Altavita Memory Care Centre LLC

A relicensure and complaint revisit was completed on 2/19/25 for the previous deficiencies cited on 12/4/24. Deficiencies were cited.Tag S1528 (14.10) was not cited in the previous event; however, the deficiency was included in the previous event' s informational 999 tag. Based on interview and record review, the residence failed to ensure qualified medication administration persons (QMAPs) did not assess residents or make decisions regarding administering medications pro re nata (PRN), affecting one sample resident (#3) residing in the secure environment.Findings include:Resident #3 was admitted to the residence on 10/20/20 with diagnoses of Alzheimer' s disease, anxiety disorder, and irritable bowel syndrome.A written practitioner order, dated 9/13/24, directed the residence to administer one disintegrating ondansetron 4 mg every six hours as needed for nausea and vomiting. The February 2025 medication administration record (MAR) revealed that the health and wellness assistant #1 (HWA1) administered the medication on 2/5/25.A written practitioner order, dated 9/13/24, directed the residence to administer one loperamide HCl 2 mg as needed for diarrhea: administer two tablets with the first loose stool, then one tablet after each subsequent loose stool. The February 2025 MAR revealed that Staff #5 administered one 2 mg tablet on 2/6/25.On 2/19/25 at 10:12 a.m., the health and wellness director (HWD) stated that Resident #3 was unable to request PRN medications by name. She added that she was a nurse and that the regulation required a nurse to make decisions regarding PRN medications. The HWD stated that these decisi.. Based on interview and record review, the residence failed to ensure resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affects a resident' s physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident' s changing needs, affecting one sample resident (#6) residing in the secure environment.This deficiency was cited previously during a relicensure survey and complaint investigation on 12/4/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #6 was admitted to the residence on 12/19/23.Progress notes, dated 2/2/25 and 2/3/25, read in part that Resident #6 had pain; however, the note contained no documented action taken by the residence to meet the resident' s needs.On 2/19/25 at 12:38 p.m., the administrator stated that the residence failed to document the staff actions in progress notes.On 2/19/25 at 12:44 p.m., the health and wellness director stated that on 2/3/25 she completed a full assessment on Resident #6; he was able to move comfortably, and she contacted the resident' s power of attorney and practitioner. However, she stated she did not document her actions in the progress notes.

A relicensure survey with complaints #CO38180 and #CO38342 was completed on 12/4/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure a resident had the right to be free from neglect, affecting one former resident (#5). (Cross-reference S2230)Specifically, the residence failed to provide, in a timely manner, medical care for Resident #5. Resident #5, in a period of eight days, reported pain frequently and was administered medication which was recorded as ineffective. Furthermore, Resident #5 had hallucinations and the residence failed to follow up with the practitioner or transport the resident to the emergency department. Additionally, the residence failed to provide details of the pain to the practitioner and, in turn, Resident #5 went without treatment for the pain for more than 24 hours and without treatment for a urinary tract infection (UTI) for approximately eight days. Findings include:1. Reference Chapter VII regulations governing assisted living residences, part 2.12, defines "Caretaker neglect" as neglect that occurs when adequate food, clothing, shelter, psychological ca.. Based on observation, interview, and record review, the residence failed to ensure that staff documented, before the end of their shift, any out-of-the-ordinary event or issue regarding a resident that they observed or was reported to them, along with the action taken by staff to address that resident' s needs, affecting three of four sample residents (#1, #3, #4) and one former resident (#5). (Cross-reference S1324)Findings include:Resident #3 was admitted to the residence on 10/20/20 with a diagnosis of Alzheimer' s disease.On 12/3/24 at 11:15 a.m., a soiled incontinence product was in the garbage can in the resident' s room. An odor of urine was detectable from the hallway while the resident' s door was closed.An external service provider (ESP) note, dated 10/22/24, read in part that the resident had a history of urinary tract infection (UTI) and that staff should monitor the resident' s behavior, encourage fluids, and check urine as needed. An electronic message, dated 12/1/24 from a family member of the resident to the administrator, read i.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.18 The assisted living residence' s policy shall also require documentation of the action taken by staff and ongoing efforts to prevent a reoccurrence of the situation in the future. 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks:(F) Decision making regarding PRN or "as needed" medication administration.14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routi..