Legacy at Monte Vista, the

A revisit survey was completed on 10/12/23 for all previous deficiencies cited on 6/26/23. 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 6/26/23. 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 two of five sample participants (residents) (#3, #4).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.29, requires that the residence list all pro re nata (PRN) medications on a medication administration record, that the MAR reflected the correct times for administration, and that each qualified medication administration person (QMAP) accurately document medication administration at the time the event is completed for each resident.a. Residence PolicyThe residence' s medication policy, dated October 2022, read in part that the residence added prescribed medications to the MAR following the prescription label for medication spelling, time to administer, and dosage. The residence maintained MARs for all medications administered by the residence staff, in accordance with standard practices. b. Resident #1 was admitted to the residence on 5/30/23 with diagnoses including right lower lobe pulmonary embolism.EliquisA written practitioner' s order, dated 5/30/23, directed the residence to administer Eliquis 5 mg twice daily. However, the June 2023 MAR revealed the residence listed Eliquis 5 mg to be administered every twelve hours. Additionally, the June 2023 MAR read to administer Eliquis every eight hours and at 8:00 a.m. and 8:00 p.m. Additionally, the June 2023 MAR revealed a blank space for the administration of Eliquis on 6/11/23.On 6/26/23 at 1:06 p.m., the administrator stated the blank space was the QMAP' s documentation error. She acknowledged the June 2023 MAR included inaccurate instructions for the administration of Eliquis, adding that she did not notice the inaccuracy until the date of the on-site visit.Docusate SodiumA written practitioner' s order, dated 5/30/23, directed the residence to administer docusate sodium 100 mg t..

A relicensure survey was completed on 6/26/23. A deficiency was cited. Based on record review and interview, the residence failed to ensure that all pro re nata (PRN) medications were listed on the medication administration record (MAR), that the MAR reflected the correct times for administration, and that each qualified qualified medication administration person (QMAP) accurately documented medication administration at the time the event was completed for each resident, affecting two of four sample residents (#1, #2).Findings include:1. Residence PolicyThe residence' s medication policy, dated October 2022, read in part that the residence added prescribed medications to the MAR following the prescription label for medication spelling, time to administer, and dosage. The residence maintained MARs for all medications administered by the residence staff, in accordance with standard practices. 2. Resident #1 was admitted to the residence on 5/30/23 with diagnoses including right lower lobe pulmonary embolism.a. EliquisA written practitioner' s order, dated 5/30/23, directed the residence to administer Eliquis 5 mg twice daily. However, the June 2023 MAR revealed the residence listed Eliquis 5 mg to be administered every twelve hours. Additionally, the June 2023 MAR directed QMAPs to administer Eliquis every eight hours and at 8:00 a.m. and 8:00 p.m. Additionally, the June 2023 MAR revealed a blank space for the administration .. 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 7.14.21 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.