Aladdin at Brush

A recertification survey with complaint #CO35814 was completed on 5/9/24. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting five of five sample participants (residents) (#1, #9-#12).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires the residence to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. The residence' s medication policy, dated May 2021, read in part, "the (residence) is responsible for complying with physician orders, associated with the administration of medication or treatment, unless the resident self-administers such medication or treatment." b. Resident #10 was admitted to the residence on 4/28/10 with unrelated diagnoses. A written practitioner' s order, dated 1/24/24, directed the residence to administ.. Based on record review and interview, the facility (residence) failed to conduct assessments annually, affecting three of five sample participants (residents) (#1, #9, #10). (Cross-reference Q625)Findings include: 1. Reference and Residence policya. The residence' s resident agreement, dated December 2020, read in part that when a resident' s condition changed, the residence reassessed the resident' s needs.b. The residence' s assessment policy, dated May 2021, read in part that the residence updated the comprehensive assessment for each resident at least annually and whenever the resident' s condition changed from baseline status.2. Resident #10 was admitted to the residence on 4/28/24 with diagnoses including bipolar disorder, hypertension, and hypothyroidism. a. Record ReviewAn assessment, dated 4/11/23, read in part that Resident #10 had substantial dependence for toileting needs. In addition, the resident may need hands-on assistance with undressing, using toilet, and cleaning self. Progress notes dated 10/28/2.. Based on record review and interview, the facility (residence) failed to include in a care plan all special health or behavioral management needs to support the participant' s (resident' s) individual needs affecting five of five sample residents (#1, #9, #10). (Cross-reference Q212)Findings include:1. Residence Policiesa. The residence' s care plan policy, dated May 2021, read in part that the residence developed a care plan with input from the resident, promoted resident independence and safety, and included personal specific needs and preferences along with the staff tasks necessary to meet those needs. The residence updated the care plan to address the resident' s physical, behavioral, cognitive, and functional condition. It further identified the services that the residence provided to address the resident' s changing needs. The residence updated the care plan, when necessary, to note a significant change in baseline status.b. The residence' s resident agreement, dated December 2020, read in part that the residence custom..

A relicensure survey with complaint #CO35813 was completed on 5/9/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting five of five sample residents (#1, #9-#12).Findings include: 1. Residence Policy The residence' s medication policy, dated May 2021, read in part "each qualified medication administration person, nurse, or practitioner must accurately document each medication administration or monitoring event at the time the event is completed for each resident."2. Resident #9 was admitted to the residence on 6/24/22. A written practitioner' s orde.. Based on observation, interview, and record review, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting two of five sample residents (#10, #11).Findings include: 1. Residence PolicyThe residence' s medication policy, dated May 2021, read in part, "the (residence) is responsible for complying with physician orders, associated with the administration of medication or treatment, unless the resident self-administers such medication or treatment." 2. Resident #10 was admitted to the residence on 4/28/10 with unrelated diagnoses. A written practitioner' s order, dated 1/24/24, directed the residence to administer albuterol 90.. Based on record review and interview, the residence failed to detail in each resident' s care plan the individualized approach necessary to address fall risk and provide resident engagement activities to improve strength and balance, affecting one of five sample residents (#9). (Cross-reference S1150)Findings include:1.Residence PolicyThe residence fall management policy, dated May 2021, read in part that the residence' s fall management program included detailing in each resident' s care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment. Addition.. Based on record review and interview, the residence failed to detail personal service needs and preferences along with staff tasks necessary to meet those needs, affecting three of five sample residents (#1, #9, #10). (Cross-reference S1146)Findings include:1. Residence Policiesa. The residence' s care plan policy, dated May 2021, read in part that the residence developed a care plan with input from the resident, promoted resident independence and safety, and included personal specific needs and preferences along with the staff tasks necessary to meet those needs. The residence updated the care plan to address the resident' s physical, behavioral, cognitive, and functional condition. It.. Based on record review and interview, the residence failed to update comprehensive assessments at least annually, affecting three of five sample residents (#1, #9, #10). (Cross-reference S1150, S1180)Findings include: 1. Residence policya. The residence' s resident agreement, dated December 2020, read in part that when a resident' s condition changed, the residence reassessed the resident' s needs.b. The residence' s assessment policy, dated May 2021, read in part that the residence updated the comprehensive assessment for each resident at least annually and whenever the resident' s condition changed from baseline status.2. Resident #10 was admitted to the residence on 4/28/24 with dia..

