Print Inspection: JLQR

Based on interview and record review, conducted during a site visit on 05/06/24, it was confirmed the facility failed to ensure the preparation, completeness, accuracy of resident records for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of Resident 1'sTemporary Service Plans (TSP) dated 07/26/23 through 10/25/23 revealed one TSP dated 08/02/23, which had the last name of the Resident 1 listed incorrectly.

During an interview on 05/06/24, Staff 2 (Administrator) and Staff 3 (Operations Specialist) confirmed staff had written the wrong last name and there was no record of a different resident with the last name on the TSP.

The findings were reviewed with and acknowledged by Staff 2 and Staff 3 on 05/06/24.

The facility failed to ensure the preparation, completeness, accuracy of resident records.

Verbal plan of Correction: In-service to be conducted at next MT meeting on Thursday 05/09/24 about record accuracy.

Based on interview and record review, conducted during a site visit on 05/06/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#6). Findings include, but are not limited to:

A review of Resident 6's signed physician orders dated 10/25/23 indicated Resident 6 had an order for:

*Carbidopa/Levo 25-100 mg tablet (A prescription for Parkinson's disease) 1 Tab by mouth three times daily at 9 am 12 pm and 5 pm.

A review of Resident 6's MAR dated 10/1/23-10/31/23 revealed on 10/27/23, the medication could not be located and the 9 am dose was not given.

The findings were reviewed with and acknowledged by Staff 2 (Administrator) and Staff 3 (Operations Specialist) on 05/06/24 who agreed the medication was not given as prescribed.

The facility failed to carry out medication orders as prescribed.

Verbal plan of correction: Administrator and facility RN to review medication pass exceptions daily. Facility is now requiring MTs to print dashboard, address any missed medications, sign and date and give to nurse daily.

Based on observation, interview and record review, conducted during a site visit on 05/06/24, it was confirmed the facility failed to have accounting records for handling residents' personal incidental funds for 3 of 3 sampled residents (#s  4, 6 and 7). Findings include, but are not limited to:

During an observation and interview on 05/06/24, Staff 3 (Operations Specialist) stated the s/he had found a binder of Personal Incidental Funds (PIF) locked in the old Executive Director's office and was not sure who was managing them previously. Staff 3 brought three envelopes with Resident #s 4, 6, and 7 names on them, which contained cash and were observed, but not handled by the Compliance Specialists. The envelope with Resident 6's name on it contained a receipt. Staff 3 stated there were no accounting records or sign in/sign out forms for any cash received.

There was no documented evidence of any accounting for personal incidental funds.

The findings were reviewed with and acknowledged by Staff 2 (Administrator) and Staff 3 on 05/06/24.

The facility failed to have accounting records for handling residents' personal incidental funds.

Verbal plan of correction:  Administrator and Operations Specialist will meet with new business office manager to count each person's remaining PIF. They will request permission and guidance from Frontier on how to handle cash by end of day 05/10/24.