PRIMROSE RETIREMENT COMMUNITY OF PUEBLO

A revisit survey was completed on 9/24/25 for all previous deficiencies cited on 7/29/25. The facility is in compliance with all deficiencies that were cited.

A relicensure and complaint revisit was completed on 7/29/25 for all previous deficiencies cited on 3/18/25. A deficiency was cited. The regulations governing Assisted Living Residences were revised, and the new Chapter VII regulations were implemented on 7/1/25.

Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S (A-I), affecting 43 current residents. This deficiency was cited previously during a survey and complaint investigation concluded on 3/18/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 7/29/25 at approximately 8:17 a.m., the Involuntary Discharge Grievance Policy was requested. The residence was unable to provide an Involuntary Discharge Grievance Policy. On 7/29/25 at approximately 3:00 p.m., the administrator stated the corporate office was responsible for creating the policies and procedures for the residence. She stated that after the previous event on 3/18/25, she sent the regulation to the corporate office, and they reviewed their involuntary discharge policy. She further stated that the corporate office did not make any changes and submitted their plan of correction to the department, which was accepted. The administrator stated that because their plan of correction was accepted, she was under the impression that everything was fine.

A complaint revisit was completed on 7/29/25 for all previous deficiencies cited on 3/18/25. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event OB4R13 were cited prior to the regulation revision that was implemented on 7/1/25.

A licensure revisit was completed on 7/29/25 for all previous deficiencies cited on 3/18/25. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event P5FG14 were cited prior to the regulation revision that was implemented on 7/1/25.

A relicensure survey with complaint #CO38127 was completed on 3/18/25. Deficiencies were cited.

12.2.1 (Generic Tag) Infectious Disease Mitigation, Vaccine, and Treatment Plans (A) All facilities licensed under this chapter shall establish and maintain an infectious disease mitigation, vaccine and treatment plan. This plan shall address, at a minimum, the following:(1) Identification of designated staff who shall coordinate vaccine information, administration, and tracking and reporting of the vaccination status of staff and, if applicable, residents on an ongoing basis;(2) The name and location of the infectious disease vaccine and treatment provider(s) that will be used by the facility to facilitate administration of vaccines and treatment;(3) How the facility will assess and address the vaccination of new staff and, if applicable, residents. Based on record review and interview, the residence failed to establish, maintain, and implement infectious disease mitigation, vaccine and treatment plans, affecting 42 current residents. Findings include:On 3/18/25 at 7:42 a.m., the residence's infectious disease mitigation, vaccine, and treatment plans were requested but not provided. On 3/18/25 at 3:00 p.m., the administrator acknowledged that the residence did not have an infectious disease mitigation, vaccine, and treatment plan.

12.2.2 (Generic Tag) Infection Control Officer(B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility ' s Infection Prevention and Control Program and training. This individual shall be responsible for the following:(1) Completing an infection prevention and control training from a nationally-recognized provider within two (2) weeks of appointment/designation that meets the following requirements based on facility type;(a) Infection Control Officers at nursing care facilities and intermediate care facilities for persons with intellectual and developmental disabilities shall complete at least nineteen (19) hours of initial training.(b) Infection Control Officers at assisted living residences and all group homes for persons with intellectual and developmental disabilities shall complete at least 1.5 hours of initial training.(2) Completing a minimum of 1.5 hours of continuing education in infection prevention and control on an annual basis from a nationally-recognized provider sufficient to stay current on changing guidance and requirements in the field;(3) Providing on-site management of infectious disease prevention and response activities and general infection prevention duties;(4) Ensuring the facility complies with Department reporting requirements related to infectious diseases;(5) Providing facility access to, and ensuring proper supply, use, handling, and implementation of Personal Protective Equipment (PPE) and disinfectants, used per manufacturer ' s guidelines;(6) Maintaining a facility respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protection standard (29 CFR 1910.134);(7) Advising and educating residents, staff, and visitors on current precautions being taken in the facility for infectious diseases and the prevention of their spread; and(8) Notifying residents, designated representatives, and staff of updated Centers for Disease Control (CDC) vaccination recommendations, and ensuring vaccines for infectious diseases are available to staff and residents inside their facility within sixty (60) days of any update to the CDC's vaccine recommendations. Based on record review and interview, the residence failed to assign at least one staff member responsible for the site management of the residence's infection prevention and control program and training, affecting 42 current residents. Findings include:On 3/18/25 at 7:42 a.m., the residence's completed training certificates for the infection prevention and control officer were requested but not provided. On 3/18/25 at 3:00 p.m., the administrator acknowledged that the residence did not have a designated infection control officer; therefore the residence had not completed training from a nationally recognized provider for the infectious diseases mitigation program.

