Castle Rock Assisted Living at Eveningsong LLC

A relicensure survey was completed on 8/2/23. A deficiency was cited. Based on record review and interview, the residence failed to ensure the medication administration record (MAR) documented accurate information including the date and time of administration, affecting two of three sample residents (#1, #3). Findings include:1. Policies and Procedures The residence' s Medication Administration policy, dated 1/1/15, read in part, "For residents whose medications are monitored or administered by the facility staff, a current record shall be maintained of the resident' s medications including name of drug, dosage, route of administration of medication and directions for administration of medication. The administration of medication shall be documented at the time of administration."2. Record Review a. Resident #1 was admitted to the residence on 4/27/23. A written practitioner' s order dated 5/26/23 directed the residence to administer haloperidol 2 mg/ml, 0.25 ml, three times a day. The July 2023 medication administration record (MAR) had a blank space for the administration on 7/25/23. b. Resident #3 was admitted to the residence on 8/19/22.A written practitioner' s order dated 6/19/23 directed the residence to administer acetaminophen 500 mg, three times a day; Advair 250-50 mcg, twice a day; Levetiracetam 750 mg, twice daily; melatonin 5 mg, daily; risperidone 0.5 mg at bedtime; and vitamin D 50 mcg daily. The July 2023 MAR revealed blank spaces for the administration on the following dates for the following medications:Acetaminophen - 7/25/23 for the noon and evening dosesAdvair - the evening dose on 7/27/23 through 7/30/23Levetiracetam - the evening dose on 7/2/23 and 7/25/23Melatonin - 7/2, 7/23, 7/24, 7/27 through 7/30/23Risperidone - 7/2, 7/25/23Vitamin D - 7/2, 7/25/233. InterviewOn 8/2/23 at 10:20 a.m. the administrator stated the administration of medications was not documented because the residents were not at the residence and there was no option in the computer system to document as such therefore staff left the MAR blank rather than mark it as refused as that would..

An initial certification survey was completed on 8/2/23. A deficiency was cited. Based on record review and interview, the facility (residence) failed to comply with written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting two of three sample residents (participants) (#1, #3).Findings include:1. Reference and Residence Policy a. Chapter VII regulations governing assisted living residences, part 14.29, requires that the assisted living residence shall ensure 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 administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.(B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials.(C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.(D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.b. The residence' s Medication Administration policy, dated 1/1/15, read in part, "For residents whose medications are monitored or administered by the facility staff, a current record shall be maintained of the resident' s medications including name of drug, dosage, route of administration of ..