Elite Memory Care LLC

Based on record review, documentation review, and interview, for one of three caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided services. The deficient practice posed a health and safety risk to residents if a caregiver did not have the documented skills and knowledge to provide services for residents. Findings include: 1. In record review, the personnel record for E4 (hired as an assistant caregiver on December 21, 2024), did not include documentation of the verification of skills and knowledge for E4. 2. In documentation review, a facility policy, titled, "Staffing and Record Keeping," documented, "... The facility manager shall ensure that a personnel record for each employee... a. includes ... iii. Documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties..." 3. During an interview, E1 reported E4 was E1's family and helped out temporarily as an assistant caregiver. E4 acknowledged E4's personnel record did not include documentation of the verification of the caregiver's skills and knowledge, which was required before a caregiver provided services for residents.

Based on record review, documentation review, and interview, for one of three caregivers reviewed, the manager failed to ensure an assistant caregiver received orientation specific to the duties to be performed by the assistant caregiver. The deficient practice posed a health and safety risk to residents if an assistant caregiver was not oriented, as required. Findings include: 1. In record review, the personnel record for E4 (hired as an assistant caregiver on December 21, 2024), did not include documentation E4 received orientation. 2. In documentation review, a facility policy, titled, "Staffing and Record Keeping," documented, "... The facility manager shall ensure that a personnel record for each employee... a. includes... iii. Documentation of ... The individual's completed orientation ... required by policies and procedures..." 3. During an interview, E1 reported E4 was E1's family, and helped out temporarily as an assistant caregiver. E1 acknowledged the personnel record for E4 did not include documentation E4 received orientation, which was required before E4 provided services for residents.

Based on observation, record review, documentation review, and interview, for one resident reviewed, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication that was administered. The deficient practice posed a health and safety risk if the resident received medication and the Department was unable to verify an order for the medication. Findings include: 1. In observation, the Compliance Officer observed the facility had Escitalopram and Trazadone medications on site for R1. 2. In record review, R1's medical record (received directed care and medication administration services) included documentation the caregiver administered the Escitalopram and Trazadone medications to R1 daily, December 21, 2024, through January 22, 2025. R1's medical record did not include documentation of medication orders for the Escitalopram and Trazadone medications, until January 14, 2025. 3. In documentation review, a facility policy titled, "... Medications Including Opioids and Narcotics," documented, "... Whenever possible, written medication orders will be obtained prior to the resident's admission or by verbal order the day of the resident's admission into the facility. a. If orders are not obtained prior to admission, after contacting the doctor and verifying the medications to be taken, the caregiver will list the medications including strength.... as well as instructions of administration on the "Initial Medication Order" form... Part III - Medication Administration.... 1. No medication or treatment is to be administered to the resident without the order and instructions of a physician or medical practitioner. 4. During an interview, E1 reported R1's family provided the Escitalopram and Trazadone medications to the facility when R1 was accepted, and the medications were administered by the caregivers without an order from a medical practioner. E1 reported medication orders for the Escitalopram and Trazadone were not obtained until January 14, 2025. E1 acknowledged medication orders were required from a medical practitioner for each medication administered to a resident.

Based on observation, record review, documentation review, and interview, for one resident reviewed, the manager failed to ensure documentation of medication administration included the date and time of administration, the strength, dosage, and route of administration, and the name and signature of the individual administering medication. The deficient practice posed a health and safety risk to a resident if the facility did not properly document medication administration for a resident. Findings include: 1. In observation, R1's medications were observed on site, and included a container of Cipro medication, which indicated 14 tablets were dispensed, and one tablet remained in the medication bottle. 2. In record review, R1's medical record included a medication order, dated January 15, 2025, for "Cipro 500 mg/5ml, give 5 ml po twice daily x 7 days - ABT..." R1's medication administration record (MAR), dated January, 2025, did not include documentation the Cipro medication was administered to R1, as ordered. 3. In documentation review, a review of the facility policy titled, "Medications Including Opioids and Narcotics" documented, "7... medication administration provided to a resident is in compliance with an order and is documented in the resident's medical record... 10. The trained caregiver will initial in the MAR and include the date and time the medicine was given to the resident and the medications that were taken..." 4. During an interview, E1 reported the Cipro medication was administered to R1, in tablet form, and not liquid form, as ordered; however, reported the change was approved by the medical practitioner. E1 acknowledged the medication administration was not documented by the caregiver. E1 acknowledged R1's medical record did not include documentation of the date and time of administration, the strength, dosage, and route of administration, and the name and signature of the individual who administered the medication.

Based on observation, record review, documentation review, and interview, for one resident reviewed, the manager failed to ensure when a verbal order for a resident's medication was received from a medical practitioner, the verbal order was documented in the resident's medical record. The deficient practice posed a health and safety risk if a resident received medication and the Department was unable to verify an order for the medication. Findings include: 1. In observation, the Compliance Officer observed the facility had a container of Cipro medication for R1; the medication bottle indicated 14 tablets were dispensed, and the Compliance Officer observed one tablet remained in the bottle. The Compliance Officer did not observe any other Cipro medication for R1. 2. In record review, R1's medical record (received directed care and medication administration services) did not include documentation of a medication order for the Cipro medication tablets. The medical record included a medication order, dated January 15, 2025, for "Cipro 500 mg/5ml, (a liquid medication) give 5 ml po twice daily x 7 days - ABT..." 3. In documentation review, a facility policy titled, "... Medications Including Opioids and Narcotics," documented, "... Whenever possible, written medication orders will be obtained prior to the resident's admission or by verbal order the day of the resident's admission into the facility. a. If orders are not obtained prior to admission, after contacting the doctor and verifying the medications to be taken, the caregiver will list the medications including strength.... as well as instructions of administration on the "Initial Medication Order" form. b. The verbal order shall be dated and signed by the person receiving the order by filling out the "Verbal Order" form, as well as the name and telephone number of the Physician or medical practitioner... Part III - Medication Administration.... 1. No medication or treatment is to be administered to the resident without the order and instructions of a physician or medical practitioner. 4. During an interview, E1 reported the Cipro tablets were administered per the physician's instructions because the Cipro liquid was unavailable. E1 reported the facility did not have a medication order for the Cipro tablets, which were administered to R1. E1 acknowledged medication orders were required from a medical practitioner for each medication administered to a resident, and the verbal order was not documented, as required.