Extended Family Assisted Living INC

A recertification survey was completed on 10/17/23. A deficiency was cited. Based on observation, 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 six current participants (residents).Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.31, requires the administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence' s Quality Management Program assessment and review. On 10/17/23 at 7:45 a.m., Staff #1 was requested to provide the residence' s quarterly medication cart audits; however, he was unable to provide the documentation. On 10/17/23 at 2:00 p.m., the administrator stated the pharmacy the residence used conducted the medication cart audits on a monthly basis; however, she had not participated with the audits. She stated she had conducted the audits in the past; however, could not recall exactly when the pharmacy had taken over that duty.

A relicensure survey was completed on 10/17/23. Deficiencies were cited. Based on interview and record review, the residence failed to ensure at least one staff member was onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting six current residents. (Cross-reference Q0732)Findings Include:1. Referencesa. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that' s useful in many emergencies, such as a heart attack or near drowning, in which someone' s breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CP.. Based on observation, record review and interviews, the residence failed to request, prior to staff hire, a name-based criminal history record check for each prospective staff member for two sample staff (#1, #2), affecting six current residents. (Cross-reference Q0664)Findings include:1. ReferencesChapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall i.. Based on record review and interview, the residence failed to ensure each personnel file included the required information, affecting two of two sample staff for whom there was a personnel file (#1, #2). (Cross-reference Q0610)Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 7.8 (A), requires the assisted living residence shall ensure each staff member or volunteer completes an initial orientation prior to providing any care or services to a resident. Such orientation shall include, at a minimum, all of the following topics:(1) The care and services provided by the assisted living residence;(2) Assignment of duties and responsibilitie.. 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 six current residents.Findings include:On 10/17/23 at 7:45 a.m., Staff #1 was requested to provide the residence' s quarterly medication cart audits; however, he was unable to provide the documentation. On 10/17/23 at 2:00 p.m., the administrator stated the pharmacy the residence used conducted the medication cart audits on a monthly basis; however, she had not participated with the audits. She stated she had conducted the audits in the past; however, co.. Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting 27 current residents. (Cross-reference Q0734)Findings include: 1. Referencea. According to VeryWell Health, "First aid is the emergency care a sick or injured person gets. In some cases, it may be the only care someone needs, while in others, it may help them until paramedics arrive or they are taken to the hospital. The best way to prepare for these events is to get official first aid training" Brouhard, R., EMT (11/30/21) First Aid, 10 Basic First Aid Procedures, retrieved from: https..