Hawkeye Care Home LLC

A revisit survey was completed on 4/3/24 for all previous deficiencies cited on 11/1/23. 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 11/1/23. Deficiences were cited. Based on interview and record review, the administrator and the qualified medication administration person (QMAP) supervisor failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting three of three sample residents (#1-#3). Findings include:On 11/1/23 at approximately 8:39 a.m., documentation of medication audits from the previous three quarters were requested but not provided.On 11/1/23 at 12:36 p.m., the administrator designee stated she was unaware of the requirement to complete quarterly medication audits. The administrator designee stated the residence' s preferred pharmacy conducted the audits of the current medication lis.. Based on interview and record review, the residence failed to ensure each personnel file included first aid certifications, affecting eight current residents.Findings include:On 11/1/23 at approximately 8:39 a.m., first aid certifications were requested for Staff #1, the administrator designee and the administrator.On 11/1/23 at approximately 11:31 p.m., cardio-pulmonary resuscitation (CPR) certifications were provided for the administrator and administrator designee, dated 4/18/23. However, the certifications did not include the first aid component, and no first aid certification was in the personnel files as required. On 11/1/23 at approximately 1:00 p.m., a cardio-pulmonary resuscitation (CPR) certification was provided for Staff #1 dated 5/24/22. However, the certificati.. Based on record review and interview, the residence failed to ensure that only medication ordered by an authorized practitioner was prepared for or administered to residents, affecting two of three sample residents (#1, #2).Findings include: 1. Residence PolicyThe residence' s Medication Administration policy, dated July 2020, read in part: "Any changes to medication amount, type, or dosage, must be accompanied by a written or faxed document that includes a signed request directly from the health professional' s office."2. Resident #2 was admitted to the residence on 5/30/23 with a diagnosis of major depressive disorder. a. TrazodoneThe October 2023 electronic medication administration record (eMAR) read Resident #2 was administered trazodone 100 mg once at bedtime from 10/3-10/21/23 for a total .. 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 2.2.3.6 Applicants must show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements as set forth in section 26-3.1-111, C.R.S.

A recertification survey was completed on 11/1/23. A deficiency was cited. Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting three of three sample participants (residents) (#1-#3). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.11, requires only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.The residence' s Medication Administration policy, dated July 2020, read in part: "Any changes to medication amount, type, or dosage, must be accompanied by a written or faxed document that includes a signed request directly from the health professional' s office."a. Resident #2 was admitted to the residence on 5/30/23 with a diagnosis of major depressive disorder. TrazodoneThe October 2023 electronic medication administration record (eMAR) read Resident #2 was administered trazodone 100 mg once at bedtime from 10/3-10/21/23 for a total of 19 doses. Additionally, the October 2023 eMAR read Resident #2 was administered trazodone 50 mg once at bedtime from 10/1-10/3/23 for a total of three doses. However, the residence was unable to provide a signed practitioner' s orders for the above timeframes for the administration of trazodone at both the 50 mg and 100 mg. Prazosin The October 2023 eMAR read Resident #2 was administered prazosin 1 mg once at bedtime from 10/1-10/3/23 for a total of three doses. Additionally, the October 2023 eMAR read prazosin 2 mg was administered 10/1/23 for a total of one dose. However, the residence was unable to provide a signed practitioner' s orders for the above timeframes for the administration of prazosin at the 1 mg and 2 mg.On 11/1/23 at approximately 12:36 p.m., the administrator designee stated she was unable to locate signed practitioner' s orders for Resident #2' s trazodone and prazosin for the above administrations. The administrator..