Bethhaven House

A relicensure survey was completed on 12/12/23. Deficiencies were cited. Based on observations, record review, and interview, the residence failed to comply with the Colorado Clean Indoor Air Act at Sections 25-14-201 through 25-14-209, C.R.S., affecting eight current residents.Findings include:The Colorado Clean Indoor Air Act, section 25-14-203 (7), defines "Entryway" as the outside of the front or main doorway leading into a building or facility that is not exempted from this part 2 under section 25-14-205. "Entryway" also includes the area of public or private property within a specified radius outside of the doorway. The specified radius may be determined by the local authority pursuant to section 25-14-207 (2)(a), but must be at least twenty-five feet unless section 25-14-207(2)(a)(II)(B) or (2)(a)(II)(C) applies. If the local authority has not acted, the specified radius is twenty-five feet. Colorado Public Health and Environment, retrieved from: https://sbg.colorado.gov/sites/sbg/files/documents/Colorado%20Clean%20Indoor%20Air%20Act.pdfThe residence' s H.. Based on record review and interview, the residence failed to prepare or administer only medication that has been ordered by an authorized practitioner, affecting three of three sample residents (#1-#3).Findings include:1. Residence PolicyThe residence' s medication policy, dated 7/1/16, read in part: "prescription and non-prescription medications are administered only by a qualified medication administration person (QMAP) and only upon a written order of a licensed (practitioner)."2. Resident #3 was admitted to the residence on 10/1/07 with a diagnosis of schizoaffective disorder. a. AtorvastatinThe November and December 2023 medication administration records (MARs) read Resident #3 was administered atorvastatin 40 mg once daily from 11/1-11/25, 11/27 and 11/30-12/11/23 for a total of thirty eight doses. However, the residence was unable to provide a signed practitioner' s order for the medication.b. AspirinThe November and December 2023 MARs read Resident #3 was administered aspirin 81 mg once daily from 11/1-12/12/23.. Based on record review, observation, and interview, the residence failed to ensure the resident' s rights to privacy, affecting eight current residents. Findings include:1. Residence PolicyThe undated residents' Resident Rights policy read in part that residents had the right to privacy.2. ObservationsOn 12/12/23 at 7:56 a.m., a camera was observed on a computer monitor in the staff office behind the medication cart. The camera in the medication room pointed toward residents walking in the common area hallway.On 12/12/23 between approximately 7:30 a.m. - 1:00 p.m., the following observations were made: residents were observed on camera walking in the common area residence hallway when staff were inside the medication room. Further, Resident #4 was observed on the monitor speaking with the residential care coordinator (RCC) inside the medication room. 3. InterviewsOn 12/12/23 at 7:24 a.m., the RCC stated the residence had a camera in the medication room to monitor all current residents. The RCC stated there was a cam..

A recertification survey was completed on 12/12/23. Deficiences were cited. Based on interviews and record review, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting three of three sample participants (residents) (#1-#3).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.11, requires that only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.The residence' s medication policy, dated 7/1/16, read in part: "prescription and non-prescription medications are administered only by a qualified medication administration person (QMAP) and only upon a written order of a licensed (practitioner)."a. Resident #3 was admitted to the residence on 10/1/07 with a diagnosis of schizoaffective disorder. AtorvastatinThe November and December 2023 medication administration records (MARs) read Resident #3 was administered atorvastatin 40 mg once daily from 11/1-11/25, 11/27 and 11/30-.. Based on observation and interviews, the setting (residence) failed to ensure individuals' (residents' ) right to privacy to be free of cameras, affecting eight current residents.Findings include:1. Residence PolicyThe undated residents' Resident Rights policy read in part that residents had the right to privacy.2. ObservationsOn 12/12/23 at 7:56 a.m., a camera was observed on a computer monitor in the staff office behind the medication cart. The camera in the medication room pointed toward residents walking in the common area hallway.On 12/12/23 between approximately 7:30 a.m. - 1:00 p.m., the following observations were made: residents were observed on camera walking in the common area residence hallway when staff were inside the medication room. Further, Resident #4 was observed on the monitor speaking with the residential care coordinator (RCC) inside the medication room. 3. InterviewsOn 12/12/23 at 7:24 a.m., the RCC stated the residence had a camera in the medication room to monitor all current res.. Based on observation, interview and record review the facility (residence) failed to ensure residents had the right to dignity and privacy in their living unit, affecting eight current participants (residents).Findings include:1. Residence PolicyThe undated residents' Resident Rights policy read in part that residents had the right to privacy.2. ObservationsOn 12/12/23 at 7:56 a.m., a camera was observed on a computer monitor in the staff office behind the medication cart. The camera in the medication room pointed toward residents walking in the common area hallway.On 12/12/23 between approximately 7:30 a.m. - 1:00 p.m., the following observations were made: residents were observed on camera walking in the common area residence hallway when staff were inside the medication room. Further, Resident #4 was observed on the monitor speaking with the residential care coordinator (RCC) inside the medication room. 3. InterviewsOn 12/12/23 at 7:24 a.m., the RCC stated the residence had a camera in the medicati..