Based on record review and interview, the residence failed to ensure the administrator completed the additional 10 hours of training as required, affecting 42 current residents. Findings include:The personnel record for the administrator contained a certificate for a 30-hour administrator training course dated 5/24/17. The record did not contain an additional 10-hour training course as required. On 3/18/25 at approximately 11:30 a.m., the administrator stated that she completed the 30-hour training; however, she was not aware of the additional 10 hours of training that was required.

Based on record review and interview the residence failed to have at least one staff member onsite at all times who was certified in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognised organization, affecting 42 current residents. (Cross-reference S914)Findings include:On 3/18/25 the residence provided all CPR certifications for all certified staff, however, Staff #27 had a CPR certification that expired January 2025. A staff schedule of staff members certified in CPR for the dates 3/18/25 through 3/22/25 read that Staff #27 worked, without other CPR certified individuals, as follows:3/19/25 between 2:00 a.m. and 6:00 a.m. 3/20/25 between 6:00 a.m. and 2:00 p.m. 3/21/25 between 6:30 a.m. and 2:30 p.m. On 3/18/25 at approximately 9:30 a.m., the administrator stated that the CPR certifications that were provided were all that were available. She stated that she was aware that Staff #27 had an expired CPR certification.

Based on record review and interview the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S (A-I), affecting 42 current residents. Findings include:On 3/18/25 at approximately 7:30 a.m. the Involuntary Discharge Grievance Policy was requested. The residence was unable to provide an Involuntary Discharge Grievance Policy. On 3/18/25 at approximately 3:30 p.m., the administrator stated that she was unaware of the regulation requirements for an Involuntary Discharge Grievance Policy.

Based on record review and interview the residence failed to have a roster of current residents which included emergency contact information and residence diagram showing room locations, affecting 42 current residents. (Cross-reference S914)Findings include:On 3/18/25 at approximately 7:30 a.m., a resident roster was requested. On 3/18/25 at approximately 8:00 a.m., the residence provided a resident roster, however, the resident roster that was provided did not include residents emergency contact information or a residence diagram showing room locations. On 3/18/25 at approximately 3:30 p.m., the administrator stated that she was unaware of the regulation requirement that resident rosters include emergency contact information and a residence diagram showing room locations.

Based on record review and interview, the residence failed to develop policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, affecting 42 current residents. (Cross-reference S0734 and S910)Findings include:On 3/18/25 at approximately 7:30 a.m., all emergency preparedness policies were requested. On 3/18/25 at approximately 6:00 p.m., the residence provided a document titled Evacuation of Residents. The document provided failed to address the continuation of necessary care to all residents for at least 72 hours immediately following any emergency. On 3/18/25 at approximately 5:00 p.m., the administrator stated that she would email the document titled Evacuation of Residents. She stated that this document would fulfill the requirement for the continuation of necessary care to all residents for at least 72 hours following any emergency to include a long-term power failure. On 3/18/25 at approximately 5:00 p.m., the administrator stated this deficiency that was previously cited was not corrected because she believed the document titled Evacuation of Residents met the requirements.

