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Source: CO Dept. of Public Health & Environment
No deficiencies are reported in this inspection record.
A revisit survey was completed on 2/12/24 for all previous deficiencies cited on 11/1/23. 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 was completed on 11/1/23. Deficiencies were cited. A change of ownership occurred on 8/3/23. Based on observation and interview, the residence failed to ensure all medications, including controlled substances, were stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons or other licensed staff, affecting four current residents (#2-#5). Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 14.39, requires that controlled substances shall be kept in double lock storage.2. Observations and interviewsOn 11/1/23 at 7:35 a.m., an environmental tour of the residence revealed that the medication cart had been left unlocked with drawers open, and medications were left on top of the medication cart and on the table next to the medication cart. Residents #3 and #4 had sat at the dining room table. The medication cart had been positioned approximately 20 feet from the dining room table adjacent to the kitchen; no staff were present. On 11/1/23 at 7:35 a.m., Staff #1 opened the front door to the residence. After talking for a f.. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting two of three sample residents (#1, #2).Findings include:1. Residence PolicyThe residence' s written orders policy, dated 2023, read, "The residence shall be responsible for complying with authorized practitioner' s orders associated with medication administration except for those medications which a resident self-administers." 2. Resident #2 was admitted to the residence on 7/1/23 with diagnoses including unspecified dementia.a. Zolpidem A written practitioner' s order, dated 6/12/23, directed the residence to administer zolpidem tart 10 mg before bed. However, the October 2023 medication administration record (MAR) read a circle with initials that the medication was not available and not administered on 10/2-10/3/23, for a total of two missed doses. b. GuaiFENesin DMA written practitioner' s order, dat.. 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. 21.4 Porches, stairs, handrails, and ramps shall be maintained in good repair.
A recertification survey was completed on 11/1/23. A deficiency was cited. 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 five current residents (#1-#5).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.a. Residence PolicyThe residence' s written orders policy, dated 2023, read, "The residence shall be responsible for complying with authorized practitioner' s orders associated with medication administration except for those medications which a resident self-administers." b. Resident #2 was admitted to the residence on 7/1/23 with diagnoses including unspecified dementia.Zolpidem A written practitioner' s order, dated 6/12/23, directed the residence to administer zolpidem tart 10 mg before bed. However, the October 2023 medication administration record (MAR) read a circle with initials that the medication was not available and not administered on 10/2-10/3/23, for a total of two missed doses. GuaiFENesin DMA written practitioner' s order, dated 10/2/23, directed the residence to administer GuaiFENesin DM 10 ml every four hours. However, the October 2023 MAR read X, and the medication was not administered until 10/12/23 for a total of 73 missed doses. c. Resident #1 was admitted to the residence on 9/18/23 with diagnoses including unspecified dementia.Metoprolol A written practitioner' s order, dated 10/14/23, directed the residence to administer metoprolol tartrate 25 mg, 1/2 tab by mouth twice daily. However, the October 2023 medication administration record (MAR) read X, and the medication was not administered on the mornings of 10/30 and 10/31/23, and the evening doses on 10/30/23 and 10/31/23, for a total of four missed doses. Vitamin B12 ..
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