Haven, the

A revisit survey was completed on 10/11/23 for all previous deficiencies cited on 6/21/23. 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 6/21/23. 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 two of three sample residents (participants) (#2, #3).Findings include:1. Reference and Residence Policy Chapter VII regulations governing assisted living residences, part 14.21, requires that 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.The residence' s undated Prescribed Medications and Treatments policy read in part: "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." 2. Resident #2 was admitted to the residence on 7/11/22. A written practitioner' s order, dated 7/6/22, directed the residence to administer Protonix 40 mg once daily. The residence' s June 2023 medication administration record (MAR) read Resident #2 was not administered Protonix on 6/14-6/21/23. There were a total of eight missed doses. On 6/21/23 at approximately 12:30 p.m., a medication audit revealed Resident #2' s Protonix was out of stock. On 6/21/23 at approximately 12:30 p.m., Staff #1 stated Resident #2' s Protonix had been out of stock for a few days and she believed it was due to a delay from the external pharmacy the residence used to fill prescriptions. On 6/21/23 at approximately 12:45 p.m., the registered nurse caregiver supervisor (RNCS) stated she had been trying to get Resident #2' s Protonix refilled for weeks and the residence was waiting for the external pharmacy to deliver the medication. 3. Resident #3 was admitted to the residence on 11/17/22. A written practitioner' s order, dated 6/8/23, directed the residence to administer nystatin powder two times daily. The residence' s June 2023 MAR read Resident #3 was not ad..

A relicensure survey was completed on 6/21/23. A deficiency was cited. A change of ownership occurred on 12/30/21. Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication, affecting two of three sample residents (#2, #3). Findings include: 1. Residence Policy The residence' s undated Prescribed Medications and Treatments policy read in part: "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." 2. Resident #2 was admitted to the residence on 7/11/22. A written practitioner' s order, dated 7/6/22, directed the residence to administer Protonix 40 mg once daily. The residence' s June 2023 medication administration record (MAR) read Resident #2 was not administered Protonix on 6/14-6/21/23. There were a total of eight missed doses. On 6/21/23 at approximately 12:30 p.m., a medication audit revealed Resident #2' s Protonix was out of stock. On 6/21/23 at approximately 12:30 p.m., Staff #1 stated Resident #2' s Protonix had been out of stock for a few days and she believed it was due to a delay from the external pharmacy the residence used to fill prescriptions. On 6/21/23 at approximately 12:45 p.m., the registered nurse caregiver supervisor (RNCS) stated she had been trying to get Resident #2' s Protonix refilled for weeks and the reside.. 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 and 6 CCR 1011-1, Chapter 2.14.29 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. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.