Aslan Adult Care Home

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility documentation revealed the facility had one shift. 2. A review of facility documentation revealed the most recent disaster drill was conducted on August 11, 2024. 3. In an interview, E1 acknowledged disaster drills were not conducted and documented on each shift at least once every three months.

Based on record review, and interview, before or within five working days after a resident's acceptance by an assisted living facility, the manager failed to obtain on the residency agreement, the signature of the resident, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a residency agreement. However, the residency agreement was signed by R2 eleven days after R2’s acceptance by the facility. 2. In an interview, E1 acknowledged the residency agreement was signed by R2 more than five working days after R2's acceptance by the assisted living facility.

Based on documentation review and interview, the manager failed to ensure an evacuation drill was conducted at least once every six months. Findings include: 1. A review of facility documentation revealed the most recent evacuation drill was conducted on August 20, 2024. 2. In an interview, E1 acknowledged an evacuation drill was not conducted at least once every six months.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a directed care service plan, which detailed R1 received assistance with showering, incontinence care, skin care, grooming, and dressing. 2. A review of R1's medical record revealed documentation of the services provided were last recorded in September of 2022. A review of the medication administration record (MAR) revealed tracking of medication administered and bowel movements. 3. A review of R2's medical record revealed a personal care service plan which detailed R1 received assistance with showering, incontinence care, skin care, grooming, and dressing. 4. A review of R1's medical record revealed documentation of the services provided were last recorded in September of 2022. A review of the MAR revealed tracking of medication administered and bowel movements. 5. In an interview, E1 confirmed the medical records contained no documentation of the services provided to each resident since September 2022.

Based on documentation review, record review, observation, and interview, the manager failed to ensure policies and procedures were implemented for discarding medication. Findings include: 1. A review of the facilities policies and procedures revealed a policy titled, "OPIOID PRESCRIBING AND TREATMENT POLICIES AND PROCEDURES"... "DISCONTINUED OR EXPIRED OPIOID MEDICATIONS,,, 2. Expired medications awaiting return to the family/responsible party or disposal are stored in a locked ...Documentation of the list of medications returned and the name of the receiving party should be obtained and remain at the facility." 2. A review of R2's medical record revealed R2 was prescribed Hydrocodone/Acetaminophen 5/325 as needed for pain. A review of the "Narcotic Record" log revealed R2 had six pills remaining. 3. In an interview, E1 reported R2 was prescribed the medication for acute pain and the balance of the pills were returned to the family. E1 provided no documentation of the date or the receiving party. 4. In an interview E1 acknowledged the manager failed to implement the medication policy for discarding an opioid medication.