Alternative Care Homes-Marshall

A revisit survey was completed on 11/4/25 for all previous deficiencies cited on 5/20/25. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A Relicensure Survey and complaint revisit was completed on 5/20/25 for all previous deficiencies cited on 12/5/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 3/17/25. Based on observation, record review, and interview, the residence failed to follow their policy and procedure in place regarding the destruction and disposal of outdated, unused, and discontinued and/or expired medications that were not returned to the representative or legal guardian, affecting all current residents. This deficiency was cited previously during a complaint survey on 12/5/23. 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 Medication Destruction and Disposal Policy, dated 11/17/22, read in part "The assisted living residence follows the procedure below regarding the destruction and disposal of outdated, unused, discontinued and/or expired medications within 30 days. Medication will be destroyed on-site in the presence of two individuals, one being a facility qualified medication administration person and the second being a pharmacy consultant. All medications will be destroyed in a manner that renders the substances totally irretrievable. There will be documentation which identifies the medications, the date of destruction and the signatures of the witnesses performing the medication destruction."2. Record ReviewThe residence medication disposal log read that the last me.. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A recertification survey with complaint #CO34188 was completed on 12/5/23. Deficiencies were cited. Based on interview and record review, the facility (residence) failed to ensure the lease, residency agreement, or other written agreement was signed by all parties, including the individual or, if within the scope of their authority, their guardian or other legally authorized representative, affecting three of six sample participants (residents) (#1, #2, #3).Findings include:1. Record Reviewa. Resident #1 was admitted to the residence on 10/1/15. Review of the resident agreement revealed the resident agreement had been signed by the resident and was not dated or signed by the facility administrator.b. Resident #2 was admitted to the residence on 8/30/23. As of 12/5/23 there was no signed resident agreement in the file for Resident #2.c. Resident #3 was admitted to the residence on 9/27/23. Review of the resident agreement revealed the resident agreement had been signed by the resident on 10/10/23 and was not signed by the facility administrator.2. InterviewsOn 12/5/23 at 2:10 p.m. the administrator stated the resident agreement f.. Based on observation, record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting four of four sample participants (residents) (#3, #9, #10, #14).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, require the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.Based on observation, record review, and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting three of six sample residents (#1, #2, #3)Findings include:a. Resident #2 was admitted on 8/30/23 with a diagnosis of bipolar disorder.Omega 3A written practitioners .. Based on record review, observation and interview, the facility (residence) failed to provide age appropriate activities & materials that foster social, intellectual, communicative, & emotional development & challenge the persons receiving services (PRS) to use their skills in these areas, while considering their chronological age, developmental level, and physical skills for PRS receiving day habilitation services affecting six current participants.Findings include:1. Record ReviewReview of the activity schedule revealed two activities would be conducted on 11/5/23 at 9:00 a.m. and 2:00 p.m. The activity schedule was a four week alternating rotation of activities being conducted during the month.2. ObservationOn 12/5/23 at 9:00 a.m. and 2:00 p.m. the scheduled activities for the day were not conducted during the on site visit.3. InterviewsOn 12/5/23 at 8:50 a.m., Resident #5 stated that activities were not conducted.On 12/5/23 at 9:01 a.m., Resident #6 stated that they did not have activiti..

A relicensure survey with complaint #CO34187 was completed on 12/5/23. Deficiencies were cited. Based on interview, and record review, the residence failed to ensure only medications ordered by an authorized practitioner were administered to residents, affecting two of six sample residents (#1, #3).Findings include:1. Record Review Resident #1 was admitted on 10/1/15 with a diagnosis of Bipolar disorder.The October, November, and Dece.. Based on observation, record review, and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting three of six sample residents (#1-#3)Findings Include:1. Resident #2 was admitted on 8/30/23 with a diagnosis of bipolar disorder.a. Omega 3A wri.. Based on observation, record review, and interview, the residence failed to follow their policy and procedure in place regarding the destruction and disposal of outdated, unused, and discontinued and/or expired medications that were not returned to the representative or legal guardian, affecting one of four sample residents with unused medications.. Based on observation, record review, and interview, the residence failed to provide laundry services for the resident affecting one of six sample resident (#2)Findings include:1. Residence PolicyThe residence ' s blank resident agreement read in part, "Facility will provide; laundry services".2. ObservationOn 12/5/23 during an environmental t.. Based on record review and interview, the residence failed to ensure the resident agreement was signed and dated by both parties, affecting three of six sample residents (#1, #2, #3).Findings Include:1. Record Reviewa. Resident #1 was admitted to the residence on 10/1/15. Review of the resident agreement revealed the resident agreement had been .. Based on record review, and interview, the residence failed to implement and follow their policy pertaining to fall management, including detailing in the resident ' s care plan with the individualized approaches necessary to address fall risks, affecting one of six sample residents (#2).Specifically, Resident #2 was admitted to the residence on 8/30/.. Based on record review, observation and interview, the residence failed to provide age appropriate activities & materials that foster social, intellectual, communicative, & emotional development & challenge the persons receiving services affecting six current residents (#1-#6).Findings Include:1. Record Reviewa. Review of the activity s.. Based on record review, observation, and interview, the residence failed to store refrigerated medications in a refrigerator that was not accessible to the residents, affecting 10 current residents.Findings include:1. Residence Policya. The undated medication administration policy, read in part, "Medication that require refrigeration will be ke.. 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 7.14.27 No stock medications shall be stored or administered by qualified medication administ..