fall, staff response to the fall, if any, as related to the resident's care. Seek to determine why the resident fell and follow up as appropriate to notify management about action suggested to prevent a recurrence. However, the fall management program failed to include how the residence would routinely inspect and maintain the interior and exterior environment and provide staff training related to fall prevention as specified in part 7.8 (B)(6). On 6/27/23 at 10:25 a.m., the regional nurse consultant (RNC) stated the policy that was provided was the residences fall management program and she was not aware why all of the elements that were required were not addressed in the policy. On 6/27/23 at 4:00 p.m., the administrator and the regional director of operations (RDO) stated they were not aware the policy was missing the requirements. 2. Failure to implement the fall management program a. Resident #21 was admitted to the residence on 12/28/19 with a diagnosis of Parkinson's disease. A care plan for Resident #21, dated 4/6/23, read in part: Resident #21 required two person staff assistance with transfers, the resident required staff assistance to transfer to chair, toilet, bed, recliner etc. Resident #21 was resistant to transfers, had a high back wheelchair to prevent her from sliding out, staff to use caution and protect extremities during transfers. The category titled fall prevention read the resident was at risk for falls staff was instructed to ensure the resident was upright in her wheelchair, position if sliding, encourage the resident to sleep towards the middle of her bed, staff to provide transfer assistance and night staff were instructed to routinely check on the resident throughout the night. A progress note, dated 5/19/23, read Resident #11 was on alert charting due to a fall with skin tear to the right elbow which occurred on 5/17/23A progress note, dated 6/6/23, read interdisciplinary team review of fall on 5/17/23. No further falls had happened since new interventions were put in place. Resident was checked on throughout the night, made sure she was in the middle of her bed and fall mats placed on the floor. The record for Resident #21 revealed no evidence of a temporary care plan or care plan update to include the individualized approach necessary to address fall risk after Resident #21 fell on 5/19/23. On 6/27/23 at 10:25 a.m., the regional nurse consultant (RNC) any time a resident fell, the caregiver, herself and the qualified medication administration person would huddle and write down interventions which were then discussed in the weekly fall meetings. She stated a fall required alert charting and a temporary care plan would be implemented. The RNC stated the temporary care plan would instruct staff on interventions following any falls and was accessible to staff. On 6/27/23 at 12:39 p.m., a family member for Resident #21 stated the resident was prone to falling when she tried to complete a task without asking for assistance. On 6/27/23 at 2:36 p.m., Staff #47 stated she was not aware of any fall interventions that were implemented for Resident #21. She stated Resident #21 did not even ambulate independently and she was not aware that the resident was a fall risk. On 6/27/23 at 3:15 p.m., The RNC stated she did not remember discussing the fall with Resident #21 and would have to investigate the incident. On 6/27/23 at 4:00 p.m., the administrator stated Resident #21 on 5/19/23 had fallen out of bed and further stated nothing different should have been done. b. Resident #33 was admitted to the residence on 5/11/23 with diagnoses of osteoporosis and advanced dementia. A progress note, dated 4/28/23 read the resident was on alert charting from a fall which occurred on 4/26/23. Fall interventions were reviewed and no further falls had occurred since new interventions were put in place. The record for Resident #33 revealed no evidence of a temporary care plan after the fall that occurred on 4/26/23. A progress note, dated 4/30/23 read Resident #33 had a fall which occurred between 4:11 a.m. and 4:30 a.m. The resident was found on the floor by staff and stated she had hit the back of her head and stated she fell because she felt weak. Resident #33 did not sleep well and was up and down all night. A progress note, dated 5/13/23 read Resident #33 was on alert charting for a fall without injury which occurred on 4/30/23. Resident #33 rarely slept at night. The practitioner was aware and making adjustments. Resident stays up at night and drinks coffee, this seems to increase the risk of her falling. Requested decaffeinated coffee from the family. A care plan for Resident #33, dated 5/16/23, read in part: The resident was at risk for falls. The residence was required to have the following fall interventions in place, shower mat, lamp left on at all times, encourage the use of her walker for all mobility, check the resident apartment for trip hazards frequently, ensure proper footwear when out of her room physical therapy orders sent to home health. The resident had a tendency to walk around without her assistive device, slightly hunched over with her hands behind her back and has a tendency to make sudden moves. Resident #33 had several falls in the last 90 days, one resulting in a nose fracture. The record for Resident #33 revealed no evidence of temporary care plans and no evidence of the fall intervention of decaffeinated coffee per the residence's progress note written on 5/13/23. A progress note, dated 6/25/23, read Resident #33 had a fall without injury. Staff witnessed the fall and assisted her, she fell on her bottom and staff informed the memory care director and the practitioner. Safety checks completed on the resident. On 6/27/23 at 2:38 p.m., Staff #47 stated the only fall intervention for Resident #33 that she was aware of, was to ensure the resident utilized her walker when ambulating. On 6/27/23 at 3:15 p.m., RNC stated the residence's process for fall management was to discuss falls and fall interventions weekly during a meeting. She stated this process was implemented around May 2023. She further stated regarding the fall on 6/25/23 that the residence had not discussed the fall because the residence met on Thursdays and discussed falls (the next meeting was scheduled 6/29/23. On 6/27/23 at 4:00 p.m., the RDO stated when a resident fell the process was for the residence to put a temporary care plan in place to prevent further falls.

Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of five sample residents (#11, #21, #33, #35). This deficiency was cited previously during a state licensure survey 11/2/22. 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 Systems policy read in part; "The (residence) must obtain and review orders signed by a legally authorized practitioner for each resident who receives assistance with administration of medication ... Staff shall follow requirements for (residence/practitioner) communication about orders, as specified in the communication system description ..."2. Resident #35 was admitted to the residence on 4/24/23 with no listed diagnoses. a. AtorvastatinA written practitioners order dated 5/1/23 directed the residence to administer atorvastatin 20 mg daily. However, the May 2023 medication administration record (MAR) read the medication was not administered as ordered on 5/14-5/17/23 due to the medication not being unavailable, for a total of four missed doses. b. DonepezilA written practitioners order dated 5/1/23 directed the residence to administer Donepezil 5 mg daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/11, 5/12 and 5/14/23 due to the medication being unavailable, for a total of three missed doses. A written practitioners order dated 6/5/23 directed the residence to discontinue Donepezil 5 mg daily. However, the June 2023 MAR read the medication continued to be administered on 6/6-6/9/23, for a total of four additional doses.c. FurosemideA written practitioners order dated 5/1/23 directed the residence to administer furosemide 20 mg daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/11/23, due to the medication being unavailable, for a total of one missed dose. d. Glipizide A written practitioners order dated 5/1/23 directed the residence to administer Glipizide 5 mg 1 and one half tablets daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/10 and 5/11/23 due to the medication being unavailable, for a total of two missed doses. e. Magnesium A written practitioners order dated 5/1/23 directed the residence to administer magnesium 250 mg daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/4/23 due to the medication being unavailable, for a total of one missed dose. f. Metoprolol A written practitioners order dated 5/1/23 directed the residence to administer metoprolol tartrate 25 mg one half tablet twice daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/11/23 due to the medication being unavailable, for a total of two missed doses. g. Theragran-MA written practitioners order dated 5/1/23 directed the residence to administer theragran-M premier 50 plus 400-250-375 MCG daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/4 and 5/7-5/11/23 due to the medication being unavailable, for a total of three missed doses. On 6/27/23 at approximately 3:15 p.m., the regional nurse consultant stated she was aware of the medication issues with Resident #35. She stated she had communicated with the residence to resolve the medication issues. She stated she could not recall why the medications had such difficulties. The regional nurse consultant stated the medications should have been administered as ordered. She stated the residence staff should have contacted the practitioner to get a hold order or an order for a comparative medication depending on the reason it was unavailable. The regional nurse consultant stated if the residence received a discontinue order for a medication the medication should not have been administered additional doses. On 6/27/23 at 4:00 p.m., the administrator stated she did not remember why the medications were not administered for Resident #35. She stated if a medication was discontinued the medication should not have been administered. On 6/27/23 at approximately 4:00 p.m., the regional director of operations stated if they residence had orders to administer the medications the medications should have been administered. She stated she believed if a discontinue order was received for a medication the residence should have had time to process the order before stopping the medication. 3. Resident #11 was admitted to the residence on 1/28/22 with a diagnosis of atrial fibrillation. A written practitioner's order, dated 3/28/23, directed the residence to administer warfarin sodium 5 mg every Monday, Tuesday, Thursday, Friday and Sunday. However, the May 2023 MAR read the medication was not administered on 5/28 and 5/29/23 as the medication was not available. On 6/27/23 at 12:36 p.m., the responsible party for Resident #11 stated she had not been made aware the resident did not receive her warfarin sodium as prescribed. On 6/27/23 at 4:00 p.m., the administrator stated she was not aware why Resident #11 went without her prescribed warfarin sodium. She further stated that the medication was not on cycle fill which may have been the reason why the medication was not available to administer. 4. Resident #21 was admitted to the residence on 12/28/19 with a diagnosis of Parkinson's disease. A written practitioner's order, dated 3/28/23, directed the residence to administer carbidopa-levodopa 25-100 three times daily. However, the May 2023 MAR read the medication was not administered on 5/30/23 at 4:00 p.m. as the medication was not available. On 6/27/23 at 3:15 p.m., the regional nurse consultant stated she was aware the carbidopa-levodopa was not administered; however, she could not recall the reason. She further stated the residence was notified each time a medication was not administered and she reviewed the notes regularly and followed up with staff. On 6/27/23 at 4:00 p.m., the administrator stated she was aware Resident #21 had missed her carbidopa-levodopa. However, she stated she was not sure why the medication was missed as it was cycle filled and confirmed it should have not been missed. A written practitioner's order, dated 6/16/23, directed the residence to administer ondansetron 4 mg three times daily. However, the June 2023 MAR read the medication was administered twice on 6/21/23 at 9:00 p.m. 5. Resident #33 was admitted to the residence on 5/11/23 with a fractured nose. A written practitioner's order, dated 5/31/23, directed the residence to administer hydrocodone - acetaminophen 5-325 once daily at bedtime. However, the June 2023 MAR read the medication was not administered from 6/19-6/26/23 as the medication was out of stock. A practitioner's notification, dated 6/23/23, read the medication had not been administered as it required a refill. During a medication cart audit it was revealed the medication was not in stock. On 6/27/23 at 4:00 p.m., the administrator stated she was not aware of the circumstances regarding the hydrocodone- acetaminophen for Resident #33.

A licensure revisit was completed on 6/27/23 for all previous deficiencies cited on 11/2/22. Deficiencies were cited.

Based on observation, interview and record review the residence failed to either directly or indirectly through a resident agreement provide personal services and a safe and sanitary environment affecting two of five sample residents (#11, #21). Findings include:1. Residence PolicyThe residence's resident agreement, dated February 2019, read in part: The residence agreed to provide personal services. Chapter VII regulations governing assisted living residences, defines personal services as services that an assisted living residence and its staff provide for each resident including, but not limited to: (D) Assistance with activities of daily living. 2. Resident #21 was admitted to the residence on 12/28/19 with a diagnosis of Parkinson's disease. a. Safe and Sanitary Environment On 6/27/23 at 7:41 a.m., during morning medication pass the memory care director (MCD) prepared a medication for Resident #21 and dispensed it into a cup. The MCD subsequently closed the medication cart and removed her keys. She then opened the door that led to Resident #21's room. The MCD once in the room, greeted Resident #21 and administered her medication while the resident was laying down. The medication subsequently fell out of the side of her mouth. The MCD picked up the pill with her bare hand off the resident's bedding and placed the pill back into Resident #21's mouth. The MCD had her swallow the medication with a cup of water. Progress notes read in part:On 2/2/23, Resident #11 was having difficulty getting food down at lunch. Staff assisted the resident with clearing the food object. Resident was placed on alert charting due to coughing during meals. On 2/5/23 Resident #11 was on alert charting due to coughing during meals. Since having issues swallowing, the resident has been very scared to eat any meals. Care staff have been cutting meals very small for the resident to make sure she does not cough during meals again. On 6/27/23 at 3:57 p.m., the regional nurse consultant stated medication should have not been administered while laying down and the resident should have been upright to take the medication. The regional nurse further stated that the MCD should have not picked up the medication with her bare hand after it fell and administer it to the resident. On 6/27/23 at 4:00 p.m., the administrator stated the medication should have not been picked up with the MCD's bare hand and she should have worn a glove. b. Personal ServicesThe care plan for Resident #21, dated 4/6/23, read in part: Staff were to use caution and protect extremities during transfers to prevent bruises and lacerations. A written practitioner's order, dated 4/27/23, directed the residence to administer arm protectors each morning. However, the May 2023 medication administration record (MAR) read they were not administered on 5/14 and 5/16/23. On 6/27/23 at 12:39 p.m., the family member for Resident #21 stated the last couple times he had visited the residence. Resident #21 was not observed to have been wearing her protective sleeves. 3. Resident #11 was admitted to the residence on 1/28/22 with a diagnosis including acute kidney failure. The care plan for Resident #11, dated 10/3/22, read in part staff were to put compression stockings on in the morning and remove them at night. The care plan further read staff were to wash the compression stockings nightly after each use and hang dry. A written practitioner's order, dated 3/28/23, directed the residence to administer compression stockings once daily in the morning and remove at night. However, the June 2023 MAR read the compression stockings were not administered from 6/10-6/26/23 as they were too small. MAR exceptions for June 2023 read in part:On 6/10/23 at 8:36 a.m., compression stockings were not administered as they were too small and needed a larger size. On 6/10/23 at 8:17 p.m., compression stockings were not administered as the wrong size came in and the residence was waiting on a new pair. On 6/11/23 at 9:32 a.m., compression stockings were not administered as they were the wrong size and the residence was awaiting a new pair. On 6/13/23 at 8:24 a.m., left compression stockings off due to staff not removing prior to bedtime. Swelling and circulation cut off was observed. On 6/15/23 at 8:28 a.m., compression stockings were too small for the resident. On 6/17/23 at 9:14 a.m., staff spoke with the family for Resident #11 and they stated they would obtain new compression stockings next week. On 6/19/23 at 8:35 a.m., compression hose were too small and not administered. On 6/21/23 at 8:57 a.m., family was ordering the compression stockings. On 6/25/23 at 10:09 a.m., the practitioner sent an order for a larger size last week. Family was buying a larger size from an online retailer. On 6/27/23 at 12:36 p.m., a family member for Resident #11 stated she has purchased compression stockings of multiple sizes in the past for the resident. She stated she was not aware that the resident needed new compression stockings. On 6/27.23 at 4:00 p.m., the administrator stated that she was notified the day of the on-site visit that Resident #11 had been without her compression stockings.

