Everwood Alh LLC

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution documented the identification of the patient's need for the opioid and the effect of the opioid administered. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility’s policies and procedures revealed a document titled, "Medications Including Opioids, Narcotics and Schedule 2", that contained the following verbiage: "For Narcotics, Opioids, Schedule 2 Medications, Controlled Substances administration or assistance with self-medication administration on a PRN basis, the authorized personnel will determine the need of such administration by evaluating the necessity given by the situation of the resident, at the time, for the medication. Subsequently the resident is monitored for the effects of the medication administered to determine the response of the patient to the medication. Documentation in the NAR will include at minimum: a. Reason for the need of administration b. Evaluation of the Resident need for this administration c. The amount of medication given and number of medication left in the container. d. How effective the dose of the medication administered at half an hour, two hours and four hours after administration." 2. A review of R1's medical record revealed a signed medication order dated August 7, 2025. This order stated "Tramadol 50mg Tab 1 tablet orally twice daily and 1 additional tablet daily as needed." 3. A review of R1's medical record revealed an August 2025 and September 2025 medication administration record (MAR). These MARs indicated Tramadol 50 mg 1 tablet was administered two times a day at 8am and 8pm, from August 7th at 8pm to September 11th at 8am. Additionally, R1's medical record revealed a Narcotic Administration Record (NAR) that indicated Tramadol 50 mg was administered two times a day, from August 19th at 7pm to August 27th at 8am. This NAR included documentation showing the need for opioid administration and the effect of the opioid administered. However, documentation was not available showing the need for opioid administration and the effect of the opioid administered on August 27th at 8pm to September 11th at 8am. 4. A review of R1's medical record revealed R1 did not have an end-of-life condition or an active malignancy. 5. 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 that the caregiver or assistant caregiver documented the services provided in a resident’s medical record according to the resident’s service plan for two out of two residents sampled. 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 required services stated in their service plan, which included the following: Eating, three times daily and as needed with snacks Nail care, check nails daily and trim as needed Transferring, daily and as needed 2. A review of R1’s activities of daily living sheet revealed the following missing documentation of required services to be provided to R1 in accordance with the services in their service plan: No documentation of eating dinner on September 10 No documentation of nail care on September 8-10 No documentation of transferring resident on September 10 3. A review of R2’s medical record revealed required services stated in their service plan, which included the following: Eating, three times daily and as needed Nail care, check nails daily and trim as needed Transferring, daily and as needed 4. A review of R2’s activities of daily living sheet revealed the following missing documentation of services required to be provided to R2 in accordance with the services stated in their service plan: No documentation of eating dinner on September 10 No documentation of nail care on September 10 No documentation of transferring resident on September 10 5. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that safeguards existed to prevent unauthorized access to residents' medical records for one resident. The deficient practice posed a risk of protected, sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. During an environmental tour of the facility with E1, the Compliance Officers observed a conspicuously posted paper on the wall disclosing the health information of R1, the name of the medication R1 was taking, and the instructions on when R1 should take the medication. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order for one out of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R2's medical record revealed no signed medication order for Metoclopramide Hydrochloride, 10mg, 1 tablet four times daily. 2. A review of R2's medical record revealed a September 2025 medication administration record (MAR). This MAR stated "Metoclopramide Hydrochloride, 10 mg, 1 tablet by mouth four times daily," and indicated one tab was administered at 6:00am, 11:00am, 4:00pm, and 7:00pm every day from September 1-11, 2025 with a missed dose at 11:00am and a missed dose at 4:00pm on September 4, 2025. 3. During an observation of R2's medications, the Compliance Officers (CO) observed R2's Metoclopramide medication was available. The COs also observed there was a tablet for this medication in R2's medication organizer, however, there was only one tablet in the "noon" section and one tablet in the "eve" section. The "morning" and 'bed" section did not contain any tablets for this medication. 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 that a medication administered to a resident was documented in the resident’s medical record, for two of the two residents sampled. The deficient practice posed a risk as medication administration could not be verified against a medication order and false or misleading information was provided to the Department. Findings include: 1. The Compliance Officers (COs) requested a printed copy of R1's and R2's September 2025 medication administration records (MARs) at the start of the inspection. 2. A review of R1’s September 2025 MAR revealed no documentation that the following medications were administered on September 5, 2025: Buspirone, 7.5 mg, 1 tablet po TID, missed at 12pm; Cetirizine 10 mg, 1 tablet po qd, missed at 12pm; Memantine, 10 mg, 1 tablet po BID, missed at 5pm; and Oxcarbazepine, 300 mg, 1 tablet po QD, missed at 4:30pm. 3. A review of R2’s September 2025 MAR revealed no documentation that the following medications were administered on September 4, 2025: Sertraline 100 mg, 1 tablet po QD, missed at 8:00am; Senna Plus, 8.8-50 mg, 2 tablets BID, missed at 8:00am; Metoclopramide, 10 mg, 1 tablet po QID, missed at 11:00am and 4:00pm; and Triad 1, 1 topical cream QD, missed at 8:00am. 4. In an exit interview, the findings were reviewed with E1. After the findings were reviewed, E1 reported the findings were incorrect and that the missed documentation was due to a technical error with the software, Synkwise, which was used by the facility to electronically record the residents' medication administration. E1 proceeded to reprint R1’s and R2’s electronic MARs and provided them to the COs at approximately 4:24pm. The reprinted MARs showed no missing documentation for any of the medications listed above.