Legacy at Burlington, the

A revisit survey was completed on 4/17/25 for all previous deficiencies cited on 12/11/24. 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 12/11/24. A deficiency was cited. Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor, on a quarterly basis, audited the accuracy and completeness of the medication administration records (MAR), affecting 12 current residents. Findings include:On 12/10/24 at 8:36 a.m., documentation of the residence' s quarterly medication audits were requested but none were provided.On 12/10/24 at 1:23 p.m., documentation of the residence' s quarterly medication audits were requested a second time but were not provided.On 12/10/24 at approximately 8:20 a.m., Staff #1 stated the resident care coordinator (RCC) and a QMAP completed medication cart audits. On 12/10/24 at 2:10 p.m., the RCC stated the resident' s assigned physician completed quarterly medication audits. The RCC also stated that she and a QMAP completed medication cart audits, but they did not keep documentation. Further, the RCC stated the administrator did not complete quarterly medication audits.On 12/11/24 at 9:30 am., the administrator stated she was aware of the required quarterly medication audits, but she was under the impression that they had to be completed by the assigned physician. She acknowledged that she, along with the QMAP supervisor, failed to audit the accuracy and completeness of the MAR q.. 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 7.14.33 The assisted living residence shall ensure that the resident' s authorized practitioner and resident' s legal representative are promptly notified of: (B) A resident' s pattern of refusal.

A recertification survey was completed on 12/11/24. No deficiencies were cited. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10, Section 8.7000 - A1350 Alternate Care Facility Provider Agency. 8.7414.A.2 The Provider Agency shall ensure that a Member' s refusal to take medication(s) and/or any adverse reaction to a medication are recorded in the Member' s medication administration record and reported to the Member' s licensed medical provider.

A licensure complaint, prompted by #CO34087 was completed on 11/13/23. One deficiency was cited. Based on record review and interview, the residence failed to have a method for the integration of the records that allowed for effective continuity of care, which included effective management for capturing reporting, processing, and retrieving care/service data and information of medication, affecting 3 sample residents. Findings include:The residence' s health record policy dated October 2022 read, in part, that records shall be maintained and organized in such a manner as to be protected from loss, damage, or unauthorized use in the residence.On 11/13/23 at 7:45 a.m., resident medication administration records (MARs) for October through November 2023 were requested from the assistant administrator. Review of the electronic October 2023 medication administration records (MARs) revealed the following:There were blank spaces for the administration of medication for Residents #1-#3 on 10/1/23 through 10/10/23.On 11/13/23 at 10:56 a.m., the assistant administrator stated they were working on retrieving the first part of October MAR ' s, there was a change in electronic MAR systems in the beginning of October 2023. On 11/13/23 at 11:43 a.m., the assistant administrator stated they are waiting for the company from their old system to email or fax the beginning of October 2023 MARs. On 11/13/23 at 12:05 p.m., the assistant administrator stated they have no update on October 2023 MARs.On 11/13/23 at 12:17 p.m., the assistant administrator stated they were unable to produce October 2023 MARs for the requested sample residents.