Friendship House at the Home

A revisit survey was completed on 9/19/23 for all previous deficiencies cited on 6/1/23. 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 6/1/23. 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 27 current residents.(Cross-Reference Q0732). Findings Include:1. References and Residence Policya. 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 .. Based on interview and record review, the residence failed to ensure each resident had an accurate medication administration record (MAR), affecting three of three sample residents (#1-#3). Findings include: 1. Reference The residence' s Medication Administration policy, dated 4/7/23, read in part, "Make a record thereof with regard to each medication administered, including the time and amount taken ..."2. Resident #1 was admitted to the residence on 8/3/22. A written practitioner' s order, dated 3/29/23, directed the residence to administer lisinopril 10.. Based on observation and interview, the residence failed to ensure resident rooms occupied by smokers had fire resistant wastebaskets, affecting 11 residents (#4-#14).Findings include:On 6/1/23 at 10:00 a.m., the administrator provided a list of residents that identified Residents #4-#14 as smokers. On 6/1/23 at 10:30 a.m., an environmental tour of Residents #4-#14' s rooms revealed they did not contain fire resistant wastebaskets. On 6/1/23 at 12:30 p.m., the administrator acknowledged the smokers' rooms had not contained fire resistant wastebaskets. She stated she wa.. 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. Reference and Residence Policya. 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 th.. Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents, affecting two of three sample residents (#1, #2). Findings include: 1. References a. According to Colorado Revised Statutes (2020) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembl.. 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 7.7.12 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(E) Results of background checks and follow up, as applicable.

A recertification survey was completed on 6/1/23. A deficiency was cited. Based on record review and interview, the facility (residence) failed to comply with written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting three of three sample participants (residents) (#1-#3). Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.29, requires all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident' s room location, any known allergies, and the name and telephone number of the resident' s authorized Practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.a. Reference The residence' s Medication Administration policy, dated 4/7/23, read in part, "Make a record thereof with regard to each medication administered, including the time and amount taken ..."b. Resident #1 was admitted to the residence on 8/3/22. A written practitioner' s order, dated 3/29/23, directed the residence to administer lisinopril 10 mg one tablet daily. However, the May 2023 MAR revealed blank spaces on 5/19/23 and 5/31/23. On 6/2/23 at 4:45 p.m., the administrator stated she was unsure if the medication had been administered or not; however, it was most likely the qualified medication administration person (QMAP) had forgotten to document at the time of administration. She acknowledged that the medication administration should have been documented at the time of administration. c. Resident #2 was admitted to the resident on 12/20/22. A written practitioner' s order, dated 5/22/23, directed to administer the following medications: Vitamin D 125 mcg once daily Propranolol 40 mg one tablet twice daily However, the May 2023 MAR revealed a blank blank space on 5/31/23 for the morning dose. On 6/1/23 at 5:00 p.m., the administrator stated she was unsure if the..