Mesa View Retirement Home INC

A licensure revisit was completed on 1/24/24 for all previous deficiencies cited on 5/23/23. A deficiency was cited. Based on interview and record review, the residence failed to prepare and administer only medications ordered by an authorized practitioner to residents, affecting one of three sample residents (#1).This deficiency was cited previously during a state licensure survey on 5/23/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #1 was admitted to the residence on 6/11/20. Written practitioner orders, dated 5/30/23, included a signature by a pharmacist. However, there was no evidence that the medications were ordered by the Resident #1' s authorized practitioner prior to 1/24/24.The January 2024 medication administration record revealed the residence administered the following medications from 1/1/24 to 1/23/24:Loratadine 10 mg dailyMultivitamin dailyCalcium 600 mg twice dailyThe residence administered acetaminophen 650 mg as needed on 1/2-1/19 and 1/23/24.An audit of Resident #1' s medications revealed the residence had the following medications in stock:Loratadine 10 mgMultivitaminCalcium 600 mgThe audit revealed an empty container labeled acetaminophen 325 mg.On 1/24/24 at 3:00 p.m., the administrator stated that this deficiency that was previously cited was not corrected because she did not realize that the written orders in the record were not signed by Resident #1' s authorized practitioner. She stated that a nurse from the resident' s practitioner' s office informed her that they would provide written practitioner' s orders, but they failed to do so.

A certification revisit was completed on 1/24/24 for the previous deficiency cited on 5/23/23. A deficiency was cited. The regulations governing Alternative Care Facilities were revised and the new regulations were implemented on 11/15/23. Based on interview and record review, 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 one of three sample participants (residents) (#1).This deficiency was cited previously during a state licensure survey on 5/23/23. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Resident #1 was admitted to the residence on 6/11/20. Written practitioner orders, dated 5/30/23, included a signature by a pharmacist. However, there was no evidence that the medications were ordered by the Resident #1' s authorized practitioner prior to 1/24/24.The January 2024 medication administration record revealed the residence administered the following medications from 1/1/24 to 1/23/24:Loratadine 10 mg dailyMultivitamin dailyCalcium 600 mg twice dailyThe residence administered acetaminophen 650 mg as needed on 1/2-1/19 and 1/23/24.An audit of Resident #1' s medications revealed the residence had the following medications in stock:Loratadine 10 mgMultivitaminCalcium 600 mgThe audit revealed an empty container labeled acetaminophen 325 mg.On 1/24/24 at 3:00 p.m., the administrator stated that this deficiency that was previously cited was not corrected because she did not realize that the written orders in the record were not signed by Resident #1' s authorized practitioner. She stated that a nurse from the resident' s practitioner' s office informed her that they would provide written practitioner' s orders, but they failed to do so.

A relicensure survey was completed on 5/23/23. Deficiencies were cited. Based on interview, observation and record review, the residence failed to ensure at least one staff member was onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting nine current residents who requested CPR. (Cross-Reference Q0732)Specifically, the residence failed to have at least one staff member onsite at all times who had current CPR certification from a nationally recognized organization for nine current residents who requested CPR in the event of an emergency. Additionally,without CPR certification, staff have not been trained properly on obstru.. Based on observation, record review, and interview, the residence failed to ensure only medications ordered by an authorized practitioner were administered to residents, affecting two of three sample residents (#1, #3).Findings include: 1. Residence Policy The residence' s undated Medication Administration policy read, "Only medication that has been ordered by an authorized practitioner shall be prepared and administered to residents."2. Resident #1 was admitted to the residence on 6/11/20. Review of the May medication administration record (MAR) for Resident #1 revealed the residence administered the following medications; however, the record for the resident did not contain.. Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents, affecting two of three sample residents (#1, #3).1. References a. According to Colorado Revised Statutes (2020) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that w.. Based on record review and interview,the residence failed to ensure medication audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting nine current residents.Findings include:On 5/23/23 at 8:20 a.m., the administrator was requested to provide the residence' s quarterly medication cart audits; however, she was unable to provide the documentation. On 5/23/23 at 8:45 a.m., the administrator stated that the medication cart audits were not being completed, as she was unaware of the requirement. Based on record review, observation and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting nine current residents. (Cross-Reference Q0734)Findings include: 1. Reference and Residence Policya. According to VeryWell Health, "First aid is the emergency care a sick or injured person gets. In some cases, it may be the only care someone needs, while in others, it may help them until paramedics arrive or they are taken to the hospital. The best way to prepare for these events is to get official first aid training" Brouhard, R., EMT (11/30/21) First Aid, 10 Basic First Aid ..

A recertification survey was completed on 5/23/23. Deficiencies were 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 nine current participants (residents). 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 oradministered to residents.Findings include: a. Residence Policy The residence' s undated Medication Administration policy read, "Only medication that has been ordered by an authorized practitioner shall be prepared and administered to residents."b. Resident #1 was admitted to the residence on 6/11/20. Review of the May medication administration record (MAR) for Resident #1 revealed the residence administered the following medications; however, the record for the resident did not contain practitioner orders for the medications, as follows:Loratadine 10 mg, administered once daily from 5/1-5/23/23.Multi-vitamin, administered once daily from 5/1-5/23/23.Celecoxib 200 mg, administered daily from 5-1-5/23/23.Calcium 600 mg-10 mcg, administered twice daily (BID) from 5/1-5/23/23. Citalopram 20 mg, administered once daily from 5/17-5/23/23. Diflunisal 500 mg, administered BID from 5/17-5/23/23.A cart audit on 5/23/23 at approximately 2:30 p.m. revealed all of the above medications were available to administer to the resident. c. Resident #3 was admitted to the residence on 4/13/18.Review of the May MAR for Resident #3 revealed the residence administered the following medications; however, the record for the resident did not contain practitioner orders for the medications, as follows:Furosemide 40 mg, administered once daily from 5/1-5/23/23.Potassium 10 meq, administered once daily from 5/1-5/23/23.Creative antioxidant, administered once daily from 5/1-5/23/23.Duloxetine 60 mg, administered once daily from 5/1-5/23/23.Levocitirizine 5 mg, administer..