Devonshire Care Center

A revisit survey was completed on 8/17/23 for all previous deficiencies cited on 5/4/23. No deficiencies 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 5/4/23. Deficiencies were cited. Based on interview and record review, the residence failed to have at least one staff member onsite at all times who has current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization, affecting 10 current residents.Findings include:The residence' s undated policy for staffing read, in part, that the residence had at least one staff member onsite at all times who has current certification in CPR from a nationally recognized organization.On 5/4/23 at approximately 2:10 p.m., documentation of current staff' s first aid certification was reque.. Based on interview and record review, the residence failed to have at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization, affecting 10 current residents.Findings include:The residence' s undated policy for staffing, read in part: The residence had at least one staff member onsite at all times who has current certification in first aid from a nationally recognized organization.On 5/4/23 at approximately 2:10 p.m., documentation of current staff' s first aid certification was requested. The only current cert.. Based on observation and interview, the residence failed to label all over the counter medications with the individual resident' s full name, affecting two of three residents (#1, #2).Findings include:1. Residence PolicyThe residence' s medication policy, dated 2001, read in part: All medications in the residence were properly labeled in accordance with current state guidelines and regulations.2. ObservationsOn 5/4/23 at 1:20 p.m., an audit of Resident #1 medications revealed the following six bottles of medications that were not labeled with Resident #1' s full name:Vita.. Based on observation, record review and interview, the residence failed to ensure a name-based criminal history check conducted by the Colorado Bureau of Investigation (CBI) was completed for each prospective staff member prior to staff hire, affecting four of four sample staff (#1-#4).Findings include:Throughout the onsite inspection on 5/4/23 from 7:30 a.m. to 3:45 p.m., Staff #4 was observed providing care and services to the residents.Personnel files revealed hire dates as follows:Staff #1: 7/27/22Staff #2: 10/18/18Staff #3: 8/24/17Staff #4: 2/27/23The April and M.. Based on record review and interview, the residence failed to include written documentation regarding orientation, affecting three of four sample staff (#1, #2, #4).Findings include:The residence' s orientation program policy, dated 2008, read in part: The residence' s orientation program was an in-depth review of policies and procedures. A checklist was used to record materials reviewed with each staff member. A written record of each staff' s orientation was maintained and filed in the staff' s personnel file upon completion.On 5/4/23, a review of the personnel files for Staff.. 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 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.13.1 The assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the rights an..

A recertification survey was completed on 5/4/23. A deficiency was cited. Based on record review and interview, the residence (facility) failed to follow written policies and procedures procedures for the administration of medication in accordance with Chapter VII medication administration regulations, affecting two of three sample participants (residents) (#1, #2).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.27, requires that all over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident' s full name.A. Residence PolicyThe residence' s medication policy, dated 2001, read in part: All medications in the residence were properly labeled in accordance with current state guidelines and regulations.B. ObservationsOn 5/4/23 at 1:20 p.m., an audit of Resident #1 medications revealed the following six bottles of medications that were not labeled with Resident #1' s full name:Vitamin E 180 mgAreds 2Potassium 99 mgComplete MultivitaminVitamin D 25 mgPolyethylene GlycolOn 5/4/23 at 1:20 p.m., an audit of Resident #2' s medications revealed a bottle of magnesium 250 mg. The bottle was not labeled with Resident #2' s full name.C. InterviewsOn 5/4/23 at approximately 1:20 p.m., Staff #4 acknowledged the above medications were not labeled with the resident' s full names. She stated it was the responsibility of the qualified medication administration persons (QMAP) to ensure that all resident medications were labeled with the residents' first and last names. Staff #4 stated Resident #1 was new and her family provided medications, which were labeled only with the resident' s first initial and last name.On 5/4/23 at 2:54 p.m., the administrator stated that she was not aware of the requirement to label all over the counter medications with residents' full names, adding she thought labeling medications with the residents' first initials and last names met the regulatory requirement.2. Chapter VII regulations governing assisted living residences, part 14.11, required only medication that has been ordered by an authorized practitioner shall be ..