Charleston Assisted Living

A licensure complaint, prompted by #CO40799, was completed on 8/26/25. Deficiences were cited. Based on interviews and record review, the residence failed to ensure each resident care plan promoted resident mobility and safety and detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting one of three sample residents (#1) and one former resident (#4). (Cross reference U1146)Findings include:1. Record reviewResident #1 was admitted to the residence on 3/1/24 with a diagnosis of dementia. The residence' s comprehensive assessment and care plan for Resident #1, both dated 10/1/24, read the resident did not have a history of falls.A progress note, dated 8/20/25, read Resident #1 tripped on the porch stairs t.. Based on record review and interview, the residence failed to update the comprehensive assessment after a resident' s condition changed from baseline status, affecting one of one sample residents who experienced a change (#1) and one former resident (#4). (Cross reference U1150)Findings include:1. Residence PolicyThe residence' s comprehensive resident assessment policy, dated July 2018, read in part: "the comprehensive assessment shall be updated for each resident at least annually and whenever the resident' s condition changes from baseline status."2. Record reviewResident #1 was admitted to the residence on 3/1/24 with a diagnosis of dementia. The residence' s comprehe.. Based on record reviews and interviews, the residence failed to document and retain a comprehensive assessment in the resident' s health information record, affecting two of three sample residents (#2, #3) and one former resident (#4). Findings include:1. Residence PolicyThe residence' s comprehensive resident assessment policy, dated July 2018, read in part: "the comprehensive assessment shall be documented in writing and kept in the resident' s health information record."2. Record ReviewResident #2 was admitted to the residence on 3/17/22.On 8/26/25 at approximately 1:30 p.m., review of Resident #2' s record revealed there were no comprehensive assessments. On 8/2.. Based on record reviews and interviews, the residence failed to ensure resident records contained a facesheet, individualized care plan and documentation of ongoing services provided by external service providers, affecting two of three sample residents (#1, #2) and one former resident (#4). Findings include:The residence' s resident health information records policy, dated July 2018, read in part: "resident records contain, but are not limited to ... face sheet ... individualized resident care plan ... (and) documentation of on-going services provided by external service providers."Resident #2 was admitted to the residence on 3/17/22.Review of res.. 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 7.7.9 The assisted living residence shall ensure that each staff member and volunteer receives orientation and training, as follows: (B) Dementia Training Requirements (1) As of January 1, 2024, each assisted living residence shall ensure that its direct-care staff members meet the dementia training requirements in this Part 7.9(B).7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following it..

A revisit survey was completed on 3/24/25 for all previous deficiencies cited on 8/27/24. 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 8/27/24. Deficiencies were cited.A change of ownership occurred on 11/30/23. Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting two of three sample residents (#1 and #2).Findings include:1. Resident #1A written practitioner' s order, dated 2/9/24, directed the residence to administer the following medications:Pantoprazole 40 mg twice dailyLoratadine 10 mg once dailyFurosemide 20 mg once dailyFluticasone Prop 50 mg once dailyCholecalciferol 1250 .. Based on observation, record review and interview, the residence failed to ensure personnel files included documentation of background check results and verification of licensure or certifications for two of three staff (#1 and #2), affecting six current residents.Findings include:1. Record reviewThe personnel files for Staff #1 and #2 revealed that neither staff member' s personnel files contained background check results. The personnel files for Staff #1 and Staff #2 failed to contain verification of the Qualified Medication administration person (QMAP) certifications. 2. Obs.. Based on record review and interview, the residence failed to ensure there was at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized CPR organization, affecting six current residents. Findings include:Documented CPR certification for Staff #1 revealed a CPR completion date of 11/20/23. However, the certification was not from a nationally recognized organization.The staff schedule from 8/1/24 to 8/31/24 revealed the residence failed to ensure the follo.. Based on record review and interview, the residence failed to have readily available a roster of current residents along with a residence diagram showing room locations and emergency contact information, affecting six current residents.Findings include:On 8/27/24 at 7:30 a.m., the resident roster for emergency preparedness was requested but was not provided. On 8/27/24 at 7:30 a.m., Staff #1 stated she did not have a list of residents to provide in case of emergency. On 8/27/24 at 9:20 a.m., the resident roster for emergency preparedness was requested from the ad.. Based on record review and interview, the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting seven of six current residents.Findings include:On 8/27/24 at 9:20 a.m. the last two quarterly medication audits prior to the onsite visit were requested from the administrator. However, no documentation was provided.On 8/27/24 at approximately 2:00 p.m., the administrator stated she was unaware of the requirement to participate in and document MAR audits. She stated she .. 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 7.7.1 In order to ensure that staff members and volunteers are of good, moral, and responsible character, the assisted living residence shall request, prior to staff hire or volunteer on-boarding, a name-based criminal history record check for each prospective staff member and volunteer. (A) If the applicant has lived in Color..