Eben Ezer Lutheran Care Center Ft Morgan #1

A revisit survey was completed on 4/3/24 for all previous deficiencies cited on 11/16/23. 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 was completed on 11/16/23. Deficiencies were cited. A change of ownership occurred on 4/15/21. Based on observation and interview, the residence failed to ensure that rooms occupied by smokers was equipped with fire resistant wastebaskets, affecting two of two residents who smoked (#3, #4).The residence' s undated administrator job description read in part that the administrator oversaw a monthly walk-through inspection of the home to ensure safety from potential hazards and complied with all state laws concerning licensure.On 11/16/23 at 8:29 a.m., Residents #3 and #4 were observed to be smoking cigarettes in the residence' s designated smoking area.On 11/16/23 at 9:48 a.m., an environmental tour of the residence revealed that neither Resident #3 nor #4' s rooms were equipped with fire resistant wastebaskets.On 11/16/23 at 12:49 p.m., Resident #3 stated she sat on a couch in the residence' s .. Based on observation, record review, and interview the licensee failed to notify the department of a change in administrator, at least 30 calendar days in advance, affecting 10 current residents.Findings include:1. Record ReviewOn 11/16/23, the department' s database read that the administrator of record, not the owner nor the manager, was the current administrator of the residence.2. ObservationOn 11/16/23, during the on-site visit from 7:30 a.m. to approximately 3:00 p.m., a paper posted to the residence' s front office door read in part: "All complaints or concerns ... Contact the Administrator." This was followed by the manager' s name and the manager' s telephone number.3. InterviewsOn 11/16/23 at 8:38 a.m., Staff #4 stated that the manager was the administrator. She stated t.. Based on record review and interview. the residence failed to ensure that each qualified medication administration person (QMAP) accurately documented each medication administration event at the time the event was completed for each resident, affecting two of three sample residents (#1, #3).1. Residence PolicyThe residence' s undated medication administration policy read in part that QMAPs documented the administration of medication at all times. The residence documented the delivery of care, including refusal by the resident, of the medication treatment.2. Resident #1 was admitted to the residence on 6/6/19 with diagnoses including dementia and depression.A written practitioner' s order, dated 4/11/22, directed the residence to administer the following:Ayr nasal gel in both nostrils twice dailyMel.. 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.22.30 The assisted living residence shall prohibit smoking in areas where oxygen is stored and/or used and shall post a conspicuous "No Smoking" sign in those areas.

A recertification survey was completed on 11/16/23. Deficiencies were cited. Based on observation and interview, the facility (residence) failed to ensure that participants (residents) had access to nutritious food and beverages at all times, affecting 10 current residents.Findings include:The residence' s undated resident agreement read in part that the residence provided daily snacks in their monthly rate. The residence included direct services to the residents including snacks as desired.On 11/16/23 from 7:30 to approximately 2:00 p.m., no snacks were readily observed to be readily accessible to the residents. Throughout this time there were snacks located in a locked pantry in the hallway behind the kitchen. Fresh fruit was observed inside the refrigerator. On 11/16/23 at 8:29 a.m., Resident #3 stated she did not get snacks throughout the day. She stated that if staff offered snacks, she did not get them. Resident #3 stated that maybe she was in her room when the staff offered snacks.On 11/16/23 at 10:36 a.m., Staff #4 stated residents were required to ask for snacks when they wanted them. She stated that otherwise, staff provided snacks only in the mid-mornings and mid-afternoons. She stated that the residence had apples and other fruit in the refrigerator, but the residents were required to ask staff for them.On 11/16/23 at 12:53 p.m., Staff #5 stated that staff offered residents snacks between 10:00 a.m. and 10:30 a.m. and again between 2:00 .. Based on record review and interview, 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 two of three sample participants (residents) (#1, #3).Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.29, requires each qualified medication administration person, nurse, or practitioner to accurately document each medication administration or monitoring event at the time the event is completed for each resident.a. Residence PolicyThe residence' s undated medication administration policy read in part that QMAPs documented the administration of medication at all times. The residence documented the delivery of care, including refusal by the resident, of the medication treatment.b. Resident #1 was admitted to the residence on 6/6/19 with diagnoses including dementia and depression.A written practitioner' s order, dated 4/11/22, directed the residence to administer the following:Ayr nasal gel in both nostrils twice dailyMelatonin 3 mg at bedtimeDonepezil 10 mg at bedtimeThe November 2023 medication administration record (MAR) revealed no documentation for the administration of the above listed medications for the bedtime doses on 11/13/23.On 11/16/23 at 1:00 p.m., the administrator stat..