Based on interview and record review the residence failed to develop and implement a fall management program affecting 70 current residents. This deficiency was cited previously during a state licensure survey 11/2/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Failure to develop a fall management program:a. Chapter VII regulations governing assisted living residences, requires in 7.8 (B) (6), that the The assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self study courses, or on-the-job training, and shall include, but is not limited to, the following topics:Training related to fall prevention and ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobility. b. The residence's fall management policy, dated 8/27/20, read in part: The residence would provide initial and ongoing evaluations of each resident's mobility needs as well as seek to minimize risk of injury from falls while promoting resident independence and safety. Residents and their environments were evaluated to identify those at risk for falling, and interventions that might reduce that potential. After any resident fall, staff would review specific care coordination needs and seek to minimize recurrence. Health services staff would evaluate each resident to determine resident status at each of the following times: at time of move in, post occurrence, quarterly, after any change in living location within the residence. Documentation of such evaluation was maintained in the resident's record. An evaluation of the fall potential tool for data collection was available electronically as desired but not required. When an evaluation identified potential risk, staff should discuss and document the following with the resident and/or responsible party: contributing factors linked to creating the risk/trend. Explanation of the evaluation, discussion regarding the benefits of proposed interventions, outcomes, including responses about resident ability and preference related to the proposed interventions. Available resources to assist the resident in achieving mobility goals such as community exercise activities and outside agencies such as physical therapy and occupational therapy. Staff must specify in the care plan any trends, contributing factors and interventions used as well as residents preferred level of participation in interventions which could include refusal of offered increased assistance, participation in outside therapies, participation in the community exercise or activity programs. c. The residence's Caregiver Training policy, dated 9/20/22, read in part: A caregiver who sees or was in contact with a resident about to fall should immediately act as follows; Bring the resident as close to your body as possible, as quickly as possible. Wrap your arms around the resident's wait or hold them under the arms as you begin to guide them down with your feet in a firm stance, flat and wide. Bend at your hips and knees as you begin to slide the resident down your leg. Summon a supervisor immediately and decide what further assistance or care the resident requires. Complete the occurrence report process and document the resident's behavior and actions before the fall, staff response to the fall, if any, as related to the resident's care. Seek to determine why the resident fell and follow up as appropriate to notify management about action suggested to prevent a recurrence. However, the fall management program failed to include how the residence would routinely inspect and maintain the interior and exterior environment and provide staff training related to fall prevention as specified in part 7.8 (B)(6). On 6/27/23 at 10:25 a.m., the regional nurse consultant (RNC) stated the policy that was provided was the residences fall management program and she was not aware why all of the elements that were required were not addressed in the policy. On 6/27/23 at 4:00 p.m., the administrator and the regional director of operations (RDO) stated they were not aware the policy was missing the requirements. 2. Failure to implement the fall management program a. Resident #21 was admitted to the residence on 12/28/19 with a diagnosis of Parkinson's disease. A care plan for Resident #21, dated 4/6/23, read in part: Resident #21 required two person staff assistance with transfers, the resident required staff assistance to transfer to chair, toilet, bed, recliner etc. Resident #21 was resistant to transfers, had a high back wheelchair to prevent her from sliding out, staff to use caution and protect extremities during transfers. The category titled fall prevention read the resident was at risk for falls staff was instructed to ensure the resident was upright in her wheelchair, position if sliding, encourage the resident to sleep towards the middle of her bed, staff to provide transfer assistance and night staff were instructed to routinely check on the resident throughout the night. A progress note, dated 5/19/23, read Resident #11 was on alert charting due to a fall with skin tear to the right elbow which occurred on 5/17/23A progress note, dated 6/6/23, read interdisciplinary team review of fall on 5/17/23. No further falls had happened since new interventions were put in place. Resident was checked on throughout the night, made sure she was in the middle of her bed and fall mats placed on the floor. The record for Resident #21 revealed no evidence of a temporary care plan or care plan update to include the individualized approach necessary to address fall risk after Resident #21 fell on 5/19/23. On 6/27/23 at 10:25 a.m., the regional nurse consultant (RNC) any time a resident fell, the caregiver, herself and the qualified medication administration person would huddle and write down interventions which were then discussed in the weekly fall meetings. She stated a fall required alert charting and a temporary care plan would be implemented. The RNC stated the temporary care plan would instruct staff on interventions following any falls and was accessible to staff. On 6/27/23 at 12:39 p.m., a family member for Resident #21 stated the resident was prone to falling when she tried to complete a task without asking for assistance. On 6/27/23 at 2:36 p.m., Staff #47 stated she was not aware of any fall interventions that were implemented for Resident #21. She stated Resident #21 did not even ambulate independently and she was not aware that the resident was a fall risk. On 6/27/23 at 3:15 p.m., The RNC stated she did not remember discussing the fall with Resident #21 and would have to investigate the incident. On 6/27/23 at 4:00 p.m., the administrator stated Resident #21 on 5/19/23 had fallen out of bed and further stated nothing different should have been done. b. Resident #33 was admitted to the residence on 5/11/23 with diagnoses of osteoporosis and advanced dementia. A progress note, dated 4/28/23 read the resident was on alert charting from a fall which occurred on 4/26/23. Fall interventions were reviewed and no further falls had occurred since new interventions were put in place. The record for Resident #33 revealed no evidence of a temporary care plan after the fall that occurred on 4/26/23. A progress note, dated 4/30/23 read Resident #33 had a fall which occurred between 4:11 a.m. and 4:30 a.m. The resident was found on the floor by staff and stated she had hit the back of her head and stated she fell because she felt weak. Resident #33 did not sleep well and was up and down all night. A progress note, dated 5/13/23 read Resident #33 was on alert charting for a fall without injury which occurred on 4/30/23. Resident #33 rarely slept at night. The practitioner was aware and making adjustments. Resident stays up at night and drinks coffee, this seems to increase the risk of her falling. Requested decaffeinated coffee from the family. A care plan for Resident #33, dated 5/16/23, read in part: The resident was at risk for falls. The residence was required