Rocky Mountain Assisted Living at Chestnut Hill

A complaint survey, prompted by #CO36483 was completed on 7/9/24. Deficiencies were cited. 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 15 current residents. Findings include:1. Record ReviewOn 7/9/24 at 8:20 a.m., the residence' s resident roster for emergency preparedness was requested.On 7/9/24 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 information for each resident.2. InterviewsOn 7/9/24 at 9:13 a.m., the administrator stated that the roster provided was the official roster.On 7/9/24 at 1:25 p.m., the administrator stated that the provided roster was not the official roster and asked staff to print the correct roster. The administrator acknowledged the residence did not have ready access to the complete roster that included a residence diagram. The administrator acknowledged the importance of having ready access to a roster that included a diagram showing resident room locations and emergency contact information as part of the resident roster for emergency preparedness. Based on record review and interview, the residence failed to update comprehensive assessments at least annually or with a change in residents baseline condition, affecting two (#1,#2) of three sample residents.Findings include: 1. Record ReviewOn 7/9/24 at 9:15 a.m., resident records for Residents #1 and #2 were requested. There were no comprehensive assessments presented during the onsite visit after residents had a change in condition or fall. A progress note for Resident #1, dated 5/4/24, read in part, "resident cried for a while on shift since another resident had taken a fall earlier that evening, but eventually calmed down. nothing else to report ".An incident report for Resident #2, dated 6/4/24, read in part, "This morning he had a fall. I heard a big sound and I went into the room and found him on the floor on butt by the bed and nightstand. He had a right skin abrasion on upper arm. Me and the caregiver cleaned him up and took vitals. They were b/p-104/163, temp- 98.5, resp-18, Pr-91, oxygen- 92. All important people were contacted and are aware. "2. InterviewsOn 7/2/24 at approximately 11:00 a.m., the administrator stated she considered a fall a change in condition and expected there to be an updated assessment completed after a fall. On 7/2/24 at 1:15 p.m., the director of nursing stated she had a process in place for assessm..

A relicensure survey was completed on 3/3/23. Deficiencies were cited. Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of three sample residents (#2).1. Residence PolicyThe residence' s Medication Administration policy, dated February 2022, read in part: "The community (residence) is responsible for complying with practitioner orders, associated with the administration of medication or treatment."2. Record ReviewResident #2 was admitted to the residence on 8/9/22. Diagnoses included: dementia and diabetes. a. RopiniroleA written practitioner' s order, dated 2/23/21, directed the residence to administer Ropinirole 0.75 milligram (mg) one-tab per oral (PO) three times per day (TID) for tremors. However, the February and March 2023 electronic medication administration record (eMAR) revealed on 2/21/23 during the afternoon and evening administration staff provided a 0.5 mg tablet; and from 2/2/23 to 3/2/23 during the morning, afternoon, and evening administration staff provided a 0.5 mg tablet. There were a total of 32 incorrect doses administered to Resident #2 by staff. b. RybelsusA written practitioner' s order, dated 8/11/22, directed the residence to administer Rybelsus seven mg tablets once daily for diabetes. However, the February 2023 MAR revealed from 2/12/23 to 2/16/23 the ordered Rybelsus was not provi.. Based on observation, record review and interview, the residence failed to ensure files for current employees were readily available onsite for department review, affecting two of two sample staff (#1 and #2).Findings include:1. ReferenceChapter VII regulations governing assisted living residences, section two, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide resident care services. "Staff" does not include individuals providing external services, as defined herein. 2. ObservationOn 3/3/23 from 7:30 a.m. to 1:30 p.m., Staff #1 and #2 provided personal care and services to all the residents. 3. Record ReviewOn 3/3/23 at 8:30 a.m., personnel files for Staff #1 and #2 were requested from the resident care coordinator. On 3/3/23 at 10:30 a.m., personnel files for Staff #1 and #2 were requested from the administrator. 4. InterviewOn 3/3/23 at 10:40 a.m., the administrator stated she had to reach out to the human resources (HR) department to get the personnel files. She stated the personnel files were never kept onsite. The administrator further stated the staff from this residence worked at another building and it would be hard to keep them in one location. On 3/3/23 at 11:10 a.m., the HR manager stated she managed all staff files. She stated all the staff files were with her in the office, which was 15 mi..