Monarch Greens Assisted Living Home

A relicensure survey with complaint #CO35240 was completed on 8/28/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting two of three current sample residents (#1,#2).Findings include:1. Resident #1A written practitioner' s order, dated 2/28/24, directed the residence to administer the following medications:Fluticasone 220 mcg twice dailymenthol 3% gel 74 ml three times dailyProcto-med 2.5% cream twice dailyThe July and August 2024 M.. Based on observation and interview, the residence failed to ensure all medications were stored in a locked storage area when unattended by a qualified medication administration person (QMAP) or other licensed staff, affecting eight current residents. Findings include: On 8/28/24 at 7:35 a.m., an environmental tour revealed medication for Resident #1 stored in a shared residence bathroom. The medication was not stored in a locked storage area; therefore, the medication was easily accessible to four current residents who used the bathroom.On 8/28/24 at 8:54 a.m., Staff #3 .. 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 four of four sample residents (#1-#4) whose medications were administered.Findings include:On 8/28/24 at 8:27 a.m., Staff #3 washed their hands, walked over to the medication cart and unlocked the medication cart. Staff #1 touched the laptop, medication pack, and the medication cup. Staff .. Based on record review and interview, the residence failed to ensure personnel files included documentation of training and orientation for three of three staff (#1-#3), affecting eight current residents.Findings include:1. Record reviewThe personnel files for Staff #1-#3 were reviewed, revealing that Staff #1-#3, personnel files failed to contain documentation of staff training and orientation. 2. InterviewsOn 8/28/24 at approximately 10:45 a.m., the administrator stated he expected there to be documentation of staff training and orientation in their personnel files .. Based on record review and interview, the residence failed to update comprehensive assessments at least annually and whenever the resident' s condition changed from baseline status, affecting two of four sample residents (#2, #3) and one former resident (#5). Findings include: 1. Resident #2 was admitted to the residence on 2/17/23. A comprehensive assessment for Resident #2, dated 2/26/23, read in part "low capacity for self care, requires full assistance." The comprehensive assessment was not updated annually.2. Former Resident #5 was admitted to the residence on 9/24/2.. Based on record review and interview, the residence failed to, on a quarterly basis, audit the accuracy and completeness of medication administration records (MARs), affecting eight current residents.Findings include:On 8/28/24 at 8:30 a.m., the last two quarterly medication audits were requested from the administrator. However, no documentation was provided.On 8/28/24 at approximately 10:15 a.m., the administrator stated he was unaware of the requirement to perform and document medication administration audits. He stated she had not completed a med..