to have the following fall interventions in place, shower mat, lamp left on at all times, encourage the use of her walker for all mobility, check the resident apartment for trip hazards frequently, ensure proper footwear when out of her room physical therapy orders sent to home health. The resident had a tendency to walk around without her assistive device, slightly hunched over with her hands behind her back and has a tendency to make sudden moves. Resident #33 had several falls in the last 90 days, one resulting in a nose fracture. The record for Resident #33 revealed no evidence of temporary care plans and no evidence of the fall intervention of decaffeinated coffee per the residence's progress note written on 5/13/23. A progress note, dated 6/25/23, read Resident #33 had a fall without injury. Staff witnessed the fall and assisted her, she fell on her bottom and staff informed the memory care director and the practitioner. Safety checks completed on the resident. On 6/27/23 at 2:38 p.m., Staff #47 stated the only fall intervention for Resident #33 that she was aware of, was to ensure the resident utilized her walker when ambulating. On 6/27/23 at 3:15 p.m., RNC stated the residence's process for fall management was to discuss falls and fall interventions weekly during a meeting. She stated this process was implemented around May 2023. She further stated regarding the fall on 6/25/23 that the residence had not discussed the fall because the residence met on Thursdays and discussed falls (the next meeting was scheduled 6/29/23. On 6/27/23 at 4:00 p.m., the RDO stated when a resident fell the process was for the residence to put a temporary care plan in place to prevent further falls.

Based on record review and interview, the residence failed to ensure qualified medication administration persons (QMAPs) were not permitted to make decisions regarding as needed (PRN) medication or utilize judgment in regards to medication effect, affecting two of five sample residents (#33,#34). Findings include: 1. Resident #33 was admitted to the residence on 5/11/23 with diagnoses that included constipation. A written practitioner's order, dated 5/17/23, directed the residence to administer polyethylene glycol 17 g once daily. However, the June 2023 medication administration record (MAR) read the medication was held due to loose stools on 6/14/23 and 6/22/23. The June 2023 MAR had notes documented by Staff #45, a QMAP, that read the following:On 6/14/23 Staff #45 documented Resident #33's polyethylene glycol was "held due to resident having a lot (sic) of loose bowel movement overnight and during morning." On 6/22/23 Staff #45 documented Resident #33's polyethylene glycol was "withheld due to loose watery stools and stomach issues." The residence was unable to provide a written practitioner's order directing the residence to hold the medication. On 6/27/23 at approximately 3:15 p.m., the regional nurse consultant stated she was aware QMAPs could not make the judgement to hold Resident #33's polyethylene glycol. She acknowledge she was aware the medication was held. On 6/27/23 at 4:00 p.m., the administrator stated without a practitioner's order or external hospice providing a verbal order the QMAP should not have held Resident #33's medication. She stated the practitioner's order did not specify to hold the medication if the resident experienced loose stool. 2. Resident #34 was admitted to the residence on 3/31/18. A written practitioner's order, dated 6/16/23, directed the residence to administer lorazepam 0.5 mg every four hours as needed for anxiety and agitation. The June 2023 MAR read the residence had administered lorazepam on 6/21/23. The MAR read Staff #46 (QMAP) administered the medication. The reason the medication was given read "approved by hospice for behaviors." A progress note, dated 6/21/23, authored by Staff #46 read; "called and spoke to agent at (external hospice agency) fro(sic) approval for lorazepam PRN (prescription as needed) for behaviors. For last for (sic) days resident has not slept repeatedly presses pager insisting it was day time and wanted up ... Nurse called ... approval for PRN administration per PRN order. I (Staff #46 QMAP) administered medication." On 6/27/23 at approximately 3:15 p.m., the regional nurse consultant stated the QMAP should not have administered the PRN lorazepam to Resident #34. She stated the external hospice nurse should have came to the residence and assessed the resident. The regional nurse consultant stated if the residence had a registered nurse on staff that nurse could have assessed and administered the medication, not the QMAP. On 6/27/23 at 4:00 p.m., the administrator stated she was unaware Resident #34 had a PRN medication administered by a QMAP without requesting the medication. On 6/27/23 at approximately 4:00 p.m., the regional director of operations stated QMAPs were not allowed to make decisions related to medication. She added the residence had trained the QMAPs on 6/2/23 regarding that.

A licensure complaint, prompted by #CO31451, was completed on 6/27/23. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to ensure a current resident roster that contained resident room assignments and emergency contact information along with a residence diagram that showed rooms locations was readily available, affecting 70 current residents. Findings include: On 6/27/23 at 7:10 a.m., upon entrance to the residence, an unidentified staff member greeted the surveyors. A resident roster was requested and the staff member responded she would ask where to obtain a resident roster. On 6/27/23 at 7:43 a.m., a resident roster was requested from Staff #35. Staff #35 was unable to provide a current resident roster. On 6/27/23 at 7:43 a.m., Staff #35 stated she believed the resident roster was in the utilized computer system; however, she was unable to locate it or print documents from the computer system. She stated the residence had no resident roster required to have been provided in the event of an emergency. On 6/27/23 at 8:01 a.m., a resident roster was requested from the administrator. On 6/27/23 at 8:14 a.m., the administrator provided a resident roster that contained resident names and room numbers. However, the resident roster did not contain emergency contact information for the residents or a residence diagram that showed room locations. Additionally, the resident roster contained three former residents that were no longer current residents and were former residents prior to the onsite visit. On 6/27/23 at 3:35 p.m., the regional nurse consultant stated the resident roster was a quick print from the electronic system of resident face sheets. On 6/27/23 at 3:52 p.m., the administrator provided a second resident roster, dated 6/7/23. The second resident roster was 18 pages long and contained resident names and emergency contact information. However, the resident roster did not include room numbers or a diagram that showed room locations. The resident roster had each resident listed multiple times with different emergency contact information listed next to each one. Additionally, the resident roster contained two former residents that were no longer current residents and were former residents prior to the onsite visit. On 6/27/23 at approximately 4:00 p.m., the administrator stated the second provided resident roster was the most current resident roster as she printed it on 6/7/23. She stated she printed a current resident roster once a month. The administrator stated one of the residents that was former had recently passed away and had not yet been moved out of the financial system which was why she was still listed on the roster. The administrator stated she was not aware room numbers were required to be listed on the resident roster. She acknowledged she was not aware the resident roster should have contained a residence diagram that showed room locations.

