Good Samaritan-Water Valley Sr Living Resort

A relicensure survey with complaint #CO32699 was completed on 7/23/24. Deficiencies were cited. Based on interview and records review, the residence failed to document routinely completed audits of the accuracy and completeness of medication administration records (MARs), controlled substance lists, medication error reports, and medication disposal records affecting three of six sample residents (#1,#3, #6). Findings include:The residence ' s MARs audit tool titled Medication Error Monthly Report Totals included data of the number of residents receiving medications, the total number of medications administered, the number of errors administering medications (not charted, wrong time, wrong dose, etc.), the number of errors transcribing (missing orders, illegible orders, or.. Based on interview, and record review the residence failed to hold quarterly family meetings in the residence' s secure environment affecting 14 current residents. Findings include:The meeting minutes were requested at 8:05 a.m. However as of 1:05 p.m. no family meeting minutes were provided. On 7/23/24 at 1:05 pm., the campus administrator stated that the residence had not been doing family council and did not know it was a requirement. Based on observation and interview, the residence failed to ensure all medications were stored in a locked storage area when unattended by a qualified medication administration person (QMAP) or other licensed staff, affecting 41 current residents. Findings include:On 7/23/24 from 7:39 am -7:52 am., an environmental tour revealed the medication storage cart was left unlocked and unattended. During that time three residents were observed walking past the medication storage cart. At 11:32 am., the cart was discovered to be unlocked again, in which no QMAP or licensed person was present demonstrating a continued failure to ensure compliance with safe medication storage. A.. Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of six sample residents (#1, #3,#6). Findings include: 1. Residence PolicyThe Medication Administration and Supporting Process policy, dated 11/1/22, read in pertinent parts: "Writing (Transcribing) New Medication Orders on the medication administration record (MAR): Transcription of orders in MAR may be done by a qualified medication person (QMAP), licensed nurse or assisted living manager, per state regulations. Once an order is received, the QMAP or the registered nurse (RN) will write the medication on the MAR e.. Based on observation, record review, and interview, the residence failed to maintain the residence' s water temperature, which was accessible by residents, at or below 120 degrees Fahrenheit (F) at taps, affecting 14 current residents in the secure environment.Findings include:On 7/23/24 at 8:54 a.m., water temperatures were taken in the residence' s secure environment as follows:The common laundry area resident-accessible sink measured 142 degrees F.The common area bathroom sink #1 measured 149.9 degrees F.A resident bathroom measured 149.9 degrees F.On 7/23/24 at 4:36 pm, the maintenance director took water temperature using two different temperature gauges..