Based on interview and record review, conducted during a site visit on 02/13/24, it was confirmed the facility failed to ensure that staff visually observe the resident take the medication for 1 of 1 sampled resident (# 7). Findings include, but not limited to:

Resident 7's medication error report dated 01/22/23, January 2023 Medication Administration Record (MAR), and January 2023 progress notes, indicated that on 01/22/23, the night shift MT had documented medications were administered without visually observing the resident take his/her scheduled 8:00 pm and 9:00 pm medications. The medications were found the next morning in a cup in another resident's room.

During an interview, Staff 2 (Resident Services Coordinator) stated the med techs had to visually observe the residents take the medication before leaving the room. S/he stated staff were not supposed to be pre-popping medications.

The findings were reviewed with and acknowledged by Staff 1 (ED) and Staff 2 on 02/13/24.

It was confirmed the facility failed to ensure that staff visually observe the resident take the medication.

Verbal plan of correction: Medication error was reported to Adults and People with Disabilities. The MT responsible was counseled by the RN.

Based on interview and record review, conducted during a site visit on 02/13/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:

Resident 6's physicians orders, dated 01/26/24, indicated Resident 6 was to receive Carvedilol 6.25mg tab: 1 tablet by mouth twice daily with meals. Hold for HR less than 60, SBP less than 100 for hypertension.

Resident 6's January 2024 Medication Administration Record (MAR), and January 2024 progress notes, indicated that on 01/26/24 and 01/29/24-01/31/24, Resident 6 was not administered his/her morning dose of Carvedilol 6.25mg tab.

During an interview on 02/13/24, Staff 2 (Resident Services Coordinator) stated during an audit report missed medications were reviewed on the MAR and checked against the med cart. It was found that the medications were not given, and the vitals were not taken or documented.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 02/13/24.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: Med techs were made aware of the error. Personal one on one training was done for all med techs involved. Management to work on night shift with staff for additional training. Staff 2 had begun weekly audits of missed meds, meds not available, and refusals.

Based on interview and record review, conducted during a site visit on 02/13/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:

Resident 5's medication error report, dated 06/12/23, June 2023 Medication Administration Record (MAR), and June 2023 progress notes, indicated that on 06/12/23, s/he was given another resident's medications in error. The medications given were Primidone 100mg, Lisinopril 40mg, and Lacosamide 150mg, which were not prescribed for the resident.

During an interview, Staff 2 (Resident Services Coordinator) stated the night shift MT had two cups with medications in them and gave Resident 5 a cup with the wrong room number on it. S/he also stated staff were not supposed to be pre-popping medications.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 02/13/24.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: Personal one-on-one training was done for the med tech involved, including additional training with the lead med tech. Management to work on night shift with staff for additional training. Staff 2 had begun weekly audits of missed meds, meds not available, and refusals.

Based on interview and record review, conducted during a site visit on 02/13/24, it was confirmed the facility failed to conduct a thorough assessment before the use of supportive devices with restraining qualities for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

Resident 4's MAR, dated 05/24/23, indicated s/he had a bed rail that was placed to the right side of his/her bed.

A review of a side rail/bed cane assessment for Resident 4, indicated the facility began the assessment on 05/25/23 but did not complete or sign the assessment until 07/14/23.

An incident report, dated 07/08/23, indicated Resident 4 had fallen and had been wedged between the bed and bed rail on 07/07/23.

During an interview on 02/13/24, Staff 2 (Resident Services Coordinator) confirmed the incident on 07/08/23 did occur. S/he stated the initial bed rail assessment was started by a nurse that no longer worked at the facility, however, it was not completed before the bed rail was installed.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 02/13/24.

It was confirmed the facility failed to conduct a thorough assessment before the use of supportive devices with restraining qualities.

Verbal plan of correction: Administrator will ensure that all assessments are done before restraining devices are put into place moving forward.

Based on interview and record review, conducted during a site visit on 02/13/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:

A review of the facility's ABST and resident roster on 02/13/24 indicated the following:

- There were 76 residents listed on the roster and 73 residents entered into the ABST;

- Resident 1 had a service plan update on 01/01/24 and their ABST was last updated on 10/17/23;

- Resident 2 had an update to their service plan on 01/02/24 and their ABST was last updated on 09/27/23; and

- Resident 3 had a service plan update on 02/11/24 and the ABST was last updated on 09/28/23.

In an interview on 02/13/24, Staff 1 (Executive Director) stated the current census was 74 residents. S/he also stated there had been new move-ins, move-outs, and service plan updates, however, the ABST was not updated since the last administrator was working.

On 02/13/24, findings were reviewed with and acknowledged by Staff 1.

It was determined the facility failed to fully implement and update an ABST.