Pueblo West Gardens Assisted Living

A recertification survey with complaints #CO33171, #CO33253, #CO33470, was completed on 10/11/23. A deficiency was cited. Based on observation, record review and interview, the facility (residence) failed to 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 three sample participants (residents) (#2, #3).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.29, requires each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event iscompleted for each resident. Residence Policy The residence' s undated Medication Administration policy, read in part, "The qualified medication administration person (QMAP) will document each medication administration ..." a. Resident #2 was admitted to the residence on 10/3/11. Olanzapine A written practitioner' s order, dated 1/15/23, directed the residence to administer olanzapine 15 mg one tablet daily. However, the September and October 2023 MAR revealed a blank space on 9/2, 9/3, 9/15, 10/1, and 10/2/23, for a total of five inaccurately documented doses.Breztri InhalerA written practitioner' s order, dated 1/15/23, directed the residence to administer two puffs of the Breztri inhaler twice daily. However, the September 2023 MAR revealed a blank space on 9/8/23 for the afternoon dose, for a total of one inaccurately documented dose.b. Resident #3 was admitted to the residence on 5/13/19. Oxycodone A written practitioner' s order, dated 1/12/23, directed the residence to administer oxycodone 10 mg one tablet every morning. However, the September 2023 MAR revealed a blank space on 9/6 and 9/28/23, for a total of two inaccurately documented doses.LevothyroxineA written practitioner' s order, dated 1/15/23, directed the residence to administer levothyroxine 50 mcg one tablet daily. However, the September and October MARs revealed a blank space on 9/6, 9/18, and 10/6/23, for a total of three inaccurately documented doses..

A relicensure survey with complaints #CO33169, #CO33252, #CO33469 was completed on 10/11/23. A deficiency was 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 sample residents (#2, #3).Findings include: 1. Residence Policy The residence' s undated Medication Administration policy, read in part, "The qualified medication administration person (QMAP) will document each medication administration ..." 2. Resident #2 was admitted to the residence on 10/3/11. a. Olanzapine A written practitioner' s order, dated 1/15/23, directed the residence to administer olanzapine 15 mg one tablet daily. However, the September and October 2023 MAR revealed a blank space on 9/2, 9/3, 9/15, 10/1, and 10/2/23, for a total of five inaccurately documented doses.b. Breztri InhalerA written practitioner' s order, dated 1/15/23, directed the residence to administer two puffs of the Breztri inhaler twice daily. However, the September 2023 MAR revealed a blank space on 9/8/23 for the afternoon dose, for a total of one inaccurately documented dose.3. Resident #3 was admitted to the residence on 5/13/19. a. Oxycodone A written practitioner' s order, dated 1/12/23, directed the residence to administer oxycodone 10 mg one tablet every morning. However, the September 2023 MAR revealed a blank space on 9/6 and 9/28/23, for a total of two inaccurately documented doses.b. LevothyroxineA written practitioner' s order, dated 1/15/23, directed the residence to administer levothyroxine 50 mcg one tablet daily. However, the September and October MARs revealed a blank space on 9/6, 9/18, and 10/6/23, for a total of three inaccurately documented doses.c. Buspirone A written practitioner' s order, dated 1/15/23, directed the residence to administer buspirone 10 mg two tablets three times daily. However, the September MAR revealed a blank space for the afternoon doses on 9/11 and 9/15/23, for a total of two inaccurately documented doses.4. Interviews ..