Castle Peak Assisted Living

A revisit survey was completed on 7/18/23 for all previous deficiencies cited on 1/19/23. The facility is in compliance with all deficiencies 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 1/19/23. Deficiencies were cited. Based on interview and record review, the residence failed to ensure there was a readily available roster that included emergency contact information and a residence diagram showing room locations, affecting 18 current residents On 1/19/23, at 8:00 a.m., the administrator provided two resident rosters. Both resident rosters did not list the residents' emergency contact information or have a residence diagram attached.On 1/19/23 at 8:30 a.m., the administrator stated the two resident rosters provided were the only resident rosters. He added he did not know the requirement for a resident roster without referencing the regulations. On 1/19/23 at approximately 11:10 a.m., the administrator confirmed the resident roster provided did not include emergency contact information or a diagram that showed roo.. Based on observation, record review and interview, the residence failed to ensure all over-the-counter (OTC) medications prescribed for administration were labeled or marked with residents' full names, affecting two of four sample residents (#1, #2). Findings include: 1. Residence PolicyThe residence' s Medication Administration policy, dated 4/29/21, read in part that the residence was required to label OTC medications with the resident' s first and last name.2. Resident #1 was admitted to the residence on 12/23/20.Review of the residence' s record for Resident #1 and an audit of the residence' s medication cart revealed the following OTC medications were not labeled with the resident' s full name, as follows: A written practitioner order, dated 12/15/22, directed the residence to administer T.. Based on record review and interview, the administrator failed to, along with the qualified medication administration personnel (QMAP) supervisor, audit and document the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, and any irregularities shall be investigated and resolved, affecting four of four sample residents (#1-#4).Findings include:On 1/19/23 at 8:30 a.m., the residence' s policy for quarterly medication audits was requested from the administrator. However, a policy that addressed medication audits was not provided.On 1/19/23 at 8:30 a.m., documentation of completed quarterly medication audits was requested from the administrator. However, documentation of quarterly .. 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 7.14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident' s room location, any known allergies, and the name and telephone number of the resident' s authorized practitioner.(A) The medication administr..