Spruce House

/A revisit survey was completed on 12/7/23 for all previous deficiencies cited on 10/25/23. No deficiencies 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 10/25/23. Deficiences were cited. Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed, affecting two of three sample residents (#1, #2). 1. Residence PolicyThe residence' s Medication Error policy, dated 5/15/19, read in part: "a documentation error is any documentation that occurs that does not accurately reflect the medication administration that was performed ... documentation errors will be handled differently and as follows ... documentation error one and two ... a medication administration error report form will be filled out and submitted to (the residence' s) management ... six documentation errors ... the employee will not be allowed to administer medications until ... (management) meets to supervise their medication administration."2. Resident #1 was admitted to the residence on 5/20/22.a. Atorvastatin A written practitioner' s order, dated 9/1/23, directed the residence to a.. Based on observation, record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting one of three sample residents (#1) who was not administered two medications from one to two months. Findings include:1. Residence PolicyThe residence' s Medication Administration policy, dated 10/2/19, read in part: "(The residence) strives to ensure that participant (resident) medications are ordered and received accurately ... the assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration."2. ObservationOn 10/25/23 at 8:06 a.m., Staff #1 was unable to locate the omega 3 medication for Resident #1 and had not administered the medication.3. Resident #1 was admitted to the residence on 5/20/22 with a diagnosis of mixed hyperlipidemia.Omega 3 capsuleA written practitioner' s order, dated 9/2/23, directed the residence to administer o.. 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 7.14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.14.12 The assisted living residence shall ensure that all qualified medication administration persons are trained in and adhere to the following medication administration procedures: (A) Identification of the right resident for each medication administration or monitoring by asking for the resident ' s name or comparing the resident to a photograph maintained specifically for medication administration identification.

A recertification survey was completed on 10/25/23. A deficiency was cited. Based on observation, interview and record review, the facility (residence) failed to maintain and 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 residents, part 14.29, requires all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident' s room location, any known allergies, and the name and telephone number of the resident' s authorized practitioner. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications. The residence' s Medication Error policy, dated 5/15/19, read in part: "a documentation error is any documentation that occurs that does not accurately reflect the medication administration that was performed ... documentation errors will be handled differently and as follows ... documentation error one and two ... a medication administration error report form will be filled out and submitted to (the residence' s) management ... six documentation errors ... the employee will not be allowed to administer medications until ... (management) meets to supervise their medication administration."a. Resident #1 was admitted to the residence on 5/20/22.Atorvastatin A written practitioner' s order, dated 9/1/23, directed the residence to administer atorvastatin 20 mg daily. However, the September 2023 electronic medication administration record (eMAR) revealed blanks on 9/5 and 9/14/23. Additionally, on 9/4/23, the eMAR was marked under "missed/refused," by Staff #1, and there were no corresponding eMAR documentation notes to determine whether the medication was ..