Summit Supportive Communities

A revisit survey was completed on 4/4/24 for all previous deficiencies cited on 2/14/24. 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 revisit survey was completed on 4/4/24 for all previous deficiencies cited on 2/14/24. 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 second initial certification survey was completed on 2/14/24. Deficiencies were cited. Based on observation, interview, and record review, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting three of three sample participants (residents) (#1-#3).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires residences to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Reference and Residence PolicyThe residence' s medication policy, dated April 2022, read in part that the residence was responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.According to Medline Plus, follow the directions on the divalproex prescription label carefully. Take divalproex exactly as directed. Do not take more or less of it than prescribed by your doctor. Medline.. Based on observation, record review and interview, the facility (residence) failed to maintain a home-like quality and feel for participants (residents) at all times, affecting seven current residents.Findings include:1. Residence PolicyThe residence' s policy titled Assisted Living Residence, dated April 2022, read in part: "To create a home-like environment focused on person-centered care, the term community or home may be used in place of the word facility."2. ObservationsOn 2/14/24 from approximately 7:30 a.m. to 3:00 p.m. throughout the on site visit, the following was observed:In two bathrooms utilized by the residents, handwritten signs on white copy paper inserted in plastic sheet protectors were taped to the mirrors of each bathroom. Each sign read (in all capital letters): "Please leave (the) faucet alone. Do not turn off or they will freeze (and) pipes might burst due to sinks not dripping!! Thx (sic). (residence) staff."The same handwritten sign inserted in a plastic sheet protector was taped above the sink in the res.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.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(C)(1)(c) Participants shall be informed of their rights, according to 6 CCR 1011-1, Chapter VII, Section 13. Pursuant to 6 CCR 1011-1, Chapter VII, Section 13.1, the policy on resident rights shall be in a visible location so that they are always available to participants and visitors.1. These rights include but are not limited to:c. Participants have the right to dignity and privacy

A second initial licensure survey was completed on 2/14/24. A deficiency was cited. Based on observation, interview, and record review, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting three of three sample residents (#1-#3).Findings include:1. Reference and Residence Policya. The residence' s medication policy, dated April 2022, read in part that the residence was responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.b. According to Medline Plus, follow the directions on the divalproex prescription label carefully. Take divalproex exactly as directed. Do not take more or less of it than prescribed by your doctor. Medline Plus (2/15/24) Valproic Acid, retrieved from: https://medlineplus.gov/druginfo/meds/a682412.html 2. Resident #3 was admitted to the residence on 9/5/23 with unknown diagnoses.a. DivalproexA written practitioner' s order, dated 1/11/24, directed the residence to administer divalproex 125 mg four capsules twice daily.The February 2024 medication administration record (MAR) directed the residence to administer divalproex 125 mg four capsules (500 mg) twice daily.On 2/14/24 at approximately 7:45 a.m., Staff #1 dispensed four capsules of divalproex from the package into a medication cup. She then gave the medication.. 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 7.13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items:(A) The right to privacy and confidentiality14.12 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