Based on interview and record review, conducted during a site visit on 05/29/24, it was confirmed the facility failed to keep resident records for a minimum of three years for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

During an interview on 05/29/24, Staff 1 (Assistant Executive Director) stated the facility did have a problem in 2022 in which staff were copying over old service plans to update them, instead of copying the service plan into a new document and then editing which resulted in the facility losing the previous versions of service plans.

A review of Resident 2's available service plan revised on 07/13/24 revealed Resident 2 moved into the facility on 03/01/21. There were no previous versions of his/her service plan to review.

The facility failed to keep resident records for a minimum of three years.

The findings were reviewed with and acknowledged by Staff 2 (Administrator) on 05/29/24.

Verbal plan of correction: The facility corrected the problem in 2022.

Based on interview and record review, conducted during a site visit on 05/29/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#3). Findings include, but are not limited to:

A review of Resident 3's signed physican orders dated 12/05/22 and MAR dated 12/01/22 through12/31/22 revealed an order for:

*Acetomenophin 500 mg tablets take 2 tablets by mouth every six hours as needed for pain. Use before any narcotics.

*Hydromorphone (a narcotic pain medication) 1mg/ml solution .75 ml by mouth every hour as needed for breakthrough pain.

A review of Resident 3's MAR revealed on 12/07/22 and 12/08/22, Resident 3 was not given the ordered tylenol, but was given the ordered hydomorphone.

It was unable to be determined if an RN provided the direction as the RN is no longer employed by the facility.

The facility failed to carry out medication and treatment orders as prescribed.

The findings were reviewed with and acknowledged by Staff 2 (Administrator) on 05/29/24 who confirmed the order was not followed.

Verbal plan of correction: RN no longer employed by the facility.

Based on interview and record review, conducted during a site visit on 05/29/24, it was confirmed the facility failed to fully implement and update an ABST. Findings include, but are not limited to:

During an interview on 05/29/24, Staff 2 (Administrator) stated Resident 1 moved into the memory care portion of the facility on 05/23/24.

A review of the facility's ABST on 05/29/24 revealed Resident 1's information was not yet input into the ABST.

The facility failed to fully implement and update an ABST.

The findings were reviewed with and acknowledged by Staff 2 on 05/29/24.