Castle Rock Assisted Living III LLC

A revisit survey was completed on 12/17/24 for all previous deficiencies cited on 9/19/24. The facility is in compliance with all deficiencies that 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

A relicensure survey was completed on 9/19/24. A deficiency was cited. Based on record review and interview, the residence failed to ensure that only medication ordered by an authorized practitioner was prepared for or administered to residents, affecting one of two newly admitted sample residents (#1). Findings include:1. Residence PolicyThe residence' s Medication Administration policy, dated January 2023, read in part: the residence was to ensure that each practitioner' s order included the date of the order and signature of the practitioner.2. Resident #1 was admitted to the residence on 8/30/24. The resident record did not contain any written orders from an authorized practitioner. The August and September 2024 medication administration records revealed the residence administered medications to Resident #1 as follows:Tramadol 50 mg three times daily: 8/30 afternoon and evening doses, 8/31-9/18 all three doses and 9/19/24 in the morning, for a total of 60 doses administered.Gabapentin 300 mg three times daily: 8/30 afternoon and evening doses, 8/31-9/18 all three doses and 9/19/24 in the morning, for a total of 60 doses administered.Pilocarpine 5 mg three times daily: Gabapentin 300 mg three times daily: 8/30 afternoon and evening doses, 8/31-9/18 all three doses and 9/19/24 in the morning, for a total of 60 doses administered.Acetaminophen 325 mg two tablets three times daily: 8/30 afternoon and evening doses, 8/.. 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 7.14.29 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. (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.18.9 The face sheet shall be updated at least annually and contain the following information: (E) Date of admission and readmission, if applicable.

A recertification survey was completed on 9/19/24. A deficiency was cited. Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting two 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.A. Residence PolicyThe residence' s Medication Administration policy, dated January 2023, read in part: the residence was to ensure that each practitioner' s order included the date of the order and signature of the practitioner.B. Resident #1 was admitted to the residence on 8/30/24. The resident record did not contain any written orders from an authorized practitioner. The August and September 2024 medication administration records revealed the residence administered medications to Resident #1 as follows:Tramadol 50 mg three times daily: 8/30 afternoon and evening doses, 8/31-9/18 all three doses and 9/19/24 in the morning, for a total of 60 doses administered.Gabapentin 300 mg three times daily: 8/30 afternoon and evening doses, 8/31-9/18 all three doses and 9/19/24 in the morning, for a total of 60 doses administered.Pilocarpine 5 mg three times daily: Gabapentin 300 mg three times daily: 8/30 afternoon and evening doses, 8/31-9/18 all three doses and 9/19/24 in the morning, for a total of 60 doses administered.Acetaminophen 325 mg two tablets three times daily: 8/30 afternoon and evening doses, 8/31-9/18 all three doses and 9/19/24 in the morning, for a total of 60 doses administered.Artificial Tears in each eye three times daily: 8/30 in the evening, 8/31-9/18 all three doses and 9/19/24 in the morning, for a total of 59 doses administered.Aspercreme with Lidocaine 4% three times daily: 8/30 in the evening, 8/31-9/18 all three doses and 9/19/24 in the morning, for a total of 59 do..