Print Inspection: 08JM

Based on interview and record review, conducted during a site visit on 08/02/23, 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 not limited to:

Resident 5's signed physicians orders, May 2023 Medication Administration Record (MAR), May 2023 progress notes, and Suspected Abuse and Unexplained injury Reporting Form dated 05/31/23 indicated Resident 5 missed his/her 7:00 pm dose of Amox/Clav 875/125 mg tablet (antibiotic) on 05/31/23.

During interviews, Staff 2 (Wellness Director) stated the MT documented the medication was given, however, it was not. Witness 1 stated that one time the facility did not give Resident 5 his/her antibiotic.

The findings were reviewed with and acknowledged by Staff 1 (Business Office Manager) and Staff 2 on 08/02/23.

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

Verbal plan of correction: Wellness Director and Resident Services Director are doing weekly auditing of the MAR. Ongoing medication training at monthly MT meetings. In September's meeting they will review annual training. Staff are being pulled off medication administration as needed. The facility is no longer "pre-pouring" medications. Additional training will be provided on accurate documentation.

Based on interview and record review, conducted during a site visit on 08/02/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

Resident 4's June 2023 Medication Administration Record, June 2023 progress notes, and Suspected Abuse and Unexplained injury Reporting Form dated 06/07/23 indicated Resident 4 missed his/her 7:00 pm dose of Atorvastatin 20 mg Tab, Bupropion 150 mg SR Tab, and Advil PM CAP 200-25 mg tabs on 06/05/23.

During an interview, Staff 2 (Wellness Director) stated Resident 4's medication was found in another resident's room.

The findings were reviewed with and acknowledged by Staff 1 (Business Office Manager) and Staff 2 on 08/02/23.

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

Verbal plan of correction: Wellness Director and Resident Services Director are doing weekly auditing of the MAR. Ongoing medication training at monthly MT meetings. In September ' s meeting they will review annual training. Staff are being pulled off medication administration as needed. The facility is no longer  " pre-pouring "  medications. Additional training will be provided on accurate documentation and medication/narcotic counts.

Based on interview and record review, conducted during a site visit on 08/02/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

In review of the facility's ABST and resident roster on 08/02/23, it was determined there was 85 residents listed on the roster and only 74 residents were entered into the ABST.

In an interview on 08/02/23, Staff 1 (Business Office Manager) stated the current census was 85 residents. S/he also stated they had 4 new admissions in the last week but the ABST was not updated yet.

On 08/02/23, findings were reviewed with and acknowledged by Staff 1.

The facility failed to fully implement and update an ABST.