Gloria's Assisted Living LLC

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for two of three resident records reviewed. Findings include: 1. A review of R2's medical record revealed R2 received medication administration. 2. A review of R2's medical record revealed a signed medication order for "Levothyroxine 75mcg i/i PO BEFORE BREAKFAST", dated December 26, 2023. 3. A review of R2's medication administration record (MAR), at or about 2:15 pm on January 8, 2024, revealed the Levothyroxine was not initialed as being administered to R2 before breakfast on January 8, 2024. A statement at the bottom of the MAR stated, "Initial appropriate box when medication is given." 4. A review of R3's medical record revealed R3 received medication administration. 5. A review of R3's medical record revealed a signed medication order for the following morning medications: - "Celebrex 100mg ... PO QD"; - "Escitalopram Oxalate 10mg ... PO QD"; - "Apixaban 2.5mg ... PO BID"; - "Buspirone 5mg PO BID"; - "levothyroxine 75mcg tab ... PO QAM"; and - "Amlodipine besylate 5mg ... PO QD ... Hold for SBP <100". 6. A review of R3's medication administration record (MAR), at or about 2:15 pm on January 8, 2024, revealed the above referenced morning medications were not initialed as being administered to R3 before breakfast or in the morning, on January 8, 2024. A statement at the bottom of the MAR stated, "Initial appropriate box when medication is given." 7. A review of R3's medication organizer revealed the morning medications were taken for the morning of January 8, 2024. 8. A review of the facility's Policy and Procedure, revealed a policy titled "MEDICATION POLICY AND PROCEDURES". Page 8 of the document stated, "ASSISTING WITH SELF-ADMINISTRATION OF MEDICATIONS AND MEDICATION ADMINISTARTION ... C. A caregiver providing ... medication administration will document the medication was taken by initialing in the correct space on the resident's MAR: 1. After the resident has received and taken his or her medications." 9. In an interview, E1 and E2 acknowledged medication administered to R2 and R3 was not documented in R2's and R3's medical record for the morning of January 8, 2024.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility's work schedule revealed the facility had two shifts. 2. A review of facility documentation revealed a disaster drill conducted on "Shift #1" on January 13, 2023, April 13, 2023, and October 13, 2023. 3. A review of facility documentation revealed a disaster drill conducted on "Shift #2" on July 13, 2023. 4. In an interview, E1 and E2 acknowledged disaster drills were not conducted and documented on each shift at least once every three months.