Based on observation, interview and record review the residence failed to either directly or indirectly through a resident agreement provide personal services and a safe and sanitary environment affecting two of five sample residents (#11, #21). Findings include:1. Residence PolicyThe residence's resident agreement, dated February 2019, read in part: The residence agreed to provide personal services. Chapter VII regulations governing assisted living residences, defines personal services as services that an assisted living residence and its staff provide for each resident including, but not limited to: (D) Assistance with activities of daily living. 2. Resident #21 was admitted to the residence on 12/28/19 with a diagnosis of Parkinson's disease. a. Safe and Sanitary Environment On 6/27/23 at 7:41 a.m., during morning medication pass the memory care director (MCD) prepared a medication for Resident #21 and dispensed it into a cup. The MCD subsequently closed the medication cart and removed her keys. She then opened the door that led to Resident #21's room. The MCD once in the room, greeted Resident #21 and administered her medication while the resident was laying down. The medication subsequently fell out of the side of her mouth. The MCD picked up the pill with her bare hand off the resident's bedding and placed the pill back into Resident #21's mouth. The MCD had her swallow the medication with a cup of water. Progress notes read in part:On 2/2/23, Resident #11 was having difficulty getting food down at lunch. Staff assisted the resident with clearing the food object. Resident was placed on alert charting due to coughing during meals. On 2/5/23 Resident #11 was on alert charting due to coughing during meals. Since having issues swallowing, the resident has been very scared to eat any meals. Care staff have been cutting meals very small for the resident to make sure she does not cough during meals again. On 6/27/23 at 3:57 p.m., the regional nurse consultant stated medication should have not been administered while laying down and the resident should have been upright to take the medication. The regional nurse further stated that the MCD should have not picked up the medication with her bare hand after it fell and administer it to the resident. On 6/27/23 at 4:00 p.m., the administrator stated the medication should have not been picked up with the MCD's bare hand and she should have worn a glove. b. Personal ServicesThe care plan for Resident #21, dated 4/6/23, read in part: Staff were to use caution and protect extremities during transfers to prevent bruises and lacerations. A written practitioner's order, dated 4/27/23, directed the residence to administer arm protectors each morning. However, the May 2023 medication administration record (MAR) read they were not administered on 5/14 and 5/16/23. On 6/27/23 at 12:39 p.m., the family member for Resident #21 stated the last couple times he had visited the residence. Resident #21 was not observed to have been wearing her protective sleeves. 3. Resident #11 was admitted to the residence on 1/28/22 with a diagnosis including acute kidney failure. The care plan for Resident #11, dated 10/3/22, read in part staff were to put compression stockings on in the morning and remove them at night. The care plan further read staff were to wash the compression stockings nightly after each use and hang dry. A written practitioner's order, dated 3/28/23, directed the residence to administer compression stockings once daily in the morning and remove at night. However, the June 2023 MAR read the compression stockings were not administered from 6/10-6/26/23 as they were too small. MAR exceptions for June 2023 read in part:On 6/10/23 at 8:36 a.m., compression stockings were not administered as they were too small and needed a larger size. On 6/10/23 at 8:17 p.m., compression stockings were not administered as the wrong size came in and the residence was waiting on a new pair. On 6/11/23 at 9:32 a.m., compression stockings were not administered as they were the wrong size and the residence was awaiting a new pair. On 6/13/23 at 8:24 a.m., left compression stockings off due to staff not removing prior to bedtime. Swelling and circulation cut off was observed. On 6/15/23 at 8:28 a.m., compression stockings were too small for the resident. On 6/17/23 at 9:14 a.m., staff spoke with the family for Resident #11 and they stated they would obtain new compression stockings next week. On 6/19/23 at 8:35 a.m., compression hose were too small and not administered. On 6/21/23 at 8:57 a.m., family was ordering the compression stockings. On 6/25/23 at 10:09 a.m., the practitioner sent an order for a larger size last week. Family was buying a larger size from an online retailer. On 6/27/23 at 12:36 p.m., a family member for Resident #11 stated she has purchased compression stockings of multiple sizes in the past for the resident. She stated she was not aware that the resident needed new compression stockings. On 6/27.23 at 4:00 p.m., the administrator stated that she was notified the day of the on-site visit that Resident #11 had been without her compression stockings.

