Rosemark at Mayfair Park

A licensure complaint, prompted by #CO41780, was completed on 3/25/26. No deficiencies were cited. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLYNo response is necessary.The residence was advised to review and maintain the following processes in accordance with the existing program regulations at 6 CCR 1011-1, Chapter 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.

A licensure revisit was completed on 11/6/24 for all previous deficiencies cited on 2/7/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on interview and record review, the residence failed to implement a fall management program that included detailing in the resident' s care plan the individualized approaches necessary to address fall risks, affecting two of seven sample residents (#21 and #22).This deficiency was cited previously during a state licensure survey 2/7/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. References The residence' s 2/26/24 Fall Management Policy read in part that after a resident had fallen, interventions were developed; those interventions were identified in the resident' s care plan.2. Resident #22 was admitted to the residence on 9/22/21 with a diagnosis of Alzheimer' s Disease.A progress note, dated 10/12/24, read the resident was at an activity dancing when she lost her balance and fell to her knees. She sustained a wound on her ankle and knee. A progress note, dated 10/23/24, read the resident went to an activity and fell on her side. A care plan, dated 9/19/24, read in part that Resident #22 required one staff member to assist with getting out of bed, toileting, removing clutter from walkways, and ensuring the resident wore proper footwear; she required staff assistance and rest periods with stationary activities. The most recent interventi.. Based on observation, interview, and record review, the residence failed to be responsible for complying with authorized practitioner' s orders associated with medication administration, affecting five of seven (#22, #23, #32, #33 and #39) sample residents.This deficiency was cited previously during a state licensure survey 2/7/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: 1. Reference The residence' s 2/26/24 Medication Administration Policy read in part that the qualified medication administration personnel (QMAP) abided by the orders placed through the authorized practitioner.2. Record Review Resident #22 was admitted to the residence on 9/22/21.a. LorazepamA written practitioner' s order, dated 5/18/24, directed the residence to administer lorazepam 0.5 mg daily. However, the October 2024 medication administration record (MAR) read the residence failed to administer the medication on 10/4-10/7/24 due to the medication being unavailable, for a total of four missed doses. b. IbuprofenA written practitioner' s order, dated 5/18/24, directed the residence to administer ibuprofen 200 mg two tablets three times daily for five days. However, the November 2024 MAR revealed that staff administered the medication twice on 11/2..

A relicensure survey with complaint #CO38021 was completed on 11/6/24. Deficiencies were cited. Based on observation and interview, the residence failed to ensure each resident' s right to privacy and dignity with respect to medication monitoring and administration, affecting one current resident (#37).Findings include:1. ObservationsOn 11/6/24 at approximately 7:30 a.m., an open laptop computer was on a medication cart, and Resident 37' s electronic medication administration record (EMAR) was visible to individuals who walked by. No staff were present. On 11/6/24 at 7:42 a.m., the laptop computer was still open with, and Resident #36 was observed walking near the medication cart. 2. Interviews On 11/6/24 at 8:25 a.m., Staff #32 stated she was aware she had left the EMAR visibly accessible but had been "pulled away." She acknowledged that she was required to keep resident records confidential and that she did not ensure the right to privacy by leaving the laptop computer open and unattended. On 11/6/24 at approximately 3:36 p.m., the administrator stated that the qualified medication administration persons (QMAP) supervisor expected all QMAPs to close laptop computers when resident health information was on the screen when leaving the medication cart unattended. The administrator acknowledged the QMAP left private resident health information visible and expected the QMAP to turn the screen off when walking aw.. Based on observation, interview, and record review, the residence failed to be responsible for complying with authorized practitioner' s orders associated with medication administration, affecting five of seven (#22, #23, #32, #33 and #39) sample residents.Findings include: 1. Reference The residence' s 2/26/24 Medication Administration Policy read in part that the qualified medication administration personnel (QMAP) abided by the orders placed through the authorized practitioner.2. Record Review Resident #22 was admitted to the residence on 9/22/21.a. LorazepamA written practitioner' s order, dated 5/18/24, directed the residence to administer lorazepam 0.5 mg daily. However, the October 2024 medication administration record (MAR) read the residence failed to administer the medication on 10/4-10/7/24 due to the medication being unavailable, for a total of four missed doses. b. IbuprofenA written practitioner' s order, dated 5/18/24, directed the residence to administer ibuprofen 200 mg two tablets three times daily for five days. However, the November 2024 MAR revealed that staff administered the medication twice on 11/2, three times on 11/3, twice on 11/4 and 11/5 , for an additional nine doses more than what the written practitioner' s order directed. 3. Evidence revealed similar deficient practice for Residents #23, #32, and #33 and #39. 4. Interview ..

A relicensure survey and complaint revisit was completed on 11/6/24 for all previous deficiencies cited on 2/7/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Based on observation, interview, and record review, the residence failed to be responsible for complying with authorized practitioner' s orders associated with medication administration, affecting five of seven (#22, #23, #32, #33 and #39) sample residents.This deficiency was cited previously during a state licensure survey 2/7/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include: 1. Reference The residence' s 2/26/24 Medication Administration Policy read in part that the qualified medication administration personnel (QMAP) abided by the orders placed through the authorized practitioner.2. Record Review Resident #22 was admitted to the residence on 9/22/21.a. LorazepamA written practitioner' s order, dated 5/18/24, directed the residence to administer lorazepam 0.5 mg daily. However, the October 2024 medication administration record (MAR) read the residence failed to administer the medication on 10/4-10/7/24 due to the medication being unavailable, for a total of four missed doses. b. IbuprofenA written practitioner' s order, dated 5/18/24, directed the residence to administer ibuprofen 200 mg two tablets three times daily for five days. However, the November 2024 MAR revealed that staff administered the medication twice on 11/2, three times on 11/3, twice on 11/4 and 11/5 , for an additional nine doses more than what the written practitioner' s order directed. 3. Evidence revealed similar deficient practice for Residents #23, #32, and #33 and #39. 4. Interview On 11/6/24 at 3:58 p.m., the administrator stated she expected staff to administer medications according to the practitioner' s orders and acknowledged that staff did not do so for Residents #22, #32, #33, and #39. The administrator stated this deficiency that was previously cited was not corrected due to a lack of oversight and expected compliance from all staff.