Bonaventure of Pueblo

A relicensure survey with complaints #CO36425, #CO36650, #CO37132, and #CO38089 was completed on 11/13/24. Deficiencies were cited. Based on interview and record review, the residence failed to include in the initial 30-day involuntary discharge a detailed explanation of the reasons for the discharge, including facts and evidence supporting each reason given by the residence and a recounting of events leading to the involuntary discharge, including interactions with the resident prior to the notice and actions that were taken to avoid discharge, and did not include the process for filing a grievance to appeal the involuntary discharge, affecting one resident (#4). (Cross-reference S1064)Findings include: An involuntary discharge notice issued by the residence to Resident #4, dated 9/25/24, revealed that the residence did not include in the 30-day involuntary discharge a detailed explanation of the reasons for the discharge, including fact.. Based on interviews and record review, the residence failed to ensure the administrator and qualified medication administration persons (QMAP) supervisor audited the accuracy and completeness of the medication administration records, affecting two of seven sample residents (#3, #5).Documentation of weekly medication audits revealed that on 11/13/24, the resident care coordinator completed the medication audits, but the administrator did not participate in them.On 6/26/24 at 3:45 p.m., the administrator designee said the QMAPs completed the quarterly medication audits alone. She said she was unaware the administrator was required to be involved in medication audits. Based on observation, interview, and record review, the residence failed to implement the required process pending discharge of reassessing the resident to be discharged; revision of their care plan to identify current resident needs and what services to provide to meet those needs; and, ensure staff were aware of new directives and properly trained, affecting 65 current residents.Findings include:1. Resident #4 was admitted to the residence on 3/31/22 with diagnoses including dementia and neurocognitive disorder with behavioral disturbances.a. Progress Notes Review of the residence progress notes for Resident #4 revealed the following:Progress notes, dated, 7/30-8/3/24, read in part that Resident #4 was placed on alert charting after her return from the hospital and to observe for increased aggressi.. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders affecting two of seven sample residents (#3, #5). Findings include: 1. Resident #3 was admitted to the residence on 1/2/24, with diagnoses including interstitial lung disease, disorder of prostate, neuropathy, disorder of rotator cuff, arterial fibrillation, hyperlipidemia, aneurysm in his brain, and diabetes.a. Tamsulosin HCLA written practitioner' s order, dated 10/9/24, directed the residence to administer Tamsulosin 0.4 mg twice daily. However, the August 2024 medication administration record (MAR) revealed the residence failed to administer the medication on the morning of 8/2/24 because the medication was not in stock.b. DuloxetineA written practitioner' s order, dated 10/9/24, directed..

Deficiency cited from occurrence #2423Y771007. The facility failed to provide the final report for Physical Abuse occurrence event #2423Y771007.The findings:The facility submitted an initial Physical Abuse occurrence report on 7/24/24. The facility failed to provide the final report within the required timeframe. Department staff sent electronic late final report notices through the COHFI system on 8/6/24 and 8/13/24. A facility representative opened the notification messages sent on 8/6/24 and 8/13/24 for review, but no action was taken. On 8/20/24, an external email was sent to a facility representative requesting submission of the final report. The external email was not read by the facility representative and no action was taken. An additional electronic message was sent to the facility on 9/4/24 requesting submission of the final report. The message was not read by a facility representative and no action was taken.As of 10/1/2024, the facility had not submitted the Final Report.