Renaissance at Kiowa

A revisit survey was completed on 2/12/25 for all previous deficiencies cited on 10/1/24. 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 10/1/24. A deficiency was cited. Based on interview and record review, the facility (residence) failed to ensure that each qualified medication administration person (QMAP) documented accurate information in the medication administration record (MAR), including any medication omissions; the residence additionally failed to ensure that, as part of the MAR, the residence maintained a legible list of the names of the persons utilizing the MAR, along with their signatures and initials, affecting three of three sample members (#1-#3).Findings include:1. Residence PolicyThe residence' s undated Documentation policy read in part that "resident records are maintained to provide accurate and complete information about the care and treatment of residents."2. Resident #1A written practitioner' s order, dated 1/26/24, directed the residence to administer the following medications:Metformin HCL 1000 mg once dailyZiprasidone HCL 40 mg once dailyAtorvastatin40 mg once dailyTrazodone 100 mg once dailyDivalproex sodium 250 mg once dailyDivalproex sodium 500 mg once dailyFurosemide 20 mg twice dailyGabapentin 300 mg once dailyThe August and September 2024 MARs revealed blank spaces in the medication administration record for the administration of the following medications on the corresponding dates:Metformin HCL 8/23, 8/29, 9/5, 9/8, 9/12, 9/19, 9/21/24Ziprasidone HCL 8/23, 8/29/24Atorvastatin 9/20/24Trazodone 9/5, 9/13, 9/20/24Divalproex sodium 9/20/24Divalproex sodium 9/20/24Furosemide 20 mg 9/20/24 eveningGabapentin 300 9/5, 9/20/24However, the QMAPs failed to include corresponding documentation on the MAR detailing the reason that the staff did not sign off on the administration of the above medications.4. InterviewOn 10/1/24 at 12:46 p.m., the acting administrator stated that she was aware of the requirement for staff to accurately document medication administration in the MAR. She acknowledged that the staff failed to document medication administration in the MARs for Residents #1-#3. The administrator stated ..

A relicensure survey was completed on 10/1/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure that each qualified medication administration person (QMAP) documented accurate information in the medication administration record (MAR), including any medication omissions; the residence additionally failed to ensure that, as part of the MAR, the residence maintained a legible list of the names of the persons utilizing the MAR, along with their signatures and initials, affecting three of three sample residents (#1-#3).Findings include:1. Residence PolicyThe residence' s undated Documentation policy re.. Based on record review and interview the residence failed to ensure applicants complied with Colorado Adult Protective Service Data System (CAPS) requirements prior to hiring staff who provided care to the residents, for two of three sample staff (#1, #2) affecting eight current residents.Findings include:1. Record Reviewa. On 10/1/24 at 8:30 a.m., the personnel files for Staff #1 and #2 were requested; however, no CAPS checks were provided.b. Face sheets for Residents #1-#3 revealed their ages were as follows as of the date of the onsite visit: Resident #1 was 54 years ol.. Based on record review and interview, the residence failed to develop and implement a visitation policy which described any restriction or limitation necessary to ensure the health and safety of residents, staff and visitors, affecting eight current residents.Findings include:On 10/1/24 at approximately 8:00 a.m., the residence' s visitation policy was requested but not provided.On 10/1/24at 9:30 a.m., the administrator stated she was unaware the regulation updated on 1/1/24, requiring the residence to develop and implement a visitation policy. Based on record review and interview, the residence failed to develop and implement an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting eight current residents.Findings include:On 10/1/24 at approximately 8:00 a.m., the residence' s involuntary discharge grievance policy was requested but not provided.On 10/1/24 at 9:30 a.m., the administrator stated she was unaware the regulation updated on 1/1/24 requiring the residence to develop and implement an involuntary discharge grievance policy. Based on record review and interview, the residence failed to have readily available a roster of current residents along with a residence diagram showing room locations, and the emergency contacts for each resident, affecting five current residents.Findings include:On 10/1/24 at 8:35 a.m., the residence' s resident roster for emergency preparedness was requested.On 10/1/24 at 9:10 a.m., the residence' s resident roster was provided. However, the resident roster did not include a diagram of the residence that showed room locations or the emergency contact info.. 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 7.6.5 Each administrator shall have completed an administrator training program before assuming an administrator position. Written proof regarding the successful completion of such training program shall be maintained in the administrator ' s personnel file.7.2 If the assisted living residence becomes aware of informatio..

A revisit survey was completed on 3/26/24 for all previous deficiencies cited on 6/13/23. 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 licensure revisit was completed on 6/13/23 for all previous deficiencies cited on 9/28/21. The residence is in compliance with all regulations surveyed. 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