Print Inspection: 94KK

Based on observation, interview, and record review, conducted during a site visit on 04/23/24, it was determined the facility did not provide assistance with cleaning dishes for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

In an interview on 04/23/24 at 11:06 am, Staff 1 (ED) indicated kitchen and housekeeping staff are to provided Resident 1 with daily assistance with cleaning dishes.

In an interview on 04/23/24 at 1:01 pm, Resident 1 stated staff are not providing assistance with cleaning his/her daily dishes.

In an interview on 04/23/24 at 2:30 pm, Staff 2 (Housekeeping) stated he/she does not provide assistance with daily dishes, "they are told by management not to do them, the kitchen staff will come get them or the Resident will do them."

CS reviewed Resident 1 service plan dated 03/15/24 that confirmed assistance with cleaning daily dishes.

CS observed Resident 1 had dirty dishes in his/her apartment sink.

The above information was shared with Staff 1 on 04/23/24. S/he acknowledged the findings.

It was determined the facility does not provide assistance with cleaning daily dishes.

VPOC: ED reports the facility is developing a new cleaning check list for housekeeping and care staff that will include completing residents' daily dishes as part of the routine. As well kitchen staff will do a daily check of residents' rooms for dishes after each meal. ED reports this will start the beginning of May 2024.

Based on record review and interview, conducted during a site visit on 04/23/24, it was confirmed the facility failed to administer medication as prescribed for 1 of 1 sampled Resident (#1). Findings include, but are not limited to:  

During a review of Resident 1's MAR dated 05/01/22 through 05/31/22, incident report dated 05/26/22, progress notes dated 05/26/22 through 0531/22 and Physicians orders dated 02/16/22 the following deficiency was identified:

-On 05/26/22 Resident 1 was administered wrong medication by MT at 5 pm.

-Incident report dated 05/26/22 states the following:  MT accidently grabbed the wrong residents pre-popped cup of medication and gave it to Resident 1. MT did not notice the error until after leaving Resident 1's room and putting the empty cup back into medication cart. MT immediately notified RSM, RSM called Nurse and instructed MT to call PCP.

-MAR indicated Resident 1 was placed on alert charting for medication error 05/26/22.  

-Progress notes indicated medication error received wrong medication 05/26/22. On 05/31/22 Nursing notes/monitoring for medication error, Resident reports no side effects or negative outcomes.

-Incident report dated 05/26/22 and progress notes dated 05/31/24 confirm Resident 1 had not been administered the following medication in error:

Coumadin and Ursodiol both of which Resident 1 does not have a doctor's order for.

In an interview on 04/20/24 at 11:16 am Staff 1 (Executive Director) stated at the time the incident happened MT were pre-popping medication, and this caused medications errors. She/he stated pre-popping medication is no longer allowed. She/he stated MT are to only pop medication at the time it is given one medication and one Resident at a time.

In an Interview on 04/20/24 at 2:45 pm Resident 1 stated she/he doesn't remember the incident but doesn't have any issues or concerns about his/her medication administration at this time.

The above information was shared with Staff 1 on 04/23/24. S/he acknowledged the findings.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed for Resident 1.  

VPOC:

ED reports that staff no longer pre-pop medications, all medications are dispensed and passed individually with each resident this has helped ensure less medication errors.

Based on interview, and record review, conducted during a site visit on 04/23/24, it was determined the facility does provide assistance with ambulation for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

In an interview on 04/23/24 at 11:06 am, Staff 1 (ED) indicated staff provided Resident 1 with ambulation assistance to and from dining room for meals.

In an interview on 04/23/24 at 1:01 pm, Resident 1 stated staff was providing assistance with ambulation to dining room for meals. She/he stated no issues or concerns with ambulation to and from meals at this time.

CS reviewed Resident 1 service plan dated 03/15/24 and observations notes dated 02/01/24 through 03/31/24 that indicated assistance with ambulation to and from dining room for meals.

The above information was shared with Staff 1 on 04/23/24. S/he acknowledged the findings.

It was determined the facility does provide assistance with ambulation.