Print Inspection: DP4S

Based on interview and record review, conducted during a site visit on 06/03/24 and 06/04/24, it was confirmed the facility failed to keep resident records for a minimum of three years for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

During an interview on 06/03/23, Staff 1 (Administrator) stated they were unable to locate signed physician orders for Resident 1 or print his/her MARs as Resident 1 was deceased.

In an email received on 06/04/24 Staff 1 stated "I have been working with q mar [electronic medical record] and my consultant and we have been unable to print this MAR from a year ago because it's requiring us to approve orders and start [him/her] again and we can't because [s/he] has been gone for almost a year."

Resident 1's MAR was unable to be reviewed.

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

The findings were reviewed with and acknowledged by Staff 1 on 06/04/24.

Verbal plan of correction: Administrator was working with Regional Operations team to ensure he had access to everything.

Based on observation, interview and record review, during a site visit conducted on 06/03/24 and 06/04/24, it was confirmed the facility failed to complete service plans quarterly and make them available to staff for 2 of 3 sampled residents (#s 3 and 4). Findings include, but are not limited to:

During an interview on 06/03/24 Staff 3 (agency CG) showed the Compliance Specialist (CS) where service plans are located on each floor and stated the service plans are available to staff for review only in the binders on each floor.

Resident 3's service plan was located in the binder and dated 10/12/23.

Resident 4's service plan was located in the binder and dated 10/23/23.

During an interview on 06/04/24, Staff 1 stated he believed both Resident 3 and Resident 4 had more current service plans.

The facility failed to complete service plans quarterly and make them available to staff.

Verbal plan of correction: Administrator to audit and ensure most recent service plans are available to staff by Friday 06/07/24.  LPN and Administrator will be responsible for putting new service plans in the binders.

Based on interview and record review, conducted during a site visit on 06/03/24 and 06/04/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#2). Findings include, but are not limited to:

A review of Resident 2's signed physican orders dated 04/04/24 revealed an order for Timomptic 0.25% (eye drop) ophthalmic solution. Place 1 drop into right eye two times daily.

A review of Resident 2's MAR dated 05/01/24 through 05/31/24 revealed Resident 2 did not receive the medication on 05/04/24 due to "med not here from pharmacy. pharmacy contacted".

The facility failed to carry out medication orders as prescribed.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 06/04/24 who confirmed the error occurred.

Verbal plan of correction: The facility was hiring new staff, including MTs, several were in training and the facility utilized agency LPNs. Administrator or RN personally went to orient each new agency nurse. LPN was reviewing missed medications Monday - Friday and Administrator reviews on the weekends and staff are followed up with.

Based on interview and record review, conducted during a site visit on 06/03/24 and 06/04/24, it was confirmed the facility failed to administer medications as prescribed for 1 of 1 sampled resident (#5). Findings include, but are not limited to:

A review of Resident 5's signed physican orders revealed Clomtrimazole 1% Cream 30 GM apply to right groin twice daily was ordered on 09/29/23.

A review of Resident 5's MAR for 03/01/24 through 03/31/24 revealed Resident 5 did not receive the medication three times on 03/07/24 and 03/08/24 due to "med not here from pharmacy. pharmacy contacted."

The facility failed to administer medications as prescribed.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) who confirmed the error occurred.

Verbal plan of correction: The facility was hiring new staff, including MTs, several are currently in training and the facility utilizing agency LPNs. Administrator or RN personally come in to orient each new agency nurse. LPN is reviewing missed medications Monday - Friday and Administrator reviews on the weekends and staff are followed up with.

Based on interview and record review, conducted during a site visit on 06/03/24 and 06/04/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled residents.

A review of a facility self-report dated 07/17/23 revealed at 5:51 am Resident 1 was given .25 ml of lorazepam (anxiety medication) by mouth instead of ordered haloperidol (anxiety medication). Lorazepam had been discontinued by hospice on 07/06/23.

During interview on 06/03/23, Staff 1 (Administrator) stated they were unable to locate signed physician orders for Resident 1 or print his/her MARs as Resident 1 was deceased. Staff 1 stated if the facility self-reported the error, it must have occurred.

The nurse who made the report was no longer employed by the facility and could not be interviewed.

The facility failed to carry out medication orders as prescribed.

The findings were reviewed with and acknowledged by Staff 1 on 06/04/24.

Verbal plan of correction: The facility was hiring new staff, including MTs, several are currently in training and the facility utilizing agency LPNs. Administrator or RN personally come in to orient each new agency nurse. LPN is reviewing missed medications Monday - Friday and Administrator reviews on the weekends and staff are followed up with.