Whitcomb Terrace

A relicensure survey was completed on 10/21/25. Deficiencies were cited. Based on record review and interview, the residence failed to ensure two individuals who were qualified medication administration persons (QMAP), nurses, or practitioners jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting three of the fourteen residents prescribed controlled substances (#2, #5, #6).Findings include:1. Record ReviewA review of the controlled substance sheet for Resident #6 revealed the following:On 10/3/25, the shift from 6:30 a.m. to 3:00 p.m., had one staff signature for alprazolam.On 10/14/25, the shift from 6:30 a.m. to 3:00 p.m., had one staff signature for alprazolam.On 10/14/25, the shift from 6:30 a.m. to 3:00 p.m., had one staff signature for Zolpidem.2. InterviewOn 10/21/25 at 2:37 p.m., the clinical resource coordinator stated she expected two qualified medication administration persons (QMAP), nurses, or practitioners to jointly count all controlled substances at the end of each shift and sign d.. Based on record review and interviews, the residence medication administration record (MAR) failed to maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials, and failed to accurately document each medication administration or monitoring event at the time the event was completed affecting three of four sample residents (#1, #2, #4).Findings include:1. Record Reviewa. Incomplete MAR signature pageA record review of the October 2025 MAR for Resident #1 revealed the residence failed to maintain a legible list of all the names of the persons utilizing the MARs.Similar deficient practice occurred with Resident #2 and Resident #4.b. Accurate documentation of the administration eventResident #1' s October 2025 MAR revealed blank spaces at the bedtime (HS) administration time on 10/17/25 and 10/18/25 for the following medications: trazodone HCL, melatonin, tamsulosin, acetaminophen, pravastatin sodium, metoprolol tartra.. 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 7.10.6 Each assisted living residence ' s emergency policies shall address, at a minimum, all of the following items:(E) A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids;(I) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies.12.10 Each resident care plan shall:(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;"14.30 The assisted living residence shall maintain a record on a separate sheet for each resident receiving a controlled substance which contains the name of the controlled substance, strength and dosage, date and..

A recertification survey was completed on 10/21/25. Deficiencies were cited. Based on record review and interview, the facility failed to ensure each member' s residency agreement specified both the duration of the agreement and a provision requiring staff or contractors to provide advance notice and agree upon a time before entering the member' s unit. This deficient practice affected four (#1-#4) of six sample residents.Record review of the residency agreement for Member #4 revealed the agreement did not specify a duration and did not include a provision requiring staff or contractors to provide advance notice or agree upon a time before entering the unit.During an interview on 10/21/25 at 4:14 p.m., the administrator confirmed the agreement lacked both required elements. She stated, "I thought it did [contain the provision for advance notice], but I guess it doesn ' t," and was unable to identify such a provision in the agreement.Review of residency agreements for Members #1–#3 revealed the same deficiencies. Based on record review and interviews, the facility (residence) medication administration record (MAR) failed to accurately document each medication administration or monitoring event at the time the event was completed, affecting two of four sample members (residents) ( #1, #2).Findings include:1. Record Reviewa. Accurate documentation of the administration eventResident #1' s October 2025 MAR revealed blank spaces at the bedtime administration time on 10/17/25 and 10/18/25 for the following medications: trazodone HCL, melatonin, tamsulosin, acetaminophen, pravastatin sodium, metoprolol tartrate, and omeprazole.Similar deficient practice occurred with Resident #22. InterviewOn 10/21/25 at 2:29 p.m., the clinical resource coordinator explained she would expect staff to sign off on the MAR once the medication was administered, and acknowledged they had not always done that. She stated staff needed to be retrained.On 10/21/25 at 3:52 p.m., the administrator stated would expect staff to sign of.. 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 10 CCR 2505-10, Section 8.7000.8.7506.F. Alternative Care Facility Provider Agency Requirements4. Provider Care Plan(b) Additional Provider Care Plan Documentation:(iv) Evidence the Member and/or their Guardian, or other Legally Authorized Representative has had the opportunity to participate in the development of the Provider Care Plan, as evidenced by the Member or other Legally Authorized Representatives' signature on the plan.

A relicensure survey was completed on 4/20/23. No deficiencies were cited. 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.14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.14.29 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.(B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials.