Sopris Lodge at Carbondale

A licensure complaint, prompted by #CO32157, was completed on 7/17/23. Deficiencies were cited. Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#3-#5).Findings include:1. Residence PolicyThe residence' s Medication Management Policy, updated 3/23/22, read in part: "the residence shall administer medications upon the written order of a practitioner."2. Resident #4 was admitted to the residence on 8/24/22, with a diagnosis of Alzheimer' s Disease.a. Lidocaine patch 5%A written practitioner' s order, dated 5/18/23, directed the residence to administer lidocaine patch 5% once daily. However, the June 2023 electronic medication administration record (eMAR), read the residence did not administer the medication on 6/10-6/12/23, 6/14/23 and 6/16/23 .. Based on record review and interviews, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event is completed for each resident along with each of their signatures and, if used, their initials, and failed to document accurate information in the medication administration record (MAR), affecting one of four sample residents (#4) and one former resident (#6).Findings include:1. Residence PolicyThe residence' s Medication Management Policy, updated 3/23/22, read in part: "The administration of medication shall be documented at the time of administration."2. Resident #4 was admitted to the residence on 8/24/22, with a diagnosis of Alzheimer' s Disease.A written practitioner' .. Based on record review and interviews, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting 27 current residents and one former Resident (#6). Findings include:1. Referencea. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(I) Completing, maintaining, and submitting all reports and records required by the Department.2. Record ReviewOn 7/17/23 at 7:30 a.m. the following items were requested:a. Current resident rosterb. Current staff list with phone numbersc. December 2022 and June-July 2023 staff schedulesd. Blank resident agreeme.. Based on record reviews and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP), on a quarterly basis, audit the accuracy and completeness of the medication administration records and ensure any irregularities were investigated and resolved, affecting 27 current residents. Findings include: The residence' s Medication Management Policy, updated 3/23/22, read in part: "the administrator and wellness director will audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records at least quarterly ... audits will be documented and reviewed."On 7/17/23 at 8:56 a.m., the last three medication audits were requested from the admi..

A licensure revisit was completed on 7/17/23 for all previous deficiencies cited on 12/15/22. A deficiency was cited. Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#3-#5).This deficiency was cited previously during a state licensure survey 12/15/22. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement.Findings include:1. Residence PolicyThe residence' s Medication Management Policy, updated 3/23/22, read in part: "the residence shall administer medications upon the written order of a practitioner."2. Resident #4 was admitted to the residence on 8/24/22, with a diagnosis of Alzheimer' s Disease.a. Lidocaine patch 5%A written practitioner' s order, dated 5/18/23, directed the residence to administer lidocaine patch 5% once daily. However, the June 2023 electronic medication administration record (eMAR), read the residence did not administer the medication on 6/10-6/12/23, 6/14/23 and 6/16/23 for a total of five missed doses, due to the medication being out of stock. b. Citalopram hydrobromideA written practitioner' s order, dated 5/18/23, directed the residence to administer citalopram hydrobromide 20 mg once daily. However, the June and July 2023 eMARs read the residence did not administer the medication on 6/12 and 7/13/23 for a total of two missed doses, due to the medication being out of stock.c. AriceptA written practitioner' s order, dated 7/2/23, directed the residence to administer Aricept 5 mg once daily. However, the July 2023 eMAR read the residence did not administer the medication on 7/3/23 for a total of one missed dose, due to the medication being out of stock. d. BupropionA written practitioner' s order, dated 5/18/23, directed the residence to administer bupropion 150 mg once daily. However, the July 2023 eMAR read the residence did not administer the medication on 7/5/23 for a total of one missed dose, due to the medication being out of stock. e. IbuprofenA written practitioner' s order, dated ..