Based on record review and interview the residence failed to develop policies and procedures to establish a fall management program which detailed in each resident ' s care plan the individualized approach necessary to address fall risk, affecting five of five sample residents. (#5, #7, #11, #24, and #25). Specifically, Resident #25 had three documented falls between 1/24/25 and 3/14/25. Two of the falls resulted in injuries such as a skin tear and bleeding from her head. The residence failed to update Resident #25's care plan with individualized approaches necessary to address the resident's fall risk. Additionally, staff were unaware of individualized fall interventions for Resident #25. Findings include:Resident #25 was admitted to the residence on 10/22/22 with a diagnosis of dementia and edema. A care plan, dated January 2025, did not have any fall interventions. A change of condition document dated 1/8/25, read that Resident #25 required physical assistance of one staff member for ambulation, mobility, and/or transfer needs. Additionally, the change of condition form documented that Resident #25 was supposed to use a wheelchair for mobility. A progress note, dated 1/24/25, read that Resident #25 was found on the floor after a fall. The fall resulted in a skin tear. A care plan, dated February 2025, did not have any fall interventions. A progress note dated 2/17/25 read that Resident #25 was found on her floor bleeding from her head after a fall. Resident #25 reported that her legs were sore. Resident #25 was sent to the emergency department for further evaluation. A post fall evaluation dated 2/17/25 did not have fall interventions recorded. A progress note dated 3/14/25 read that Resident #25 sustained a fall in her bathroom after showering due to not holding onto the hand rail when directed to by the care staff. A post fall evaluation dated 3/14/25 did not have fall interventions recorded. An incident report dated 3/14/25 did not have fall interventionsOn 3/17/25 at approximately 12:30 p.m., the director of nursing stated that interventions for residents were added in the incident report, not the care plan. On 3/18/25 at 9:00 a.m., Staff #29 stated that to prevent falls for Resident #25 staff reminded her to use her walker if she woke up in pain and assisted her to her wheelchair when needed. On 3/18/25 at approximately 12:30 p.m., the administrator stated that Resident #25 had fallen right before she received her knee injections monthly. On 3/18/25 at approximately 1:00 p.m., the administrator stated that the director of nursing was responsible for updating interventions in resident care plans. On 3/18/25 at approximately 1:00 p.m., the administrator stated this deficiency was not corrected because the residence failed to resolve it. Similar deficient practice was found for Resident #5, #7, #11, and #24.

Based on record review and interview the residence failed to define procedures to prevent the spread of influenza from unvaccinated healthcare workers, affecting 42 current residents. Findings include:On 3/18/25 at 7:42 a.m., the residence's policy and procedure for unvaccinated workers was requested but not provided. On 3/18/25 at 3:00 p.m., the administrator acknowledged that the residence did not have a policy and procedure in place to prevent the spread of influenza from unvaccinated healthcare workers.

Based on record review and interview the residence failed to prepare or administer only medication that has been ordered by an authorized practitioner, affecting four of four sample residents (#5, #11, #24, and #25). Findings include:Resident #24 was admitted to the residence on 2/14/23 with a diagnosis of prostatic hyperplasia, osteoarthritis, chronic kidney disease, and type 2 diabetes. A medication administration record for March 2025 read that Resident #24 received the following medications daily:Acetaminophen 325 mgCarvedilol 12.5 mgEliquis 5 mgFurosemide 20 mgJardiance 10 mgLevothyroxine 25 mcgLosartan Potassium 50 mgOmeprazole 20 mgSpironolactone 25 mgTrelegy Ellipta 100-62.5-25 mcgOn 3/17/25 at approximately 11:00 a.m. all signed medication administration orders were requested. The residence was unable to provide signed medication administration orders for the medications listed above. On 3/17/25 at approximately 3:00 p.m., the administrator stated that she did not have any other orders for Resident #24. On 3/17/25 at approximately 3:30 p.m., the administrator stated this deficiency was not corrected because the residence failed to resolve it. Similar deficient practice was found for Resident #5, #11, and #25.