Based on interview and record review the residence failed to develop and implement a fall management program affecting 70 current residents. Findings include:1. Failure to develop a fall management program:a. Chapter VII regulations governing assisted living residences, requires in 7.8 (B) (6), that the The assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self study courses, or on-the-job training, and shall include, but is not limited to, the following topics:Training related to fall prevention and ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobility. b. The residence's fall management policy, dated 8/27/20, read in part: The residence would provide initial and ongoing evaluations of each resident's mobility needs as well as seek to minimize risk of injury from falls while promoting resident independence and safety. Residents and their environments were evaluated to identify those at risk for falling, and interventions that might reduce that potential. After any resident fall, staff would review specific care coordination needs and seek to minimize recurrence. Health services staff would evaluate each resident to determine resident status at each of the following times: at time of move in, post occurrence, quarterly, after any change in living location within the residence. Documentation of such evaluation was maintained in the resident's record. An evaluation of the fall potential tool for data collection was available electronically as desired but not required. When an evaluation identified potential risk, staff should discuss and document the following with the resident and/or responsible party: contributing factors linked to creating the risk/trend. Explanation of the evaluation, discussion regarding the benefits of proposed interventions, outcomes, including responses about resident ability and preference related to the proposed interventions. Available resources to assist the resident in achieving mobility goals such as community exercise activities and outside agencies such as physical therapy and occupational therapy. Staff must specify in the care plan any trends, contributing factors and interventions used as well as residents preferred level of participation in interventions which could include refusal of offered increased assistance, participation in outside therapies, participation in the community exercise or activity programs. c. The residence's Caregiver Training policy, dated 9/20/22, read in part: A caregiver who sees or was in contact with a resident about to fall should immediately act as follows; Bring the resident as close to your body as possible, as quickly as possible. Wrap your arms around the resident's wait or hold them under the arms as you begin to guide them down with your feet in a firm stance, flat and wide. Bend at your hips and knees as you begin to slide the resident down your leg. Summon a supervisor immediately and decide what further assistance or care the resident requires. Complete the occurrence report process and document the resident's behavior and actions before the fall, staff response to the fall, if any, as related to the resident's care. Seek to determine why the resident fell and follow up as appropriate to notify management about action suggested to prevent a recurrence. However, the fall management program failed to include how the residence would routinely inspect and maintain the interior and exterior environment and provide staff training related to fall prevention as specified in part 7.8 (B)(6). On 6/27/23 at 10:25 a.m., the regional nurse consultant (RNC) stated the policy that was provided was the residences fall management program and she was not aware why all of the elements that were required were not addressed in the policy. On 6/27/23 at 4:00 p.m., the administrator and the regional director of operations (RDO) stated they were not aware the policy was missing the requirements. 2. Failure to implement the fall management program a. Resident #21 was admitted to the residence on 12/28/19 with a diagnosis of Parkinson's disease. A care plan for Resident #21, dated 4/6/23, read in part: Resident #21 required two person staff assistance with transfers, the resident required staff assistance to transfer to chair, toilet, bed, recliner etc. Resident #21 was resistant to transfers, had a high back wheelchair to prevent her from sliding out, staff to use caution and protect extremities during transfers. The category titled fall prevention read the resident was at risk for falls staff was instructed to ensure the resident was upright in her wheelchair, position if sliding, encourage the resident to sleep towards the middle of her bed, staff to provide transfer assistance and night staff were instructed to routinely check on the resident throughout the night. A progress note, dated 5/19/23, read Resident #11 was on alert charting due to a fall with skin tear to the right elbow which occurred on 5/17/23A progress note, dated 6/6/23, read interdisciplinary team review of fall on 5/17/23. No further falls had happened since new interventions were put in place. Resident was checked on throughout the night, made sure she was in the middle of her bed and fall mats placed on the floor. The record for Resident #21 revealed no evidence of a temporary care plan or care plan update to include the individualized approach necessary to address fall risk after Resident #21 fell on 5/19/23. On 6/27/23 at 10:25 a.m., the regional nurse consultant (RNC) any time a resident fell, the caregiver, herself and the qualified medication administration person would huddle and write down interventions which were then discussed in the weekly fall meetings. She stated a fall required alert charting and a temporary care plan would be implemented. The RNC stated the temporary care plan would instruct staff on interventions following any falls and was accessible to staff. On 6/27/23 at 12:39 p.m., a family member for Resident #21 stated the resident was prone to falling when she tried to complete a task without asking for assistance. On 6/27/23 at 2:36 p.m., Staff #47 stated she was not aware of any fall interventions that were implemented for Resident #21. She stated Resident #21 did not even ambulate independently and she was not aware that the resident was a fall risk. On 6/27/23 at 3:15 p.m., The RNC stated she did not remember discussing the fall with Resident #21 and would have to investigate the incident. On 6/27/23 at 4:00 p.m., the administrator stated Resident #21 on 5/19/23 had fallen out of bed and further stated nothing different should have been done. b. Resident #33 was admitted to the residence on 5/11/23 with diagnoses of osteoporosis and advanced dementia. A progress note, dated 4/28/23 read the resident was on alert charting from a fall which occurred on 4/26/23. Fall interventions were reviewed and no further falls had occurred since new interventions were put in place. The record for Resident #33 revealed no evidence of a temporary care plan after the fall that occurred on 4/26/23. A progress note, dated 4/30/23 read Resident #33 had a fall which occurred between 4:11 a.m. and 4:30 a.m. The resident was found on the floor by staff and stated she had hit the back of her head and stated she fell because she felt weak. Resident #33 did not sleep well and was up and down all night. A progress note, dated 5/13/23 read Resident #33 was on alert charting for a fall without injury which occurred on 4/30/23. Resident #33 rarely slept at night. The practitioner was aware and making adjustments. Resident stays up at night and drinks coffee, this seems to increase the risk of her falling. Requested decaffeinated coffee from the family. A care plan for Resident #33, dated 5/16/23, read in part: The resident was at risk for falls. The residence was required to have the following fall interventions in place, shower mat, lamp left on at all times, encourage the use of her walker for all mobility, check the resident apartment for trip hazards frequently, ensure proper footwear when out of her room physical therapy orders sent to home health. The resident had a tendency to walk around without her assistive device, slightly hunched over with her hands behind her back and has a tendency to make sudden moves. Resident #33 had several falls in the last 90 days, one resulting in a nose fracture. The record for Resident #33 revealed no evidence of temporary care plans and no evidence of the fall intervention of decaffeinated coffee per the residence's progress note written on 5/13/23. A progress note, dated 6/25/23, read Resident #33 had a fall without injury. Staff witnessed the fall and assisted her, she fell on her bottom and staff informed the memory care director and the practitioner. Safety checks completed on the resident. On 6/27/23 at 2:38 p.m., Staff #47 stated the only fall intervention for Resident #33 that she was aware of, was to ensure the resident utilized her walker when ambulating. On 6/27/23 at 3:15 p.m., RNC stated the residence's process for fall management was to discuss falls and fall interventions weekly during a meeting. She stated this process was implemented around May 2023. She further stated regarding the fall on 6/25/23 that the residence had not discussed the fall because the residence met on Thursdays and discussed falls (the next meeting was scheduled 6/29/23. On 6/27/23 at 4:00 p.m., the RDO stated when a resident fell the process was for the residence to put a temporary care plan in place to prevent further falls.

