Classic Assisted Living LLC

Based on observation, record review, documentation review, and interview, for one of three residents reviewed, who received controlled substances, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for. Findings include: 1. In observation, the facility had Lorazepam medication (a Schedule IV Controlled Substance), for R1, stored by the facility. The medication container indicated 30 pills were dispensed on March 21, 2023. The compliance officer observed 46 pills in the medication container. 2. In record review, R1's medical record included a physician's order for the Lorazepam medication; 0.5mg take one tablet by mouth every four hours, as needed. There was no documentation of an inventory of the Lorazepam. 3. In documentation review, a facility policy titled, "Storing, Inventorying and Dispensing of Controlled Medications," on page 56, documented, "... When a controlled medication is received from the pharmacy (or the resident at the time of move-in), the RN or other designated staff person should count the number of tablets/capsules and enter this number on the Narcotic Inventory Sheet in the "Amount Received" column. The date, time, and signature of the person should also be entered on this form... Maintain Narcotic Inventory Sheets with the resident's current medication record...When assisting a resident in taking a controlled medication, a staff member should: Turn to the Narcotic Inventory Sheet with identifying information that corresponds to the label on the medication container. Write in the date, time and signature on the next blank line on the Narcotic Inventory Sheet... The number of each controlled medication on hand must be counted monthly, with this number compared to the last number in the "Amount Remaining" column on the Narcotic Inventory Sheet..." 4. During an interview, E1 reported being unaware Lorazepam was to be inventoried as a controlled substance. E1 and E4 acknowledged the facility stored and administered the Lorazepam medication, and did not maintain an inventory of the controlled substance per the facility's policy and procedures.

Based on record review, and interview, for three of three residents who had a health care power of attorney (POA), the manager failed to ensure a resident's medical record contained a copy of the (POA) documentation. The deficient practice posed a risk if the facility did not obtain and adhere to a resident's documentation of representation. Findings include: 1. In record review, R1's, R2's, and R3's medical records indicated R1, R2, and R3, had POAs, who signed the residents' acceptance documentation and service plans. The medical records for R1, R2, and R3 did not include a copy of the residents' POA documents. Based on the residents' acceptance dates, this documentation was required to be in the residents' records. 2. During an interview, E1 and E4 reported R1, R2, and R3, had a POA, and acknowledged the residents' medical records did not include a copy of the residents' POA documentation.

Based on observation, record review, and interview, for one of three residents reviewed, who was unable to walk, even with assistance, and received personal care services, the manager failed to ensure the resident's primary care provider (PCP) or other medical practitioner (MP) examined the resident at the onset of the condition and at least every six months throughout the duration of the resident's condition, reviewed the facility's scope of services, and signed and dated a determination stating the resident's needs were being met by the facility. The deficient practice posed a health risk to a resident if a resident's condition was not reviewed by a PCP or MP, to approve a resident's stay at the facility. Findings include: 1. In observation, the surveyor observed R1 at the facility during the inspection. 2. In record review, R1's medical record included documentation of a signed determination, dated January 20, 2022. R1's record did not include a signed and dated determination since January 20, 2022, as required. 3. During an interview, E1 reported R1 was unable to walk, even with assistance, since admission, and continued to be unable to walk. E1 acknowledged R1's record did not include a signed and dated determination stating the residents' needs could be met by the facility.

Based on observation and interview, for the facility which provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a health and safety risk to residents as an unlocked door provided access to the outside, without alerting employees. Findings include: 1. In observation, the compliance officer observed seven residents at the facility. During an environmental inspection, the compliance officer observed an unlocked sliding door, which exited to the backyard patio. The door did not control or alert employees of the egress of a resident from the facility. 2. During an interview, E1 acknowledged the door, which allowed exit to the backyard, did not have an alarm, and did not alert employees of the egress of a resident. 3. Technical assistance was provided during the compliance inspection conducted on September 22, 2022.

Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a separate locked area, used only for medication storage. The deficient practice posed a risk if medications were not stored separately with medications only. Findings include: 1. During an environmental inspection, the surveyor observed a refrigerator in a locked closet, in a hallway by resident rooms. The refrigerator contained food and drink, and had three packages of suppositories stored on a shelf on the refrigerator door. 2. During an interview, E1 reported the refrigerator was in a locked closet, and the suppositories belonged to residents. E1 acknowledged resident medications were required to be stored in a separate locked area used only for medication storage.