Based on interview and records review, the residence failed to document routinely completed audits of the accuracy and completeness of medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records affecting 42 current residents. This deficiency was cited previously during a licensure revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's MARs audit tool titled Medication Pass Report included data of the residents receiving medications, the order start date, the date when the medications were administered, the pain level scale, and the medication route. The report also indicated they were completed by a qualified medication administration personnel (QMAP). The residence's MARs audit tool failed to include: a complete audit of the accuracy and completeness of the MARs, a record of controlled substances, or a review of the disposal of medications. The reports also failed to indicate the administrator and the QMAP supervisor had completed the audits on a quarterly basis. On 3/18/25 at 3:00 p.m. the administrator acknowledged and understood the residence's current review process did not meet the requirements of a quarterly review of the MARs by the administrator and QMAP supervisor. She also stated the review must audit the accuracy and completeness of the MARs, which included controlled substances, and medication disposal. Additionally, the administrator acknowledged that this deficiency was previously cited and was not corrected because she had made a mistake and had not figured out how to do the audit with the residence's new medication administration software.

A licensure complaint revisit was completed on 3/18/25 for all previous deficiencies cited on 7/20/22. The regulations governing Assisted Living Residences were revised. Chapter VII was implemented on 3/17/25.

Based on record review and interview, the residence failed to develop policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, affecting 42 current residents. (Cross-reference S0734 and S910)This deficiency was cited previously during a licensure complaint revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 3/18/25 at approximately 7:30 a.m., all emergency preparedness policies were requested. On 3/18/25 at approximately 6:00 p.m., the residence provided a document titled Evacuation of Residents. The document provided failed to address the continuation of necessary care to all residents for at least 72 hours immediately following any emergency. On 3/18/25 at approximately 5:00 p.m., the administrator stated that she would email the document titled Evacuation of Residents. She stated that this document would fulfill the requirement for the continuation of necessary care to all residents for at least 72 hours following any emergency to include a long-term power failure. On 3/18/25 at approximately 5:00 p.m., the administrator stated this deficiency that was previously cited was not corrected because she believed the document titled Evacuation of Residents met the requirements.

Based on record review and interview the residence failed to develop policies and procedures to establish a fall management program which detailed in each resident ' s care plan the individualized approach necessary to address fall risk, affecting five of five sample residents. (#5, #7, #11, #24, and #25). Specifically, Resident #25 had three documented falls between 1/24/25 and 3/14/25. Two of the falls resulted in injuries such as a skin tear and bleeding from her head. The residence failed to update Resident #25's care plan with individualized approaches necessary to address the resident's fall risk. Additionally, staff were unaware of individualized fall interventions for Resident #25. This deficiency was cited previously during a complaint investigation on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #25 was admitted to the residence on 10/22/22 with a diagnosis of dementia and edema. A care plan, dated January 2025, did not have any fall interventions. A change of condition document dated 1/8/25, read that Resident #25 required physical assistance of one staff member for ambulation, mobility, and/or transfer needs. Additionally, the change of condition form documented that Resident #25 was supposed to use a wheelchair for mobility. A progress note, dated 1/24/25, read that Resident #25 was found on the floor after a fall. The fall resulted in a skin tear. A care plan, dated February 2025, did not have any fall interventions. A progress note dated 2/17/25 read that Resident #25 was found on her floor bleeding from her head after a fall. Resident #25 reported that her legs were sore. Resident #25 was sent to the emergency department for further evaluation. A post fall evaluation dated 2/17/25 did not have fall interventions recorded. A progress note dated 3/14/25 read that Resident #25 sustained a fall in her bathroom after showering due to not holding onto the hand rail when directed to by the care staff. A post fall evaluation dated 3/14/25 did not have fall interventions recorded. An incident report dated 3/14/25 did not have fall interventionsOn 3/17/25 at approximately 12:30 p.m., the director of nursing stated that interventions for residents were added in the incident report, not the care plan. On 3/18/25 at 9:00 a.m., Staff #29 stated that to prevent falls for Resident #25 staff reminded her to use her walker if she woke up in pain and assisted her to her wheelchair when needed. On 3/18/25 at approximately 12:30 p.m., the administrator stated that Resident #25 had fallen right before she received her knee injections monthly. On 3/18/25 at approximately 1:00 p.m., the administrator stated that the director of nursing was responsible for updating interventions in resident care plans. On 3/18/25 at approximately 1:00 p.m., the administrator stated this deficiency was not corrected because the residence failed to resolve it. Similar deficient practice was found for Resident #5, #7, #11, and #24.

