S&s Memory Care Assisted Living LLC

A revisit survey was completed on 8/2/24 for all previous deficiencies cited on 12/21/23. 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 revisit survey was completed on 8/2/24 for all previous deficiencies cited on 12/21/23. 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 relicensure survey was completed on 12/21/23. Deficiences were cited. Based on interview and record review, the administrator and the qualified medication administration person (QMAP) supervisor failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting seven current.. Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of three sample residents (#2) was administered a pro re nata (PRN) or "as needed" medication daily. Findings include:On 12/21/23 at 9:00 a.m., the surveyor attempted to as.. Based on observation, record review and interview, the residence failed to not use restraints of any kind for the purposes of care or safety, affecting one of three sample residents (#3) that had been restrained since September 2023. 1. References a. Chapter VII regulations governing assisted living residences, part 2.42, defines "Restraint" as a.. Based on record review and interview, the residence failed to ensure each personnel file contained written documentation of the required information, for three of three sample staff (#1-#3) affecting seven current residents. Findings include:1. Record Review Review of the personnel files for Staff #1-#3 revealed they were hired 8/30/23, 8/.. Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event was completed for each resident along with each of their signatures and, if used, their initials, affecting three of three s.. Based on record review and interview, the residence failed to ensure only medication that has been ordered by an authorized practitioner was administered to residents, affecting three of three sample residents (#1-#3). Findings include:1. Residence PolicyThe residence' s undated Medication Administration policy, read in part: "all medication or.. Based on record review and interview, the residence failed to have defined procedures to prevent the spread of influenza from unvaccinated healthcare workers, affecting seven current residents. Findings include: On 12/21/23 at 8:23 a.m., the residence' s influenza policy was requested. However, there was no policy or procedure to prevent the.. Based on record review and interview, the residence failed to retain in employee' s personnel files, who were qualified medication administration persons (QMAPs), documentation that the individual' s names appeared on the department' s list of individuals who had successfully completed the medication administration competency evaluation for two of t.. Based on record review and interviews, the residence failed to request, prior to staff hire, a name-based criminal history record check for each prospective staff member for two of three sample staff (#1, #2), affecting seven current residents. Findings include:1. ReferencesChapter VII regulations governing assisted living residences, part 2.45, defin.. Based on record review, and interviews, the residence failed to ensure applicants complied with Colorado Adult Protective Service Data Systems (CAPS) requirements prior to hiring staff who provided care to the residents for two of three sample staff (#1-#2), affecting seven current residents.Findings include:1. References a. According to Colorado.. 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 VII. 12.15 The assisted living residence shall develop policies and procedu..

A recertification survey was completed on 12/21/23. Deficiences were cited. Based on observation, record review and interview, the facility (residence) failed to not use restraints of any kind for the purposes of care or safety, affecting one of three sample participants (residents) (#3) that had been restrained since September 2023. 1. References a. Chapter VII regulations governing assisted living residences, part 2.42, defines "Restraint" as any method or device used to involuntarily limit freedom of movement including, but not limited to, bodily physical force, mechanical devices, chemicals or confinement.b. Chapter VII regulations governing assisted living residences, reads in part 12.14 that a device that facilitates a resident' s well-being and/or independence may be used only if all of the following criteria are met:(A) The resident has the functional ability to alter his or her position;(B) The resident is able to remove the device to allow for normal movement;(C) The device improves the resident' s physical or emotional state and allows the resident to participate in activities that would otherwise be diffi.. Based on 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 three of three sample participants (residents) (#1-#3).Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.29, requires each qualified medication administration person, nurse, or practitioner to accurately document each medication administration or monitoring event at the time the event is completed for each resident.The residence' s undated Medication Administration policy, read in part: "each qualified medication administration person shall accurately document each medication administration or monitoring event at the time it is completed for each resident."Resident #2 was admitted to the residence on 1/1/21 with a diagnosis of Dementia.AcetaminophenA written practitioner' s order dated 3/22/22 directed the residence to administer acetamin.. 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 Medical Assistance Section 8.400 Long Term Care, Nursing Facility Care, Adult Day Care Services.8.484.4 (A) Provider-Owned or -Controlled Residential Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.484.5: 2. Individuals have the right to dignity and privacy, including in their living/sleeping units.The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10 8.400.8.495.4 (1) (C) The participant' s choice to live in an ACF shall afford the participant the opportunity to responsibly contribute to the home in meaning..