Oberon House Assisted Living, the

A certification complaint, prompted by #CO35089 and #CO35209, was completed on 7/1/24. Deficiencies were 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 one of three sample participants (residents) (#1).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21 requires the residence to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. a. Record ReviewResident #1 was admitted to the residence on 12/4/22 with diagnoses that included early-onset dementia. A written practitioner' s order, dated 2/16/24, directed the residence to administer 5 mg of melatonin before bed. The June 2024 medication administration record (MAR) read that staff administered 5 mg of melatonin from 6/1 to 6/26/24, for a total of 26 doses. On 6/27/24, the label on the bottle of Resident #1' s melatonin read that one gummy was a 2.5 mg dose.b. InterviewsOn 6/27/24 at 7:00 p.m., Resident #1' s family member said that on 6/26/24, she had stopped Staff #2 from administering the medications to ensure Staff #2 had dispensed the medications as ordered. She stated the staff had only dispensed half the ordered dose of melatonin (one melatonin g.. Based on observation, record, review, and interview, the facility (residence) failed to provide personal care services as a benefit to the participant (resident), affecting one current sample resident (#1).Findings include:1. Residence PolicyThe residence' s undated resident agreement read in part that the residence provided services as required by all applicable state laws and regulations.2. Record ReviewResident #1 was admitted to the residence on 12/4/22 with diagnoses that included early-onset dementia. A care plan, dated 4/11/24, read in part that the resident required staff assistance to be toileted every two hours during awake hours the following times: 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m., 7:00 p.m., and 9:00 p.m. Staff was required to notify the resident' s family if the resident refused assistance two times in a row. A review of electronic activities of daily life revealed that staff failed to document toileting during the following times:6/1/24 at 7:00 a.m., 9:00 a.m., 11:00 a.m., and 1:00 p.m.6/2/24 at 7:00 a.m., 9:00 a.m., 11:00 a.m., and 1:00 p.m. 6/3/24 at 7:00 a.m., 11:00 a.m., and 1:00 p.m.6/4/24 at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m. , 3:00 p.m., 5:00 p.m., 7:00 p.m., and 9:00 p.m.6/5/24 at 7:00 a.m., 9:00 a.m., 11:00 a.m., and 1:00 p.m. 6/6/24 at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m. 6/7/24 at 7:00 a.m., 9:..

A licensure complaint, prompted by #CO35088 and #CO35207, was completed on 7/1/24. Deficiencies were cited. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one of three sample residents (#1). Findings include:1. Record Review Resident #1 was admitted to the residence on 12/4/22 with diagnoses that included early-onset dementia. A written practitioner' s order, dated 2/16/24, directed the residence to administer 5 mg of melatonin before bed. The June 2024 medication administration record (MAR) read that staff administered 5 mg of melatonin from 6/1 to 6/26/24, for a total of 26 doses. On 6/27/24,the label on the bottle of Resident #1' s melatonin read that one gummy was a 2.5 mg dose.2. InterviewsOn 6/27/24 at 7:00 p.m., Resident #1' s family member said that on 6/26/24, she had stopped Staff #2 from administering the medications to ensure Staff #2 had dispensed the medications as ordered. She stated the staff had only dispensed half the ordered dose of melatonin (one melatonin gummy at 2.5 mg). The family member said Staff #2 informed her that she had given half of the ordered dose for "the entire time" of the written practitioner' s order (on 2/16/24). On 6/27/24 at 7:45 p.m., Staff #2 acknowledged that she had administered the wrong dose of melatonin a.. Based on record review, observation, and interview, the residence failed to make a sanitary environment available, either directly or indirectly through a resident agreement, affecting one of three sample residents. (#1) Findings include:Residence PolicyThe residence' s undated resident agreement read in part that the residence provided services as required by all applicable state laws and regulations.Record ReviewResident #1 was admitted to the residence on 12/4/22 with diagnoses that included early-onset dementia. A care plan, dated 4/11/24, read in part that the resident required staff assistance to be toileted every two hours during awake hours the following times: 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m., 7:00 p.m., and 9:00 p.m. Staff was required to notify the resident' s family if the resident refused assistance two times in a row. A review of electronic activities of daily life revealed that staff failed to document toileting during the following times:6/1/24 at 7:00 a.m., 9:00 a.m., 11:00 a.m., and 1:00 p.m.6/2/24 at 7:00 a.m., 9:00 a.m., 11:00 a.m., and 1:00 p.m. 6/3/24 at 7:00 a.m., 11:00 a.m., and 1:00 p.m.6/4/24 at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m. , 3:00 p.m., 5:00 p.m., 7:00 p.m., and 9:00 p.m.6/5/24 at 7:00 a.m., 9:00 a.m., 11:00 a.m., and 1:00 p.m.6/6/24 at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m.6/7/24 at 7:00 a.m., 9:0..

A revisit survey was completed on 4/23/24 for all previous deficiencies cited on 11/20/23. 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