A relicensure survey and complaint revisit was completed on 5/9/24 for all previous deficiencies cited on 11/16/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 11/15/23. Based on record review and interview, the residence failed to detail in each resident' s care plan the individualized approach necessary to address fall risk and provide resident engagement activities to improve strength and balance, affecting one of five sample residents (#9). (Cross-reference S1146, S1150)This deficiency was cited previously during a state licensure survey 11/26/23. 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 fall management policy, dated May 2021, read in part that the residence' s fall management program included detailing in each resident' s care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment. Additionally, the residence provided resident engagement activities to improve strength and balance.2. .. Based on record review and interview, the residence failed to detail personal service needs and preferences along with staff tasks necessary to meet those needs, affecting three of five sample residents (#1, #9, #10). (Cross-reference S1146)This deficiency was cited previously during a state licensure survey 11/26/23. 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 Policiesa. The residence' s care plan policy, dated May 2021, read in part that the residence developed a care plan with input from the resident, promoted resident independence and safety, and included personal specific needs and preferences along with the staff tasks necessary to meet those needs. The residence updated the care plan to address the resident' s physical, behavioral, cognitive, and functional condition. It further identified the services that the residence provided to address the resident' s changing needs. The residence u.. Based on record review and interview, the residence failed to update comprehensive assessments at least annually, affecting thee of five sample residents (#1, #9, #10). (Cross-reference S1150, S1180)This deficiency was cited previously during a state licensure survey 11/26/23. 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 policya. The residence' s resident agreement, dated December 2020, read in part that when a resident' s condition changed, the residence reassessed the resident' s needs.b. The residence' s assessment policy, dated May 2021, read in part that the residence updated the comprehensive assessment for each resident at least annually and whenever the resident' s condition changed from baseline status.2. Resident #10 was admitted to the residence on 4/28/24 with diagnoses including bipolar disorder, hypertension, and hypothyroidism. a. Record ReviewAn assessmen..

A recertification and complaint revisit was completed on 5/9/24 for all previous deficiencies cited on 11/16/23. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting five of five sample participants (residents) (#1, #9-#12).This deficiency was cited previously during a state licensure survey 11/26/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires the residence to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. The residence' s medication policy, dated May 2021, read in part, "the (residence) is responsible for complying with physician orders, associated with the administration of medication or treatment, unle.. Based on record review and interview, the facility (residence) failed to conduct assessments annually, affecting three of five sample participants (residents) (#1, #9, #10). (Cross-reference Q625)This deficiency was cited previously during a state licensure survey 11/26/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include: 1. Residence policya. The residence' s resident agreement, dated December 2020, read in part that when a resident' s condition changed, the residence reassessed the resident' s needs.b. The residence' s assessment policy, dated May 2021, read in part that the residence updated the comprehensive assessment for each resident at least annually and whenever the resident' s condition changed from baseline status.2. Resident #10 was admitted to the residence on 4/28/24 with diagnoses including bipolar disorder, hypertension, and hypothyroidism. a. Record ReviewAn assessment, dated 4/11/23, read i.. Based on record review and interview, the facility (residence) failed to include in a care plan all special health or behavioral management needs to support the participant' s (resident' s) individual needs affecting five of five sample residents (#1, #9, #10). (Cross-reference Q212)This deficiency was cited previously during a state licensure survey 11/26/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Residence Policiesa. The residence' s care plan policy, dated May 2021, read in part that the residence developed a care plan with input from the resident, promoted resident independence and safety, and included personal specific needs and preferences along with the staff tasks necessary to meet those needs. The residence updated the care plan to address the resident' s physical, behavioral, cognitive, and functional condition. It further identified the services that the residence provided to address the resid..

A complaint revisit was completed on 5/9/24 for the deficiency cited on 11/16/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 11/15/23. Based on record review and interview, the residence failed to detail in each resident' s care plan the individualized approach necessary to address fall risk and provide resident engagement activities to improve strength and balance, affecting one of five sample residents (#9). This deficiency was cited previously during a state licensure survey 11/26/23. 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 fall management policy, dated May 2021, read in part that the residence' s fall management program included detailing in each resident' s care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment. Additionally, the residence provided resident engagement activities to improve strength and balance.2. Resident #9 was admitted to the residence on 6/24/22 with a diagnosis of a history of falls. An incident report, dated 4/6/24, read in part, "Unwitness fall. Went to check on (Resident #9) when it was noticed he wasn' t on time for dinner. Found the resident on the floor bleeding from the head. The physician and family member were notified"A progress note, dated 4/7/24, read in part, "On 4/6/24, (Resident #9) fell over a blanket he had on the corner of his bed. This was what he reported. He was transported to the emergency room and later returned." The care plan for Resident #9, dated 4/11/23, read the resident ambulated independently, exercised independently, was independent with transfers. The care plan was not updated to address the individualized approach necessary to address fall risks.3. Interviews On 5/7/24 at 9:00 a.m., Resident #9 stated he had tripped on a blanket and fell and hit his head. He stated he was transported to the emergency room and received stitches. Resident #9 stated that was the only time he had f..