Charleston at Keenesburg LLC

A revisit survey was completed on 3/26/24 for all previous deficiencies cited on 6/8/23. 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, with complaint #CO29991 was completed on 6/8/23. Deficiences were cited. Based on observation, interview and record review, the residence failed to ensure the administrator was responsible for managing the day-to-day delivery of services to ensure residents received the care that was described in the resident agreement, the comprehensive resident assessment, and the resident care plan, affecting three current residents.Findings include:On 6/8/23 at 7:00 a.m., a posting on the wall of the residence had the acting administrator (AA) listed as the administrator. An email from a department representative, dated 6/8/23, read in part the department had not been notified of a change of administrator as required.On 6/8/23 at approximately 7:06 a.m., u.. Based on observation, record review and interview, the residence failed to ensure the residence' s roster contained current residents, their room assignments and emergency contact information, along with a residence diagram showing room locations, affecting three current residents. Findings include: On 6/8/23 at 7:45 a.m., a current resident roster was requested and not provided.On 6/8/23 at 7:58 a.m., Staff #1 revealed the first and last names of the three current residents via the electronic health system. However, she stated she was not able to provide a printed resident roster that contained current residents, their room assignments, and emergency contact information.. Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event is completed for each resident along with each of their signatures and, if used, their initials, and failed to document accurate information in the medication administration record (MAR), including any medication omissions, refusals, and resident reported responses to medications, affecting three of three sample residents (#1-#3).Findings include:1. Residence PolicyThe residence' s undated Medication Administration Policy, read in part: "medication administration .. Based on record review and interview, the residence failed to notify the department, at least 30 calendar days in advance, of a change in the administrator-of-record, affecting three current residents. (Cross-reference Q0540)Findings include:Review of the department' s database on 6/5/23 revealed the name of the administrator of record and further revealed this individual had held this position since 9/20/07. The acting administrator was not listed.An email, sent by a department representative, dated 6/8/23, read in part the licensee had not notified the department of the change in administrator at least 30 calendar days in advance as required.On 6/8/23 at 7:00 a.m., .. 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.

A recertification survey prompted by #CO29992 was completed on 6/8/23. A deficiency was cited. Based on record review and interview, the facility (residence) failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event is completed for each resident along with each of their signatures and, if used, their initials, and failed to document accurate information in the medication administration record (MAR), including any medication omissions, refusals, and participant (resident) reported responses to medications, affecting three of three sample residents (#1-#3).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.29, requires the residence to ensure each QMAP, nurse, or authorized practitioner document each medication administration or monitoring event at the time the event is completed for each resident.The residence' s undated Medication Administration Policy, read in part: "medication administration will be documented by the QMAP or nurse using the eMAR system. If a medication is not administered as ordered, the QMAP or nurse will document the reason on the eMAR."a. Resident #1 was admitted to the residence on 4/1/23 with diagnoses including hyperlipidemia and chronic obstructive pulmonary disease. SymbicortAdditionally, a written practitioner' s order, dated 3/27/23, directed the residence to administer Symbicort 160-4.5 mcg twice daily. However, the May 2023 MAR and eMAR revealed a blank on the evening of 5/1, 5/2, 5/16, and 5/19/23, for a total of four inaccurately documented doses.Calcium CarbonateA written practitioner order, dated 3/27/23, directed the residence to administer calcium carbonate 60 mg twice daily. However, the May 2023 paper MAR read Staff #3' s circled initials for the evening dose on 5/9/23, for a total of one inaccurately documented medication administration. SimvastatinA written practitioner orders, dated 3/27/23, directed the residence to administer simvastatin 10 mg daily. However, the May 2023 paper MAR read Staff #3' s circl..

A licensure revisit was completed on 6/8/23 for the previous deficiency cited on 9/25/20. No deficiences were cited. Based on observation, interview and record review, the residence failed to ensure the administrator was responsible for managing the day-to-day delivery of services to ensure residents received the care that was described in the resident agreement, the comprehensive resident assessment, and the resident care plan, affecting three current residents.Findings include:On 6/8/23 at 7:00 a.m., a posting on the wall of the residence had the acting administrator (AA) listed as the administrator. An email from a department representative, dated 6/8/23, read in part the department had not been notified of a change of administrator as required.On 6/8/23 at approximately 7:06 a.m., upon entrance to the residence Staff #2 was asked to notify the acting administrator the surveyors had arrived. Staff #2 notified the acting administrator, not the administrator of record. Staff #2 stated the AA had been responsible for the day-to-day at the residence since a month prior to the onsite investigation.On 6/8/23 at 7:21 a.m., the AA stated the owner of the sister residence had started as the administrator on 1/1/23, and then she began as the administrator after she had completed her administrator 40-hour training on 5/1/23. The AA acknowledged she was responsible for the day-to-day delivery of services at the residence since May 2023, not the administrator of record.