Highline Place

A revisit survey was completed on 9/4/24 for all previous deficiencies cited on 7/16/24. 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 7/16/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure that each personnel file included written documentation regarding orientation and training, results of background checks, and documentation of initial dementia training for four (#1-#4) of four sample staff, affecting 64 current residents.Findings include:On 7/16/24, the personnel files for Staff #1-#4 contained no documentation that staff received training prior to contact with residents. Additionally, personal records for staff #2 and #3 had no documentation of completion of initial dementia .. Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting seven (#8, #9, #10, #11, #12, #13, and #14) of seven residents whose medications were administered.Findings include:1. ObservationsOn 7/16/24 from approximately 12:05 p.m. to 12:55 p.m., during medication administration, the following was observed:Staff #4 dispensed Resident #8' s medicatio.. Based on observation, record review and interview, the residence failed to ensure residents were provided with, and acknowledged receipt of, information regarding whether the assisted living residence had video surveillance monitoring throughout the residence, affecting 64 current residents. Findings include:1. ObservationOn 7/16/24 at approximately 8:15 a.m., during an environmental tour, cameras were located at both entrances of the secure environment. Both cameras were pointed at the doors where residents and visitors entered and exited the secure en.. Based on record review and interview the residence failed to prevent qualified medication administration persons (QMAP) from masking or deceiving administration of medication administered, affecting 64 current residents.Findings include:1. Residence PolicyThe residence' s medication refusal and/or missed doses policy, dated 3/29/21, read in part: "No resident will be forced to take any medication. Steps will be taken to avoid missed or refused doses and related adverse reactions."The residence' s undated medication administration policy read in part: "Our medications a.. Based on record review and interview, the residence failed to ensure that, on a quarterly basis, the administrator and the qualified medication administration (QMAP) supervisor audited the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, affecting 64 current residents.Documentation of medication audits completed on 6/11/24 for the east and west wings, revealed that the audits were completed by a QMAP and other staff, not by the required administrator and QMAP sup.. 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 existingprogram regulations found at 6 CCR 1011-1, Chapter 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 13.1 The assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the righ..