Based on record review and interview the residence failed to prepare or administer only medication that has been ordered by an authorized practitioner, affecting four of four sample residents (#5, #11, #24, and #25). This deficiency was cited previously during a complaint investigation on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #24 was admitted to the residence on 2/14/23 with a diagnosis of prostatic hyperplasia, osteoarthritis, chronic kidney disease, and type 2 diabetes. A medication administration record for March 2025 read that Resident #24 received the following medications daily:Acetaminophen 325 mgCarvedilol 12.5 mgEliquis 5 mgFurosemide 20 mgJardiance 10 mgLevothyroxine 25 mcgLosartan Potassium 50 mgOmeprazole 20 mgSpironolactone 25 mgTrelegy Ellipta 100-62.5-25 mcgOn 3/17/25 at approximately 11:00 a.m. all signed medication administration orders were requested. The residence was unable to provide signed medication administration orders for the medications listed above. On 3/17/25 at approximately 3:00 p.m., the administrator stated that she did not have any other orders for Resident #24. On 3/17/25 at approximately 3:30 p.m., the administrator stated this deficiency was not corrected because the residence failed to resolve it. Similar deficient practice was found for Resident #5, #11, and #25.

Based on interview and records review, the residence failed to document routinely completed audits of the accuracy and completeness of medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records affecting 42 current residents. This deficiency was cited previously during a complaint revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's MARs audit tool titled Medication Pass Report included data of the residents receiving medications, the order start date, the date when the medications were administered, the pain level scale, and the medication route. The report also indicated they were completed by a qualified medication administration personnel (QMAP). The residence's MARs audit tool failed to include: a complete audit of the accuracy and completeness of the MARs, a record of controlled substances, or a review of the disposal of medications. The reports also failed to indicate the administrator and the QMAP supervisor had completed the audits on a quarterly basis. On 3/18/25 at 3:00 p.m. the administrator acknowledged and understood the residence's current review process did not meet the requirements of a quarterly review of the MARs by the administrator and QMAP supervisor. She also stated the review must audit the accuracy and completeness of the MARs, which included controlled substances, and medication disposal. Additionally, the administrator acknowledged that this deficiency was previously cited and was not corrected because she had made a mistake and had not figured out how to do the audit with the residence's new medication administration software.

A licensure revisit was completed on 3/18/25 for all previous deficiencies cited on 7/20/22. The regulations governing Assisted Living Residences were revised. Chapter VII was implemented on 3/17/25.

Based on record review and interview the residence failed to have at least one staff member onsite at all times who was certified in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognised organization, affecting 42 current residents. (Cross-reference S914)This deficiency was cited previously during a licensure revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 3/18/25 the residence provided all CPR certifications for all certified staff, however, Staff #27 had a CPR certification that expired January 2025. A staff schedule of staff members certified in CPR for the dates 3/18/25 through 3/22/25 read that Staff #27 worked, without other CPR certified individuals, as follows:3/19/25 between 2:00 a.m. and 6:00 a.m. 3/20/25 between 6:00 a.m. and 2:00 p.m. 3/21/25 between 6:30 a.m. and 2:30 p.m. On 3/18/25 at approximately 9:30 a.m., the administrator stated that the CPR certifications that were provided were all that were available. She stated that she was aware that Staff #27 had an expired CPR certification.

