Caliche Senior Living

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for one of eight residents sampled. Findings include: 1. A review of R4's medical record revealed a current service plan indicating R4 received personal care and was to receive the following services: "Grooming: Cue resident to perform grooming task daily every morning...every night...stand by;" "Denture Care: Requires assistance...daily;" and "Assurance Checks: Observe resident for safety/needs every 2 hours." 2. A review of R4's medical record revealed a document titled "Documentation Survey Report," dated November 2024, used for documenting services provided and activities of daily living (ADLs). The document did not include evidence of documentation of provision of the following services, on the dates and times indicated: "Grooming: - Day [shift], November 8, 2024; and - Evening [shift], November 4, 2024; November 8, 2024; November 11, 2024; November 14, 2024; November 18, 2024; November 29, 2024; and November 30, 2024." "Denture Care: -Evening [shift], November 12, 2024 and November 14, 2024." Further, the ADL report included a section for documenting "Assurance Checks," which indicated R4 was to be observed "every 2 hours." However, the section only included areas for documentation of the service every four hours, and evidence of documentation the services was provided was unavailable for the following dates and times: "November 12, 2024 at 2000 [hours];" and "November 14, 2024 at 0400 [hours], and 2000 [hours]." 3. In an interview, E1 acknowledged services were not being documented as described in R4's service plan.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of eight residents sampled who received medication administration. Findings include: 1. A review of R1's medical record revealed a current service plan which indicated R1 received medication administration. Further review revealed a medication order, dated September 16, 2024, for "Aspirin 81 MG Chew Tablet Chew 1 tablet by mouth and swallow once daily." A review of R1's medication administration record (MAR) for October 2024 revealed evidence of documentation indicating R1 was being administered "Aspirin 81 MG Chew Tablet" once daily on October 1 through October 6, 2024. The MAR reflected R1 refused the medication on October 7, 2024, and the medication was documented as not administered October 8 through October 31, 2024. A review of the MAR from November 2024 revealed the MAR did not contain a section for documentation of the administration of "Aspirin 81 MG Chew Tablet." 2. In an interview, E2 advised R1's medical provider had discontinued the Aspirin 81 MG medication after October 6, 2024. E2 acknowledged R1's medical record did not contain evidence of documentation of a discontinue order for the medication, from R1's medical provider.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented an event in which a resident had an accident, injury or emergency and needed medical services, as required per R9-10-818(D)(2). Findings include: 1. A review of facility incident reports from September 2024 through November 2024 in which medical services were required for a resident experiencing an accident, injury or emergency, revealed a report dated September 19, 2024, involving R9. The report indicated R9 called for assistance because "[their] heart was fluttering, [they] had a headache, nausea and dizziness." The report included documentation required for R9-10-818(D)(2)(a-e), however failed to document what action was taken to prevent the accident, emergency or injury from occurring in the future. 2. In an interview, E1 agreed the incident reports did not contain all documention required per R9-10-818(D)(2).