Roaring Fork Senior Living

A revisit survey was completed on 1/28/25 for all previous deficiencies cited on 9/25/24. 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 relicensure survey, with complaints #CO34900, #CO34111 and #CO33754 was completed on 9/25/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure the administrator and qualified medication administration persons supervisor audited the accuracy and completeness of the medication administration records, affecting 60 current residents.Findings include:On 9/25/24 at approximately 7:50 a.m., medication audits were requested however they were never received. On 9/25/24 at approximately 8:00 a.m., the administrator said she was hired approximately one month ago. She said she had not done a medication audit since she had started. She said there was no documentation that the prior administrator did medication audits. Based on observation, record review and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid and cardiopulmonary resuscitation (CPR) so that the information was readily available to staff at all times, affecting 60 current residents.Findings include:On 9/4/24 at approximately 7:45 a.m., an environmental tour of the residence revealed there was no list of staff who had current certification in first aid or CPR in a visible location inside the residence. On 9/4/24 at approximately 1:50 p.m., the assisted living director toured the residence and acknowledged there were no CPR and first aid postings in the residence. She said the residence should have this posted in case of an emergency. She said she had thought they had posted the current list of staff who have CPR and first aid certification. She confirmed the previous deficient practice was not corrected. 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 7.10.3 The assisted living residence shall develop and follow written policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency including, but not limited to, a long-term power failure.

A complaint revisit was completed on 9/25/24 for all previous deficiencies cited on 1/26/23. Deficiencies were cited.The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 1/14/24. Based on observation, record review and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid and cardiopulmonary resuscitation (CPR) so that the information was readily available to staff at all times, affecting 60 current residents.This deficiency was cited previously during a complaint revisit on 1/26/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:On 9/4/24 at approximately 7:45 a.m., an environmental tour of the residence revealed there was no list of staff who had current certification in first aid or CPR in a visible location inside the residence. On 9/4/24 at approximately 1:50 p.m., the assisted living director toured the residence and acknowledged there were no CPR and first aid postings in the residence. She said the residence should have this posted in case of an emergency. She said she had thought they had posted the current list of staff who have CPR and first aid certification. She confirmed the previous deficient practice was not corrected. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of seven sample residents (#23).This deficiency was cited previously during a complaint revisit on 1/26/23. 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 #23 was admitted to the residence on 3/10/22. A practitioner' s order dated 8/2/24 directed the residence to administer 7.5 mg of mirtazapine daily. However the September 2024 medication administration record (MAR) read staff failed to administer the medication from 9/1-9/10/24 because the medication was out of stock, for a total of 10 missed medications.A practitioner' s order dated 5/21/24 directed the residence to administer 100 mg of quetiapine fumarate twice daily. The August 2024 MAR read staff held the medication from 8/2-8/8/24, however, there was no order directing the residence to hold the medication, for a total of 13 missed doses.A practitioner' s order dated 8/29/24 directed the residence to administer 60 mg of duloxetine HCL daily. However the August and September 2024 MAR read staff failed to administer the medication from 8/29/24-9/4/24 and no reason was recorde..