Based on record review and interview, the residence failed to develop policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, affecting 42 current residents. (Cross-reference S0734 and S910)This deficiency was cited previously during a licensure revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 3/18/25 at approximately 7:30 a.m., all emergency preparedness policies were requested. On 3/18/25 at approximately 6:00 p.m., the residence provided a document titled Evacuation of Residents. The document provided failed to address the continuation of necessary care to all residents for at least 72 hours immediately following any emergency. On 3/18/25 at approximately 5:00 p.m., the administrator stated that she would email the document titled Evacuation of Residents. She stated that this document would fulfill the requirement for the continuation of necessary care to all residents for at least 72 hours following any emergency to include a long-term power failure. On 3/18/25 at approximately 5:00 p.m., the administrator stated this deficiency that was previously cited was not corrected because she believed the document titled Evacuation of Residents met the requirements.

Based on record review and interview the residence failed to develop policies and procedures to establish a fall management program which detailed in each resident ' s care plan the individualized approach necessary to address fall risk, affecting five of five sample residents. (#5, #7, #11, #24, and #25). Specifically, Resident #25 had three documented falls between 1/24/25 and 3/14/25. Two of the falls resulted in injuries such as a skin tear and bleeding from her head. The residence failed to update Resident #25 ' s care plan with individualized approaches necessary to address the resident ' s fall risk. Additionally, staff were unaware of individualized fall interventions for Resident #25. This deficiency was cited previously during a licensure revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #25 was admitted to the residence on 10/22/22 with a diagnosis of dementia and edema. A care plan, dated January 2025, did not have any fall interventions. A change of condition document dated 1/8/25, read that Resident #25 required physical assistance of one staff member for ambulation, mobility, and/or transfer needs. Additionally, the change of condition form documented that Resident #25 was supposed to use a wheelchair for mobility. A progress note, dated 1/24/25, read that Resident #25 was found on the floor after a fall. The fall resulted in a skin tear. A care plan, dated February 2025, did not have any fall interventions. A progress note dated 2/17/25 read that Resident #25 was found on her floor bleeding from her head after a fall. Resident #25 reported that her legs were sore. Resident #25 was sent to the emergency department for further evaluation. A post fall evaluation dated 2/17/25 did not have fall interventions recorded. A progress note dated 3/14/25 read that Resident #25 sustained a fall in her bathroom after showering due to not holding onto the hand rail when directed to by the care staff. A post fall evaluation dated 3/14/25 did not have fall interventions recorded. An incident report dated 3/14/25 did not have fall interventionsOn 3/17/25 at approximately 12:30 p.m., the director of nursing stated that interventions for residents were added in the incident report, not the care plan. On 3/18/25 at 9:00 a.m., Staff #29 stated that to prevent falls for Resident #25 staff reminded her to use her walker if she woke up in pain and assisted her to her wheelchair when needed. On 3/18/25 at approximately 12:30 p.m., the administrator stated that Resident #25 had fallen right before she received her knee injections monthly. On 3/18/25 at approximately 1:00 p.m., the administrator stated that the director of nursing was responsible for updating interventions in resident care plans. On 3/18/25 at approximately 1:00 p.m., the administrator stated this deficiency was not corrected because the residence failed to resolve it. Similar deficient practice was found for Resident #5, #7, #11, and #24.

Based on interview and records review, the residence failed to document routinely completed audits of the accuracy and completeness of medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records affecting 42 current residents. This deficiency was cited previously during a licensure revisit on 7/20/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's MARs audit tool titled Medication Pass Report included data of the residents receiving medications, the order start date, the date when the medications were administered, the pain level scale, and the medication route. The report also indicated they were completed by a qualified medication administration personnel (QMAP). The residence's MARs audit tool failed to include: a complete audit of the accuracy and completeness of the MARs, a record of controlled substances, or a review of the disposal of medications. The reports also failed to indicate the administrator and the QMAP supervisor had completed the audits on a quarterly basis. On 3/18/25 at 3:00 p.m. the administrator acknowledged and understood the residence's current review process did not meet the requirements of a quarterly review of the MARs by the administrator and QMAP supervisor. She also stated the review must audit the accuracy and completeness of the MARs, which included controlled substances, and medication disposal. Additionally, the administrator acknowledged that this deficiency was previously cited and was not corrected because she had made a mistake and had not figured out how to do the audit with the residence's new medication administration software.