Based on record review and interview, the residence failed to ensure qualified medication administration persons (QMAPs) were not permitted to make decisions regarding as needed (PRN) medication or utilize judgment in regards to medication effect, affecting two of five sample residents (#33,#34). Findings include: 1. Resident #33 was admitted to the residence on 5/11/23 with diagnoses that included constipation. A written practitioner's order, dated 5/17/23, directed the residence to administer polyethylene glycol 17 g once daily. However, the June 2023 medication administration record (MAR) read the medication was held due to loose stools on 6/14/23 and 6/22/23. The June 2023 MAR had notes documented by Staff #45, a QMAP, that read the following:On 6/14/23 Staff #45 documented Resident #33's polyethylene glycol was "held due to resident having a lot (sic) of loose bowel movement overnight and during morning." On 6/22/23 Staff #45 documented Resident #33's polyethylene glycol was "withheld due to loose watery stools and stomach issues." The residence was unable to provide a written practitioner's order directing the residence to hold the medication. On 6/27/23 at approximately 3:15 p.m., the regional nurse consultant stated she was aware QMAPs could not make the judgement to hold Resident #33's polyethylene glycol. She acknowledge she was aware the medication was held. On 6/27/23 at 4:00 p.m., the administrator stated without a practitioner's order or external hospice providing a verbal order the QMAP should not have held Resident #33's medication. She stated the practitioner's order did not specify to hold the medication if the resident experienced loose stool. 2. Resident #34 was admitted to the residence on 3/31/18. A written practitioner's order, dated 6/16/23, directed the residence to administer lorazepam 0.5 mg every four hours as needed for anxiety and agitation. The June 2023 MAR read the residence had administered lorazepam on 6/21/23. The MAR read Staff #46 (QMAP) administered the medication. The reason the medication was given read "approved by hospice for behaviors." A progress note, dated 6/21/23, authored by Staff #46 read; "called and spoke to agent at (external hospice agency) fro(sic) approval for lorazepam PRN (prescription as needed) for behaviors. For last for (sic) days resident has not slept repeatedly presses pager insisting it was day time and wanted up ... Nurse called ... approval for PRN administration per PRN order. I (Staff #46 QMAP) administered medication." On 6/27/23 at approximately 3:15 p.m., the regional nurse consultant stated the QMAP should not have administered the PRN lorazepam to Resident #34. She stated the external hospice nurse should have came to the residence and assessed the resident. The regional nurse consultant stated if the residence had a registered nurse on staff that nurse could have assessed and administered the medication, not the QMAP. On 6/27/23 at 4:00 p.m., the administrator stated she was unaware Resident #34 had a PRN medication administered by a QMAP without requesting the medication. On 6/27/23 at approximately 4:00 p.m., the regional director of operations stated QMAPs were not allowed to make decisions related to medication. She added the residence had trained the QMAPs on 6/2/23 regarding that.

Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of five sample residents (#11, #21, #33, #35). Findings include: 1. Residence PolicyThe residence's undated Medication Systems policy read in part; "The (residence) must obtain and review orders signed by a legally authorized practitioner for each resident who receives assistance with administration of medication ... Staff shall follow requirements for (residence/practitioner) communication about orders, as specified in the communication system description ..."2. Resident #35 was admitted to the residence on 4/24/23 with no listed diagnoses. a. AtorvastatinA written practitioners order dated 5/1/23 directed the residence to administer atorvastatin 20 mg daily. However, the May 2023 medication administration record (MAR) read the medication was not administered as ordered on 5/14-5/17/23 due to the medication not being unavailable, for a total of four missed doses. b. DonepezilA written practitioners order dated 5/1/23 directed the residence to administer Donepezil 5 mg daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/11, 5/12 and 5/14/23 due to the medication being unavailable, for a total of three missed doses. A written practitioners order dated 6/5/23 directed the residence to discontinue Donepezil 5 mg daily. However, the June 2023 MAR read the medication continued to be administered on 6/6-6/9/23, for a total of four additional doses.c. FurosemideA written practitioners order dated 5/1/23 directed the residence to administer furosemide 20 mg daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/11/23, due to the medication being unavailable, for a total of one missed dose. d. Glipizide A written practitioners order dated 5/1/23 directed the residence to administer Glipizide 5 mg 1 and one half tablets daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/10 and 5/11/23 due to the medication being unavailable, for a total of two missed doses. e. Magnesium A written practitioners order dated 5/1/23 directed the residence to administer magnesium 250 mg daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/4/23 due to the medication being unavailable, for a total of one missed dose. f. Metoprolol A written practitioners order dated 5/1/23 directed the residence to administer metoprolol tartrate 25 mg one half tablet twice daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/11/23 due to the medication being unavailable, for a total of two missed doses. g. Theragran-MA written practitioners order dated 5/1/23 directed the residence to administer theragran-M premier 50 plus 400-250-375 MCG daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/4 and 5/7-5/11/23 due to the medication being unavailable, for a total of three missed doses. On 6/27/23 at approximately 3:15 p.m., the regional nurse consultant stated she was aware of the medication issues with Resident #35. She stated she had communicated with the residence to resolve the medication issues. She stated she could not recall why the medications had such difficulties. The regional nurse consultant stated the medications should have been administered as ordered. She stated the residence staff should have contacted the practitioner to get a hold order or an order for a comparative medication depending on the reason it was unavailable. The regional nurse consultant stated if the residence received a discontinue order for a medication the medication should not have been administered additional doses. On 6/27/23 at 4:00 p.m., the administrator stated she did not remember why the medications were not administered for Resident #35. She stated if a medication was discontinued the medication should not have been administered. On 6/27/23 at approximately 4:00 p.m., the regional director of operations stated if they residence had orders to administer the medications the medications should have been administered. She stated she believed if a discontinue order was received for a medication the residence should have had time to process the order before stopping the medication. 3. Resident #11 was admitted to the residence on 1/28/22 with a diagnosis of atrial fibrillation. A written practitioner's order, dated 3/28/23, directed the residence to administer warfarin sodium 5 mg every Monday, Tuesday, Thursday, Friday and Sunday. However, the May 2023 MAR read the medication was not administered on 5/28 and 5/29/23 as the medication was not available. On 6/27/23 at 12:36 p.m., the responsible party for Resident #11 stated she had not been made aware the resident did not receive her warfarin sodium as prescribed. On 6/27/23 at 4:00 p.m., the administrator stated she was not aware why Resident #11 went without her prescribed warfarin sodium. She further stated that the medication was not on cycle fill which may have been the reason why the medication was not available to administer. 4. Resident #21 was admitted to the residence on 12/28/19 with a diagnosis of Parkinson's disease. A written practitioner's order, dated 3/28/23, directed the residence to administer carbidopa-levodopa 25-100 three times daily. However, the May 2023 MAR read the medication was not administered on 5/30/23 at 4:00 p.m. as the medication was not available. On 6/27/23 at 3:15 p.m., the regional nurse consultant stated she was aware the carbidopa-levodopa was not administered; however, she could not recall the reason. She further stated the residence was notified each time a medication was not administered and she reviewed the notes regularly and followed up with staff. On 6/27/23 at 4:00 p.m., the administrator stated she was aware Resident #21 had missed her carbidopa-levodopa. However, she stated she was not sure why the medication was missed as it was cycle filled and confirmed it should have not been missed. A written practitioner's order, dated 6/16/23, directed the residence to administer ondansetron 4 mg three times daily. However, the June 2023 MAR read the medication was administered twice on 6/21/23 at 9:00 p.m. 5. Resident #33 was admitted to the residence on 5/11/23 with a fractured nose. A written practitioner's order, dated 5/31/23, directed the residence to administer hydrocodone - acetaminophen 5-325 once daily at bedtime. However, the June 2023 MAR read the medication was not administered from 6/19-6/26/23 as the medication was out of stock. A practitioner's notification, dated 6/23/23, read the medication had not been administered as it required a refill. During a medication cart audit it was revealed the medication was not in stock. On 6/27/23 at 4:00 p.m., the administrator stated she was not aware of the circumstances regarding the hydrocodone- acetaminophen for Resident #33.

