Eben Ezer Lutheran Care Center

A revisit survey was completed on 12/15/2023 for all previous deficiencies cited on 6/7/2023. 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 recertification survey was completed on 6/7/23. A deficiency was cited. Based on interview and record review, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting 58 participants (residents).Findings include:1. Chapter VII regulations governing assisted living residences part 14.11, requires only medication that has been ordered by an authorized practitioner to be administered to residents. a. Residence PolicyThe residence' s Medication Administration policy, dated 6/8/20 read in part: "medications are administered by a qualified medication administration person (QMAP) as ordered by the physician and in accordance with professional standards of practice."The residence' s Medication Administration policy, dated 6/8/20, read in part: "medications are administered by a qualified medication administration person (QMAP) as ordered by the physician and in accordance with professional standards of practice."b. Resident #3 was admitted to the residence on 9/11/19 with diagnoses including hyperlipidemia and hypothyroidism.AcetaminophenThe May and June 2023 electronic medication administration records (eMARs) read Resident #3 was administered acetaminophen 500 mg three times on 5/21-6/6/23, twice on 5/20, and one on 6/7/23, for a total of 54 doses. However, the residence was unable to provide a signed practitioner' s order for the medication. Triamcinolone 0.1%The May and June 2023 eMARs read Resident #3 was administered triamcinolone acetonide cream 0.1% once daily on 5/7-5/13, 5/15-5/24, 5/26, 5/27, and 5/29-6/6/23, for a total of 28 doses. However, the residence was unable to provide a signed practitioner' s order for the medication. ColaceThe May and June 2023 eMARs read Resident #3 was administered colace 100 mg once daily on 5/26-6/6/23 for a total of 12 doses. However, the residence was unable to provide a signed practitioner' s order for the medication. BumetanideThe May 2023 eMAR read Resident #3 was administered bumetanide 1 mg once daily for four ..

A relicensure survey was completed on 6/7/23. Deficiences were cited. Based on interview and record review, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting 58 current residents.Findings include:1. Referencea. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (I) Completing, maintaining, and submitting all reports and records required by the Department.2. Record reviewOn 6/7/23 at 7:45 a.m., a medication administration policy, staff schedule resident roster, resident agreement and a st.. 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 two of three sample residents (#1, #3).Findings include: 1. Residence PolicyThe residence' s Medication Administration policy, dated 6/8/20, read in part: "medications are administered by a qualified medication administration person (QMAP) as ordered by the physician and in accordance with professional standards of practice."2. Resident #3 was admitted to the residence on 9/11/19 with diagnoses including hyperlipidemia and hypothyroidism.a. AcetaminophenThe May and June 2023 electronic medicati.. Based on record review and interview,the residence failed to ensure medication audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting 58 current residents.Findings include: The residence' s Medication Audit policy, dated 2/1/18, read in part: "The director of wellness completes an audit of medications quarterly or more frequently as needed. The house pharmacy may be requested to complete audits of medications quarterly or as needed. The medication audit tool is used."On 6/7/23 at 7:45 a.m., the last three medication audits were requested from the administrator; however, she was unable to prov.. Based on record review, observation and interview, the administrator failed to complete an administrator training program before assuming an administrator position in an assisted living residence, affecting 58 current residents. Findings include:Chapter VII regulations governing assisted living residences, part 4.5, requires that the licensee shall appoint an administrator who meets the minimum qualifications set forth in these regulations and delegate to that individual the executive authority and responsibility for the administration of the assisted living residence.Chapter VII regulations governing assisted living residences, part 6.6, requires that an administrator training program shall meet .. 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 7.14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing.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.