Terra Bluffs Ventures Opco Lp

A licensure complaint, prompted by #CO36185, #CO36635, #CO37045, #CO37429, #CO39177 was completed on 3/25/25. Deficiencies were cited. Based on interview and record review, the residence failed to report non-compliance of known medications by a resident who was self-administering to the resident' s authorized practitioner. Findings include: 1. Resident #6 was admitted to the residence on 8/30/24 with diagnoses including dementia, hypertension, type II diabetes, and osteoporosis. a. Record ReviewThe physician' s admission form, dated 7/16/24, read in part, "Healthcare professionals administer medications. Medications are stored in a central location and administered by healthcare professionals only ..."The care plan for Resident #6, dated 8/31/24, read in part, "(Resident #6) requires assistance from family to set up, administer, and order all medications ..." The residence' s Self-Administration of Medications Review Tool, dated 1/13/25, deemed Resident #6 fully capable and approved the resident to self-administer his medications. Additionally, the document read that the residence had obtained a physician order for the resident to self-administer; however, t.. Based on interview and record review, the residence failed to review the resident' s medication list with the resident and authorized practitioner, affecting one resident (#6) who self-administered medications. Findings include:1. Resident #6 was admitted to the residence on 8/30/24 with diagnoses including dementia, hypertension, type II diabetes, and osteoporosis. a. Record ReviewThe physician' s admission form, dated 7/16/24, read in part, "Healthcare professionals administer medications. Medications are stored in a central location and administered by healthcare professionals only ..."The care plan for Resident #6, dated 8/31/24, read in part, "(Resident #6) requires assistance from family to set up, administer, and order all medications ..." The residence' s Self-Administration of Medications Review Tool, dated 1/13/25, deemed Resident #6 fully capable and approved the resident to self-administer his medications. Additionally, the document read that the residence had obtained a physician order for the resident to s.. Based on observation, interview, and record review, the residence failed to comply with authorized practitioner' s orders, affecting three of six sample residents (#2, #4, #5). Findings include: 1. Resident #4 was admitted to the residence on 2/13/25 with diagnoses including osteoporosis, Gastroesophageal reflux disease, and chronic kidney disorder. a. Metformin A written practitioner' s order, dated 2/27/25, directed the residence to administer metformin 1000 mg one tablet twice daily. However, the March 2025 medication administration record (MAR) read that the medication was not administered from 3/1-3/5/25, as the medication was out of stock. A total of 10 doses were missed. b. Donepezil A written practitioner' s order, dated 3/6/25, directed the residence to administer donepezil, five mg two tablets at bedtime (HS). However, the March 2025 MAR read that the medication was not administered from 3/8-3/9/25, as the medication was out of stock. A total of two doses were missed. c. Mirtazapine A written practitio..

A revisit survey was completed on 7/30/24 for all previous deficiencies cited on 5/28/24. 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 with complaint #CO34898, and #CO35649 was completed on 5/8/24. Deficiencies were cited. Based on observation, record review, and interview, the residence failed to provide an enhanced care plan for four out of five sample residents (#1, #4, #5, and #6) who lived in a secured environment. Findings include:1. Residence PolicyThe residence' s Person-Centered Service Assessment policy, dated November 2019, read in part,"The service plan describes the following: services that are furnished to attain or maintain the residents ' highest practicable physical, mental, and psychosocial well-being; and personal and cultural preferences, any services that would be furnished but are not provided due to the residence exercise of rights, including the right to refuse treatment. A comprehensive service plan is prepared by an intro disciplinary team that may include the physician, nursing, approp.. Based on record review and interview, the residence failed to develop and implement policies and procedures with all of the required elements for the identification, reporting, and investigation of injuries of unknown origin, affecting 19 current residents residing in the secure environment and one former resident (#6).Findings include:1. Residence PolicyThe residence' s January 2023 Abuse, Neglect, and Exploitation Reporting policy read in part: "Injuries of unknown source: An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person, and the source of the injury could not be explained by the resident. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury.. Based on record review and interviews, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting two of three sample residents (#3, #5).Findings include:1. References and Residence PolicyThe residence' s medication administration policy, dated 11/2019, read in part: "Licensed nurse reviews the medication administration record (MAR) on a weekly basis to ensure that all previous week' s medications were administered, identifies issues and changes needed in medication regime, and contacts prescriber regarding changes needed."2. Resident #3 was admitted to the residence on 11/30/23 with diagnoses that included acute chronic diastolic (congestive) heart failure.a. Skin prepA written practitioner' s or.. 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."14.29 (C) 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. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. ""17.7 Weekly menus shall be readily availabl..