A licensure revisit was completed on 6/27/23 for the previous deficiency cited on 11/2/22. A deficiency was cited.

Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of five sample residents (#11, #21, #33, #35). This deficiency was cited previously during a state licensure survey 11/2/22. 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 Systems policy read in part; "The (residence) must obtain and review orders signed by a legally authorized practitioner for each resident who receives assistance with administration of medication ... Staff shall follow requirements for (residence/practitioner) communication about orders, as specified in the communication system description ..."2. Resident #35 was admitted to the residence on 4/24/23 with no listed diagnoses. a. AtorvastatinA written practitioners order dated 5/1/23 directed the residence to administer atorvastatin 20 mg daily. However, the May 2023 medication administration record (MAR) read the medication was not administered as ordered on 5/14-5/17/23 due to the medication not being unavailable, for a total of four missed doses. b. DonepezilA written practitioners order dated 5/1/23 directed the residence to administer Donepezil 5 mg daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/11, 5/12 and 5/14/23 due to the medication being unavailable, for a total of three missed doses. A written practitioners order dated 6/5/23 directed the residence to discontinue Donepezil 5 mg daily. However, the June 2023 MAR read the medication continued to be administered on 6/6-6/9/23, for a total of four additional doses.c. FurosemideA written practitioners order dated 5/1/23 directed the residence to administer furosemide 20 mg daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/11/23, due to the medication being unavailable, for a total of one missed dose. d. Glipizide A written practitioners order dated 5/1/23 directed the residence to administer Glipizide 5 mg 1 and one half tablets daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/10 and 5/11/23 due to the medication being unavailable, for a total of two missed doses. e. Magnesium A written practitioners order dated 5/1/23 directed the residence to administer magnesium 250 mg daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/4/23 due to the medication being unavailable, for a total of one missed dose. f. Metoprolol A written practitioners order dated 5/1/23 directed the residence to administer metoprolol tartrate 25 mg one half tablet twice daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/11/23 due to the medication being unavailable, for a total of two missed doses. g. Theragran-MA written practitioners order dated 5/1/23 directed the residence to administer theragran-M premier 50 plus 400-250-375 MCG daily. However, the May 2023 MAR read the medication was not administered as ordered on 5/4 and 5/7-5/11/23 due to the medication being unavailable, for a total of three missed doses. On 6/27/23 at approximately 3:15 p.m., the regional nurse consultant stated she was aware of the medication issues with Resident #35. She stated she had communicated with the residence to resolve the medication issues. She stated she could not recall why the medications had such difficulties. The regional nurse consultant stated the medications should have been administered as ordered. She stated the residence staff should have contacted the practitioner to get a hold order or an order for a comparative medication depending on the reason it was unavailable. The regional nurse consultant stated if the residence received a discontinue order for a medication the medication should not have been administered additional doses. On 6/27/23 at 4:00 p.m., the administrator stated she did not remember why the medications were not administered for Resident #35. She stated if a medication was discontinued the medication should not have been administered. On 6/27/23 at approximately 4:00 p.m., the regional director of operations stated if they residence had orders to administer the medications the medications should have been administered. She stated she believed if a discontinue order was received for a medication the residence should have had time to process the order before stopping the medication. 3. Resident #11 was admitted to the residence on 1/28/22 with a diagnosis of atrial fibrillation. A written practitioner's order, dated 3/28/23, directed the residence to administer warfarin sodium 5 mg every Monday, Tuesday, Thursday, Friday and Sunday. However, the May 2023 MAR read the medication was not administered on 5/28 and 5/29/23 as the medication was not available. On 6/27/23 at 12:36 p.m., the responsible party for Resident #11 stated she had not been made aware the resident did not receive her warfarin sodium as prescribed. On 6/27/23 at 4:00 p.m., the administrator stated she was not aware why Resident #11 went without her prescribed warfarin sodium. She further stated that the medication was not on cycle fill which may have been the reason why the medication was not available to administer. 4. Resident #21 was admitted to the residence on 12/28/19 with a diagnosis of Parkinson's disease. A written practitioner's order, dated 3/28/23, directed the residence to administer carbidopa-levodopa 25-100 three times daily. However, the May 2023 MAR read the medication was not administered on 5/30/23 at 4:00 p.m. as the medication was not available. On 6/27/23 at 3:15 p.m., the regional nurse consultant stated she was aware the carbidopa-levodopa was not administered; however, she could not recall the reason. She further stated the residence was notified each time a medication was not administered and she reviewed the notes regularly and followed up with staff. On 6/27/23 at 4:00 p.m., the administrator stated she was aware Resident #21 had missed her carbidopa-levodopa. However, she stated she was not sure why the medication was missed as it was cycle filled and confirmed it should have not been missed. A written practitioner's order, dated 6/16/23, directed the residence to administer ondansetron 4 mg three times daily. However, the June 2023 MAR read the medication was administered twice on 6/21/23 at 9:00 p.m. 5. Resident #33 was admitted to the residence on 5/11/23 with a fractured nose. A written practitioner's order, dated 5/31/23, directed the residence to administer hydrocodone - acetaminophen 5-325 once daily at bedtime. However, the June 2023 MAR read the medication was not administered from 6/19-6/26/23 as the medication was out of stock. A practitioner's notification, dated 6/23/23, read the medication had not been administered as it required a refill. During a medication cart audit it was revealed the medication was not in stock. On 6/27/23 at 4:00 p.m., the administrator stated she was not aware of the circumstances regarding the hydrocodone- acetaminophen for Resident #33.