Bethesda Gardens Loveland

A relicensure survey with complaints #CO34605, #CO36206 and #CO36471, was completed on 6/26/24. Deficiences were cited. Based on interview and record review, the residence failed to accurately document each medication administration at the time the event was completed for each resident, affecting one of three sample residents whose medications were reviewed (#2).Findings include:1. Residence PolicyThe residence' s Medication Administration policy, dated 5/26/22 read in part: "record in the designated area on the medication administration record (MAR) by the following means: initials (mean) given ... on the back of the MAR, note if (a medication) was held, refused, or sent along with a resident."2. Resident #2 was admitted to the residence on 5/26/21 with diagnoses that included osteoarthritis and chronic obstructive pulmonary disease. a. AlbuterolA written practitioner' s order, dated 3/12/24, directed the residence to administer albuterol 90 mcg/act two puffs by mouth four times daily. However, the June 2024 electronic medication administration record (eMAR), contained a blank space on 6/16/24 for the 12:00 p.m. dose, for a total of one inaccurately documented dose.b. Calcium Carbonate/Vitamin D3A written practitioner' s order, dated 3/12/24, directed the residence to administer calcium carbonate/vitamin D3 600 mg daily. However, the June 2024 eMAR, contained a blank space on 6/16/24, for a total of one inaccurately documented dose.3. InterviewOn 6/26/24 at 2:1.. Based on interview and record review, the residence failed to ensure the administrator and qualified medication administration persons supervisor audited the accuracy and completeness of the medication administration records affecting 105 current residents.1. Record review On 6/26/24, documentation of weekly medication audits revealed the resident care coordinator completed weekly medication audits but the administrator did not participate at all. 2. InterviewOn 6/26/24 at approximately 2:15 p.m., the administrator said took the administrator position on April 2024. She said she had not participated in a medication audit since she became the administrator. The administrator said she did not have evidence that the former administrator participated in quarterly medication audits. The administrator was unable to state why the former administrator did not document quarterly medication audits.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of seven sample residents (#20). (Cross-reference Q1514)Findings include:1. Residence Policiesa. The residence' s Medication Administration Error policy, dated 2/21/13, read, in part that a medication error included when a drug was not dispensed. Notification of the non-compliance included omission of a drug for which the reason and justification was not documented, and physician orders were implemented. b. The residence' s medication System policy, dated 1/1/15, read, "New medication will be delivered as soon as possible to the lawfully authorized staff on duty. The staff will check the me.. A licensure complaint, prompted by #CO31287, #CO32341, #CO32745, #CO33010 was completed on 8/28/23. Deficiencies were cited. Based on record review and interview, the administrator failed to, along with the qualified medication administration person (QMAP) supervisor, audit and document the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting six of six sample residents ( #13, #19, #20-#22, #27). ((Cross-reference Q1468)Findings include:On 8/28/23 at 9:35 a.m., the health services director (HSD) stated she and the resident care coordinators were responsible for physically auditing the medication carts. Additionally, she confirmed that she was unaware the administrator was required to participate in the physical audits of medication carts and that the administrator had not done so. On 8/29/23 at 2:15 p.m., Resi.. Based on record review and interview, the residence failed to ensure resident records contained progress notes regarding any out-of-the-ordinary event or issue that affected 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 (#20). Findings include:Resident #20 was admitted to the residence on 7/2/18.Progress notes for Resident #20 in July and August 2023 revealed the following:7/17/23: Resident #20 returned to the residence today from a rehabilitation (rehab) stay for fractured elbow.7/18/23: Resident #20 was unable to check her own blood glucose levels. 7/28/23: "We still do not have an anticipated return date fir (sic) (Resident #20)."8/7/23: Resident #2.. Based on record review and interview, the residence failed to update the comprehensive assessment for each resident whenever the resident' s condition changed from baseline status, affecting one sample resident (#20).Findings include:1. Residence PolicyThe residence' s Functional Assessments policy, dated January 1, 2013 read in part, functional assessments were to be completed every three months until there was no change in level of care for two consecutive assessments, then the assessment was to be reviewed every six months, upon change in condition or after hospitalization. 2. Resident #20 was admitted to the residence on 7/2/18.Progress notes for Resident #20' s for June and July 2023 revealed the following:6/20/23: Resident #20 was observed on the floor next to her kitchen table. Resi..

A licensure revisit was completed on 8/28/23 for all previous deficiencies cited on 11/10/22. A deficiency was cited. Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of seven sample residents (#20). (Cross-reference Q1514)This deficiency was cited previously during a state relicensure survey 6/9/22. 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 Medication Administration Error policy, dated 2/21/13, read, in part that a medication error included when a drug was not dispensed. Notification of the non-compliance included omission of a drug for which the reason and justification was not documented, and physician orders were implemented. b. The residence' s medication System policy, dated 1/1/15, read, "New medication will be delivered as soon as possible to the lawfully authorized staff on duty. The staff will check the medication against the physician' s order for accuracy in labeling." 2. Resident #20 was admitted to the residence on 7/2/18.A written practitioner' s order, dated 8/15/23, directed the residence to administer senna plus 8.6 twice daily. However, the August 2023 electronic medication administration record (eMAR) for Resident #20 read the medication was not available and not administered on 8/23 evening dose, 8/24-8/27 both doses and 8/28/23 morning dose, for a total of 10 missed doses. Progress notes for August 2023 for Resident #20 revealed the following:8/21/23: "Senna not sent out in cycle fill, (practitioner) informed."8/28/23: "Still have not received missing cycle medication, senna for BID (twice daily) dosing."On 8/28/23 at approximately 2:00 p.m., the health service director (HSD) acknowledged that the medication was not available and not administered, as required.

A licensure revisit was completed on 8/28/23 for all previous deficiencies cited on 6/9/22. Deficiencies were cited. Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of seven sample residents (#20). (Cross-reference Q1514)This deficiency was cited previously during a state relicensure survey 6/9/22. 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 Medication Administration Error policy, dated 2/21/13, read, in part that a medication error included when a drug was not dispensed. Notification of the non-compliance included omission of a drug for which the reason and justification was not documented, and physician orders were implemented. b. The residence' s medication System policy, dated 1/1/15, read, "New medication will be delivered as soon as possible to the lawfully authorized staff on duty. The staff will check the me.. Based on record review and interview, the administrator failed to, along with the qualified medication administration person (QMAP) supervisor, audit and document the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting six of six sample residents ( #13, #19, #20-#22, #27). ((Cross-reference Q1468)This deficiency was cited previously during a state relicensure survey 6/9/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 8/28/23 at 9:35 a.m., the health services director (HSD) stated she and the resident care coordinators were responsible for physically auditing the medication carts. Additionally, she confirmed that she was unaware the administrator was required to participate in the physical audits of medication carts and that the administrator had not done so. On 8/29/23 at 2:15.. Based on record review and interview, the residence failed to update the comprehensive assessment for each resident whenever the resident' s condition changed from baseline status, affecting one sample resident (#20).This deficiency was cited previously during a state relicensure survey 6/9/22. 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' s Functional Assessments policy, dated January 1, 2013 read in part, functional assessments were to be completed every three months until there was no change in level of care for two consecutive assessments, then the assessment was to be reviewed every six months, upon change in condition or after hospitalization. 2. Resident #20 was admitted to the residence on 7/2/18.Progress notes for Resident #20' s for June and July 2023 revealed the following:6/20/23: Resident #20 was observed on the floor next to her kitchen table. Resi..