At Sugis Assisted Living

Based on record review and interview, the manager failed to ensure, for one of ten sampled residents, a resident had a service plan which accurately included the amount, type, and frequency of assisted living services and ancillary services being provided to the resident. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. Review of R1’s current service plan dated July 2025 which revealed a section labeled, "Hygiene/ ADLs: Daily unless indicated otherwise”. Underneath the title revealed a check mark by "Documented in file”. 2. In an interview, E1 reported E1 does grooming, stand by shower assist, and oral care for R1. However, these services were not documented in R1's service plan. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record, for one of two sampled residents. The deficient practice posed a risk as services were not provided per a resident's service plan. Findings include: 1. Review of R2’s current service plan dated November 2025 revealed R2 received the following services: - “CG/ CNA patient laundrey (beddings, linens, pt clothes) 3x Week” - “Clean patient rooms (mop/ sweep/ vacuum) 4x Week” 2. Review of R2’s activity of daily living (ADL) for the month of December 2025 revealed no documentation of R2’s laundry being completed and R2’s room being cleaned. 3. In an interview, E1 reported R2’s room was being cleaned and R2’s laundry was being done. However it was not documented in the ADLs. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, upon acceptance and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2’s current service plan dated November 2025 revealed R2 was “Bed bound”. 2. Review of R2’s medical records revealed no documentation of a determination from a medical practitioner upon acceptance, which stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services. Based on R2’s acceptance date this documentation was required. 3. In an interview E1 was not aware of the documentation that was required for R2 and did not provide the required document at the time of the inspection. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, interview, and observation the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents receiving medication administration. Findings include: 1. Review of R1’s current service plan dated July 2025 revealed R1 receives medication administration. 2. Review of R1’s signed medication list dated September 2025 revealed the following medication: “atorvastatin 40 mg take 1 tablet by mouth once daily at night at bedtime.” 3. Review of R1’s medical record revealed a medication administration record (MAR) for the month of December 2025 which revealed atorvastatin 40 mg was not being administered. There were no initials which signaled atorvastatin 40 mg was administered and there was not a time recorded of the medication administration. 4. In an interview, E1 reported atorvastatin 40 mg was not administered. 5. Review of R2’s current service plan dated November 2025 revealed R2 had “staff administer medications”. 6. Review of R2’s signed medication list dated August 2025 revealed the following medication: - “24 HR metoprolol succinate 25 mg PO QD.” - “Gabapentin 300 mg 1 three times a day” 7. Review of R2’s MAR for the month of December 2025 revealed metoprolol succinate 25 mg and Gabapentin 300 mg was administered from the beginning of the month to present day. 8. The Compliance Officer observed no pill bottle for the metoprolol succinate 25 mg for R2 in the facility at the time of the inspection. 9. The Compliance Officer observed a pill bottle for R2’s Gabapentin which read, “Gabapentin 100 mg” instead of 300 mg. 10. In an interview, E1 reported the facility has never received R2’s metoprolol succinate 25 mg and E1 was marking it as administered. E1 called someone over the phone and pointed out the mistake that the Gabapentin being administered was 100 mg and not 300 mg to them. 11. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, interview, observation and documentation review, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order and the Department was provided false or misleading information. Findings include: 1. Review of R1’s current service plan dated July 2025 revealed R1 received medication administration. 2. Review of R1’s signed medication orders dated September 2025 revealed the following: - “Eliquis 5 mg take one tablet by mouth twice daily” - “Metoprolol 25 mg take .5 tablet(s) twice a day by oral route for 90 days” - Trazodone 50 mg take 1 tablet(s) every day by oral route at bedtime for 90 days” 3. Review of R1’s medication administration record (MAR) for the month of December 2025 revealed the following were not documented as administered on the 15th: Eliquis 5 mg at 12 pm Metoprolol 25 mg at 12 pm Trazodone 50 mg at “20:00” 4. Review of R2’s current service plan dated November 2025 revealed R2 had “staff administer medications”. 5. Review of R2’s signed medication orders dated, August 2025 revealed the following: - “Apixaban 2.5 mg 1 oral tablet PO BID” - “Gababentin 300 mg 1 three times a day” - “Methocarbamol 750 mg 1 oral tablet PO Q 8 HRS” - “120 ACTUAT budesonide .16 MG/ ACTUAT/ formoterol fumarate 0.0048 MG/ACtuat/ glycopyrrolate 0.009 MG/ACTUAT metered Dose inhaler 160-4.8-9 mcg/ puff 2 puffs BID” - “24 HR metoprolol succinate 25 mg PO QD” 6. Review of R2’s December 2025 MAR revealed the following were not documented: - Apixaban 2.5 mg on the 15th at “20:00” - Gabapentin 300 mg on the 15th at “20:00” - Methocarbamol 750 mg on the 14th and 15th at “16:00” - 120 ACTUAT budesonide .16 MG/ ACTUAT/ formoterol fumarate 0.0048 MG/ACtuat/ glycopyrrolate 0.009 MG/ACTUAT metered Dose inhaler 160-4.8-9 mcg/ puff on the 15th at “20:00” 7. In an interview, E1 reported medication was administered however E1 did not document it in the MAR. 8. In an interview, E1 reported R2’s metoprolol 25 mg was never delivered to the facility and E1 documented in R2’s MAR as medication was administered with E1’s signature. 9. Review of R2’s December 2025 MAR showed metoprolol 25 mg was documented as administered however according to what E1 reported it should not have been. 10. The Compliance Officer did not observe a pill bottle for R2’s metoprolol 25 mg at the time of the inspection. 11. Review of the facility’s policy and procedures revealed a policy titled, “Documenting by Medication Administration Record (MAR) and Assistance,” which stated, “The MAR is the form on which the caregiver will document that medication has been administered to the resident.” 12. In an exit interview, the findings were reviewed with E1, and no additional information was provided.