Carelink at Delta House Assisted Living INC

A relicensure survey with complaint #CO35574 and #CO36156 was completed on 3/25/25. Deficiencies were cited. A change of ownership occurred on 1/17/24. Based on record review and interview, the residence failed to accurately document each medication administration event in the medication administration record (MAR), affecting one of five sample residents (#4). Findings include:Resident #4 was admitted to the residence on 12/15/22 with a diagnosis of type two diabetes mellitus.The practitioner' s orders, dated 3/11/25, directed the residence to administer carvedilol 6.25 mg twice daily, apixaban 5 mg twice daily, pregabalin 50 mg three times daily, docusate sodium 100 mg twice daily, sacubitril/valsartan 49/51 mg twice daily, fluticasasoda/salmet 250/50 twice daily, and trazodone 100 mg at bedtime.The February 2025 medic.. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that includes all required elements, affecting 24 current residents.Findings include:The residence' s discharge and grievance sections of the resident agreement and discharge policies failed to include the following required elements:1. The ability of any of the persons in the assisted living residence is required to notify under Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after the assisted living residence provides written notice of the involuntary discharg.. Based on record review and interview, the residence failed to have emergency policies addressing all required elements, affecting 24 current residents.Findings include:The residents' emergency preparedness policies failed to address all required elements:1. Written instructions for each identified risk that includes persons to be notified and steps to be taken. The instructions shall be readily available 24 hours a day in more than one location with all staff aware of the locations. 2. A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids. 3. Assignment of specific tasks and responsibiliti.. Based on record review and interview, the residence failed to require documentation of the actions taken by staff and ongoing efforts to prevent reoccurrence of incidents in future situations, affecting one of five sample residents (#5). (Cross-reference S1146)Findings include: Resident #5 was admitted to the residence on 6/5/24 with a diagnosis of substance use disorder and alcohol dependence.An incident report dated 3/6/24 read in part: the resident fell in his room and was lying on his right side. The resident reported he was getting out of bed and became dizzy and did not remember falling. No further follow-up was documented.A progress note dated 3/6/5 read: "Fell twice - going to hos.. Based on record review and interview, the residence failed to update each resident' s comprehensive assessment whenever the resident' s condition changed from baseline status, affecting two of five sample residents (#4, #5). (Cross-reference S1194)Findings include:Resident #4 was admitted to the residence on 12/15/22 with a diagnosis of type two diabetes mellitus.The comprehensive assessment for Resident #4, dated 6/10/24, read in part: The resident had a regular diet. His special likes were Chinese, steak, and spaghetti. Resident #4 was a diabetic therefore staff were instructed to give him small desserts. No other diet-related information, alcohol use or binge eating behaviors ..

8.7506.C Alternative Care Facility Inclusions: (1) Member Eligibility a. Members enrolled in the HCBS Elderly, Blind and Disabled (EBD) and the HCBS Community Mental Health Supports (CMHS) Waivers to are eligible to receive services in an Alternative Care Facility. (i) Potential Members shall be assessed, at a minimum, by a team that includes the Member and/or Guardian or other Legally Authorized Representative, the Alternative Care Facility administrator or appointed representative, and Case Management Agency Case Manager to determined that the Alternative Care Facility is an appropriate community setting that will meet the Member' s choice and need for independence and community integration. If one of the parties listed above is not available, input or information must be obtained fro.. A recertification survey with complaint #CO35575 and #CO36157 was completed on 3/25/25. Deficiencies were cited. Based on observation and interview, the facility implemented rights modifications without a specific assessed need and justification in the Person-Centered Support Plan (PCSP), affecting one of five sample members (#3).Findings include:On 3/25/25 at approximately 8:50 p.m., Member #3 was observed requesting cigarettes from Staff #3.On 3/25/25 at 8:00 a.m., a records request for any current member rights modifications was given to the administrator.On 3/25/25 at approximately 8:55 a.m., Staff #3 stated that Member #3 smokes a lot of cigarettes in a day. He also stated her family asked that we hold them and give them out when she requested to prevent her from going through so many.On 3/25/25 at 2:24 p.m., the administrator stated that she was not aware of any rights modif.. Based on record review and interview, the facility (residence) failed to have a documented contingency plan for providing services when in an emergency or unforeseen circumstances, affecting 24 current members (residents).Findings include:The residents' emergency preparedness policies failed to address all required elements:1. Written instructions for each identified risk that includes persons to be notified and steps to be taken. The instructions shall be readily available 24 hours a day in more than one location with all staff aware of the locations. 2. A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids. 3. Assignment of specific tasks and responsibilities to the staff members on each shift, inclu.. Based on record review and interview, the facility (residence) failed to record all medications administered, affecting one of five sample members (residents) (#4). Findings include:Resident #4 was admitted to the residence on 12/15/22 with a diagnosis of type two diabetes mellitus.The practitioner' s orders, dated 3/11/25, directed the residence to administer carvedilol 6.25 mg twice daily, apixaban 5 mg twice daily, pregabalin 50 mg three times daily, docusate sodium 100 mg twice daily, sscubitril/valsertan 49/51 mg twice daily, fluticasasoda/salmet 250/50 twice daily, and trazodone 100 mg at bedtime.The February 2025 medication administration record (MAR) for Resident #4 read that all of the ordered medications to be passed at the p.m. medication administration time were not passed on 2/23/25. A ..

A revisit survey was completed on 7/17/23 for all previous deficiencies cited on 5/11/22. The facility is in compliance with all deficiencies 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