D & M Assisted Living Home

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area that monitored or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of the facility license revealed the facility was licensed at the directed care level. .2. A review of the facility's policies and procedures revealed a document titled "Memory Care: Training, Environment & Documentation", which stated: "Exit door accessible to memory care residents must be alarmed..." 3. During an environmental inspection of the facility, the Compliance Officer observed that the side door leading to the backyard had an alert. However, the alert was missing a piece and not working properly. 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 written service plan included the signature and date from the resident or representative, for one of three residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. Review of R1's medical record revealed a current written service plan dated November 1, 2023. However, this service plan did not include a signature and date from the resident or representative. 2. In an interview, E1 acknowledged R1's service plan did not include a signature and date from the resident or representative.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the manager, for one of three residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. Review of R1's medical record revealed a written service plan dated November 1, 2023. However, the service plan did not include a signature and date from the manager. 2. In an interview, E1 acknowledged R1's service plan did not include a signature and date from the manager.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a current written service plan dated November 1, 2023. This service plan stated "Catheter care...caregiver to empty bag twice a day and PRN". However, documentation was not available indicating this service was provided on November 1st - present. 2. In an interview, E1 acknowledged R1's medical record did not include documentation of the above listed service and reported the service was provided as indicated in the service plan.

Based on record review, observation, and interview, the manager failed to ensure a resident medical record contained a medication order from a medical practitioner for each medication that was administered, for one of three residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R2's medical record revealed a current written service plan dated June 23, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed no documentation of signed medication orders or verbal medication orders for the following: Calcitriol 0.25mg. 3. Review of R2's medical record revealed a November 2023 medication administration record (MAR). This MAR stated the following: "Calcitriol 0.25mg one tab daily" and indicated one tab was administered at 8am November 1 - November 13th. 4. In an interview, E1 acknowledged R2's medical record did not contain a medication order from a medical practitioner for each medication that was administered.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of three residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated June 23, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed no documentation of signed medication orders or verbal medication orders for the following: Calcitriol 0.25mg. 3. Review of R2's medical record revealed a November 2023 medication administration record (MAR). This MAR stated the following: "Calcitriol 0.25mg one tab daily" and indicated one tab was administered at 8am November 1 - November 13th. 4. In an interview, E1 reported the medication was administered per the MAR. E1 acknowledged R2's medication was not administered in compliance with an available medication order.