Vista Mesa Assisted Living Residence

A licensure complaint, prompted by #CO37770, was completed on 10/21/24. Deficiencies were cited. Based on record review and interview the residence failed to update the comprehensive assessment after a resident' s condition changed from baseline status affecting one of two sample residents (#2) and one former resident (#3). (Cross-reference 1324)Findings include:Resident #2 was admitted to the residence on 8/1/12 with a diagnosis of adult failure to thrive, a history of falls, age-related osteoporosis, overweight, and hypertension.A nursing wound protocol, dated March 2024 read in part, left heel dressing to be changed by nursing staff. Wounds should be cleaned and dressed to prevent infection, off-load of heels to prevent future pressure and facilitate healing. Off-loading of coccyx and buttocks to prevent shearing and skin breakdown. Heels should be floated on pillows while in bed. Draw sheet used for bed mobility. Wrap feet in a trash bag during the shower to keep it dry. Monitor wounds routinely for healing progress and update family. Monitor for any signs of infection such as foul odor, purulent exudate, abnormal vital signs, increased pain, and worsening wounds.The current care plan for Resident #2, dated 4/28/24 read in part, that staff was to ensure the following interventions were available and properly utilized to prevent skin breakdown: air cushion on the wheelchair, encourage Resident #2 to lay down one to two times per day to relieve pressure, home he.. Based on record review and observations the residence failed to protect the right to be free from neglect affecting one of three sample residents. (Cross-reference 1146)Specifically, the residence failed to assess Former Resident #3 who developed a pressure ulcer that progressed in severity over the course of a month prior to the residence developing and implementing strategies to prevent further development. The residence failed to complete a comprehensive assessment until after the pressure ulcer had progressed to the degree the residence was no longer able to care for the resident.1. Record ReviewFormer Resident #3 was admitted to the residence on 5/16/23 with a diagnosis of hypothyroidism, hypertension, Parkinson' s disease, atrial fibrillation, and pulmonary embolism.A care plan, dated 3/13/24 read in part, that Former Resident #3 was to receive skin integrity care through assistance with good peri care and toileting daily; provided meals and snacks, encourage hydration; encourage activity participation; perform weekly skin assessments and report any changes in skin condition to supervisor and family.A progress note, dated 8/1/24 read in part, that the external hospice provider removed the floatation mattress, and the residence would implement a rotation schedule to prevent recurrent skin breakdown. No breakdown was noted.A practitioner o..

A revisit survey was completed on 12/14/23 for all previous deficiencies cited on 8/8/23. 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 recertification survey, with complaint #CO32975, was completed on 8/8/23. Deficiencies were cited. Based on observations, record review, and interviews, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting 52 current residents. 1. Chapter VII regulations governing assisted living residences, part 14.21, require the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Residence PolicyThe residence' s undated Medication Administration Policy, read in part: "qualified staff will administer medications to residents unable to self-administer."b. Resident #3 was admitted to the residence on 6/14/21.MelatoninA written practitioner' s order, dated 7/23/22, directed the residence to administer melatonin 10 mg once at bedtime. However, the July 2023 electronic medication administration record (eMAR) for Resident #3 read the medication was not administered on 7/20/23 due to the medication being out of stock, for a total of one missed dose. AspercremeA written practitioner' s order, dated 5/26/22, directed the residence to administer aspercreme lidocaine 4% topically twice daily. However, the July 2023 (eMAR) for Resident #3 read the medication was not admin.. Based on record review and interview the facility failed to ensure there was at least one staff member for every 10 participants during the daytime hours, one staff member for every 16 participants during the nighttime shift and one staff for every six participants in the secured environment at all times, affecting 12 current participants who resided in the secure environment. Findings include:Regulations governing alternative care facilities 10 CCR 2505-10 section 8.495.6.I.3 read, an approved staffing waiver is only applicable for nighttime hours, with the exception for secured environments. b. A staffing waiver expires five years from the date of approval. Continuance of staffing waiver requires Department approval. The resident agreement read in part: "the facility would be staffed with either (2) twelve hour blocks from 6:00 a.m. to 6:00 p.m. and 6:00 p.m. to 6:00 a.m. or (3) eight hour blocks from 6:00 a.m.-2:00 p.m., 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m."Additionally, the resident agreement read: "Ratios at the residence in the non-secured unit will be 1:10 from 6:00 a.m. to 6:00 p.m.; 1:16 from 6:00 p.m.-10:00 p.m.; and 1:23 from 10:00 p.m. to 6:00 a.m. Ratios in the secured unit are 1:6 from 6:00 a.m. to 6:00 p.m.; 1:10 from 6:00 p.m.-10:00 p.m.; and 1:12 ratio from 10:00 p.m. to 6:00 a.m."The residence had a staffing..

A relicensure survey, with complaint #CO32974, was completed on 8/8/23. Deficiencies were cited. Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of three sample residents (#3). (Cross-reference Q1514)Findings include: 1. Residence PolicyThe residence' s undated Medication Administration Policy, read in part: "qualified staff will administer medications to residents unable to self-administer."2. Resident #3 was admitted to the residence on 6/14/21.a. MelatoninA written practitioner' s order, dated 7/23/22, directed the residence to administer melatonin 10 mg once at bedtime. However, the July 2023 electronic medication administration record (eMAR) for Resident #3 read the medication was not administered on 7/20/23 due to the medication being out of stock, for a tot.. Based on record review and interview, the residence failed to accurately document each medication administration at the time the event was completed for each resident, affecting one of three sample residents (#2). (Cross-reference Q1514)Findings include:1. Residence PolicyThe residence' s undated Medication Administration Policy, read in part: "the administration of medication shall be documented at the time of administration."2. Resident #2 was admitted to the residence on 5/20/21. A written practitioner' s order, dated 2/2/23, directed the residence to administer 4 ounces of house supplement daily. However, the August 2023 electronic medication administration record (eMAR) revealed a blank on 8/2 and 8/3/23. 3. InterviewsOn 8/8/23 at 2:23 p.m., the resident services director stated blanks in the eM.. Based on record review and interviews, the administrator failed to, along with the qualified medication administration personnel (QMAP) supervisor, audit the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, affecting 52 current residents. (Cross-reference Q1510 and Q1468)Findings include:On 8/8/23 at 7:06 a.m., quarterly medication audits were requested from the residence. At 10:59 a.m., only medication error reports were provided by the resident services director (RSD), which contained information about blanks in the electronic medication administration record (eMAR) and missed medications.An undated document titled May Medication Errors, did not include the name of the QMAP su.. 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 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.