Graceful Hearts Assisted Living LLC

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 12/19/23. 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 recertification survey was completed on 12/19/23. A deficiency was cited. Based on interviews 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, affecting two of three sample participants (residents) (#2, #3).Findings include:1. Chapter VII regulations governing assisted living residents part 14.33, requires the assisted living residence shall ensure that the resident' s authorized practitioner are promptly notified of: (B) A resident' s pattern of refusal; and (C) A resident ' s repetitive request for and use of PRN medication.The residence' s undated Medication Administration Policy, read in part: "the physician and administrator will be notified of each refusal by the qualified medication administration person (QMAP) on duty."a. Resident #3 was admitted to the residence on 10/19/23 with a diagnosis of schizophrenia. LithiumA written practitioner' s order, dated 10/31/23, directed the residence to administer lithium 300 mg three tablets once at bedtime. However, the November through December 2023 medication administration records (MARs) read the medication was not administered on 11/1, 11/5-11/7, 11/10-11/20, 11/22-11/30, 12/1-12/5 and 12/7-12/16/23, for a total of 39 refused doses. OlanzapineA written practitioner' s order, dated 10/31/23, directed the residence to administer olanzapine 10 mg once at bedtime. However, the November through December 2023 MARs read the medication was not administered on 11/1, 11/5-11/7, 11/10-11/20, 11/22-11/30, 12/1-12/5 and 12/7-12/16/23, for a total of 39 refused doses. On 12/19/23 at 2:38 p.m., the administrator designee stated it was his responsibility to notify the practitioner for repeated refusals. The administrator designee stated he wanted to get an order from the practitioner to put lithium and olanzapine on a PRN schedule. However, the administrator designee acknowledged he had not notified the practitioner for Resident #3 of his repeated refusals. On 12/19/23 at 3:05 p.m., a medical assistant at Resident #3' s practitioner office stated she sp..

A relicensure survey was completed on 12/19/23. Deficiencies were cited. Based on observation, record review and interview, the residence failed to ensure the house rules addressed the consumption of marijuana and action taken if any rule is knowingly violated, affecting seven current residents. (Cross reference Q1110). Findings include: 1. ReferenceChapter VII regulations governing assisted living residences, part 13.3, requires that the assisted living residence shall establish written house rules and place them in a publicly visible location so that they are always available to residents and visitors.2. ObservationOn 12/19/23 at 12:09 p.m., there was a posting on the residence patio that read that marijuana was prohibited. However, there were marijuana contai.. Based on observation, record review and interview, the residence failed to make available a physically safe and sanitary environment, affecting seven current residents. (Cross reference Q1332)Findings include:1. Residence Policiesa. The residence' s undated Service Agreement, read in part: "the (residence) both inside and outside are maintained for physical safety and sanitary conditions ... areas are cleaned by staff and maintained."b. The residence' s undated Smoking Policy, read in part: "smoking may only occur in the designated smoking area on the back porch."c. Chapter VII regulations governing assisted living residences, part 22.37, requires that designated outdoor smoking are.. Based on record review and interview, the residence failed to ensure applicants showed compliance with Colorado Adult Protective Services Data Systems (CAPS Check) prior to hiring staff who provided direct care to at-risk residents, for two of two sample staff (#1, #2) affecting seven current residents.Findings include:1. Referencesa. 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 assembly to minimize the potential for employment of persons with a hist.. Based on record review and interview, the residence failed to ensure that the residents authorized practitioner was notified of a resident' s pattern of refusal and repetitive request for and use of a pro re nata (PRN) medication, affecting two of three sample residents (#2, #3).Findings include: 1. Residence Policy The residence' s undated Medication Administration Policy, read in part: "the physician and administrator will be notified of each refusal by the qualified medication administration person (QMAP) on duty."2. Resident #3 was admitted to the residence on 10/19/23 with a diagnosis of schizophrenia. a. LithiumA written practitioner' s order, dated 10/31/23, directed the residence t.. 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 VII. 7.13 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.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.14.29 All prescribed and P..