Summit Supportive Communities

A licensure complaint, prompted by #CO00031972, was completed on 12/19/23. A deficiency was cited Based on observation, interview, and record review, the residence failed to ensure a qualified medications administration person (QMAP) did not pre-pour medications, affecting two of three sample residents (#5, #8).Findings include1. Residence policy The residence ' s 5/2021 medication administration policy read in part; the individual administering the medication must remain with the resident until the resident has taken the medication.2. ObservationsOn 12/19/23 at 7:38 a.m., Staff #3 gave Resident #5 a medication cup with his initials and medications. On 12/19/23 at 7:50 a.m., Staff #3 had given Resident #8 a medication cup with his initials and medications in the cup. On 12/19/23 at 7:50 a.m., as staff had given Resident #8 his medications there was another medication cup inside the med cart drawer labeled with Resident #6' s initials.3. InterviewsOn 12/19/23 at 7:38 a.m., Staff #3 stated around 7:30 a.m., he placed the residents' medications in individual cups and labeled them with the resident initials due to multiple residents needing medications at the same time. Staff #3 also stated, he left the cups in the medication cart drawer until the resident was in front of him to take the medication. On 12/19/23 at approximately 12:30 p.mThe administrator designee stated she was unaware of medications pre poured and staff should not pre-pour medications.

A relicensure revisit was completed on 12/19/23 for all previous deficiencies cited on 9/28/23. A deficiency was cited. Based on observations, record review and interview, the residence failed to ensure the house rules were being implemented by staff and residents in regards to marijuana use, affecting seven current residents.This deficiency was cited previously during a relicensure survey 9/28/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. ReferenceThe residence ' s 5/2021 house rules read in part; Marijuana is prohibited. There was no indication of repercussions after house rules were not followed. 2. ObservationOn 12/19/23 at 8:47 a.m., Resident #6 had walked out of the residence into the backyard with a pipe used for marijuana smoking, he was seen smoking marijuana out of the pipe.3. InterviewsOn 12/19/23 at 8:50 a.m., Resident #6 stated he bought his own marijuana and smoked in the backyard almost every day.On 12/19/23 at 9:50 a.m., Resident #5 stated he bought his own marijuana when he had the funds and smoked in the backyard. On 12/19/23 at approximately 12:30 p.m., the administrator designee stated marijuana was not allowed and was unaware there were residents that smoked it at the residence.

A Licensure Revisit was completed on 12/19/23 for all previous deficiencies cited on 9/28/23. A deficiency was cited. PROVIDER LICENSING AND CERTIFICATION REQUIREMENTS ii. Providers furnishing SLP services under a Department-approved exception are required to comply with the medication administration requirements pursuant to both the HCA licensure requirements found at 6 CCR 1011-1, Chapters 7 and 26, and Section 25-1.5-301 through 304, C.R.S. 6 CCR 1011-1, Ch. 7, Section 14, (2018) is hereby incorporated by reference. 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (H) Pre-pouring of medicationBased on observation, interview, and record review, the residence failed to ensure a qualified medications administration person (QMAP) did not pre-pour medications, affecting two of three sample residents (#5, #8).Findings include1. Residence policy The residence' s 5/2021 medication administration policy read in part; the individual administering the medication must remain with the resident until the resident has taken the medication.2. ObservationsOn 12/19/23 at 7:38 a.m., Staff #3 gave Resident #5 a medication cup with his initials and medications. On 12/19/23 at 7:50 a.m., Staff #3 had given Resident #8 a medication cup with his initials and medications in the cup. On 12/19/23 at 7:50 a.m., as staff had given Resident #8 his medications there was another medication cup inside the med cart drawer labeled with Resident #6' s initials and medications in the cup.3. InterviewsOn 12/19/23 at 7:38 a.m., Staff #3 stated around 7:30 a.m., he placed the residents' medications in individual cups and labeled them with the resident initials due to multiple residents needing medications at the same time. Staff #3 also stated, he left the cups in the medication cart drawer until the resident was in front of him to take the medication. On 12/19/23 at approximately 12:30 p.m. The administrator designee stated she was unaware of medications pre poured and staff should not pre-pour medications.