Caveo Assisted Living

Based on observation and interview the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self contained unit used only for medication storage. Findings include: 1 . During a tour of the facility the Compliance Officer observed a medication cart which the Compliance Officer was able to access. There were four residents in the vicinity of the unlocked medication cart. 2 . In an interview, E1 acknowledged the unlocked medication cart.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan (dated July 30, 2024) that indicated R1 would receive the following services: - Toileting cueing; - Partial assist with showers, twice a week and PRN; - Partial assist with dressing; - Assistance with nail care, PRN; - Encouragement to complete meals; - Offer sufficient fluids to maintain hydration; - Partial assist with skin maintenance; - Maintenance of personal space; - Laundry service; - Medication administration; and - Skin integrity, assessed PRN. 2. While on-site for the compliance inspection, the Compliance Officers requested R1's current Activities of Daily Living (ADL) documentation for the month of October 2024. ADL documentation for the month of September 2024 was provided; however, no documentation of current ADL services provided was available for Compliance Officer review. 3. A review of R2's medical record revealed a service plan (dated May 1, 2024) that indicated R2 would receive the following services: - Skin integrity, assessed PRN; - Shower, twice a week and PRN; - Shampoo, twice a week and PRN; - Partial assist with combing hair, daily; - Partial assist with oral care, PRN; - Partial assist with dressing; - Assistance with nail care, PRN; - Partial assist with eating; - Encouragement to complete meals; - Offer sufficient fluids to maintain hydration; - Skin checks during showers and brief changes; - Apply lotion, PRN; - Check on resident's location, PRN; - Intermittent partial assist with ambulation; - Change brief and peri care if soiled; - Partial assist with activities; - Staff make bed, weekly; - Staff deep clean, weekly and PRN; - Laundry service; and - Total medication administration. 4. While on-site for the compliance inspection, the Compliance Officers requested R2's current Activities of Daily Living (ADL) documentation for the month of October 2024. ADL documentation for the month of September 2024 was provided; however, no documentation of current ADL services provided was available for Compliance Officer review. 5. In an interview, E1 reported R1 and R2 received all aforementioned services in the month of October 2024. However, documentation of the services provided was not available for Compliance Officer review. E1 acknowledged a caregiver failed to document the services provided in R1's and R2's medical records.

Based on documentation review, record review, and interview, 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 false or misleading information was provided to the Department. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Administration." The policy stated, "Medication administered to a resident ... is documented in the resident's MAR within 24 hours." 2. A review of R1's and R2's medical records revealed R1 and R2 received medication administration. 3. A review of R1's medical record revealed a signed medication list (dated August 1, 2024) that included the following medications: - Amlodipine 5 milligrams (mg), 1 tablet by mouth (po) daily (qd); - Bupropion 300 mg XL, 1 tablet po qd; - Duloxetine 60 mg, 1 tablet po qd; - Gabapentin 600 mg, 1 tablet po twice a day (bid); - Gabapentin 300 mg, 1 tablet po three times a day (tid); - Levothyroxine 50 micrograms (mcg), 1 tablet po qd; - Losartan 100 mg, 1 tablet po qd; - Methocarbamol 750 mg, 1 tablet po tid; - Omeprazole 20 mg, 1 tablet po qd; - Pantoprazole 40 mg, 1 tablet po qd; and - Tamsulosin 0.4 mg, 1 tablet po qd. 4. While on-site for the compliance inspection, the Compliance Officers requested R1's medication administration record (MAR) for the month of October 2024. However, documentation was initially unavailable for Compliance Officer Review. E1 and E2 completed the documentation throughout the duration of the inspection and attempted to provide the documentation for review. 5. A review of R2's medical record revealed a signed medication order (dated June 24, 2024) for Haldol 1 mg, 1 tablet po bid. 6. A review of R2's medication administration record revealed missing documentation of Haldol 1mg, 1 tablet po bid on October 1, 2024 at 8:00 PM. 7. In an interview, E1 reported R1 and R2 had been administered all ordered medications; however, documentation was unable for review at the time of documentation request. E1 acknowledged R1's and R2's MARs did not contain accurate documentation of medication administered to the residents.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. On February 5, 2024, the Compliance Officer requested the following documents during the on-site inspection: - R1's service plan 2. In an interview, E1 reported R1 left the facility in January of 2023 and the the service plan for June of 2022 and December of 2022 were not able to be located and provided to the compliance officer, within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's service plan and updates, for one of two resident records reviewed. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not in the medical record during the inspection. Findings include: 1. A review of R1's medical record revealed R1 left the facility in January of 2023 and the most recent service plan available for review, was for personal care level of services and dated December 15, 2020. 2. In an interview, E1 reported the updated service plans for June of 2022 and December of 2022 existed, though were unable to be located. 3. In an interview, E1 reported acknowledged R1's medical record did not include the most recent service plan updates for one of two resident records reviewed.

Based on document review, observation, and interview, the manager failed to ensure a facility authorized to provide directed care services had a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed potential egress dangers to residents. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed a bedroom door leading to the secured backyard, did not include an alert. The alert above the door was missing half of the device, so the device was not able to alert the caregivers of the egress of a resident from the facility. 3. In an interview E1 reported the mechanism was believed to be stolen by R2 and E3, and was unable to be located. 4. In an interview, E1 reported the replacement device was ordered because it was part of a set and unavailable locally. 5. In an interview, E1 acknowledged the door alert was not functioning and would be unable to alert employees of the egress of a resident from the facility. E1 followed up with a voicemail advising a temporary correction had been made by placing a locally purchased alert on the door until the new one arrived.