Jolley Family Assisted Living LLC

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy, for two of two residents sampled. Findings include: 1 . A review of R1's and R2's medical records revealed documentation of negative TB skin tests. However, documentation of a TB screening conducted for R1 and R2 was not available for review. 2 . In an interview, E1 reported that E1 thought the TB screening was conducted annually after the initial TB test. E1 acknowledged R1 and R2 had no documentation of TB screening at the time of inspection.

Based on observation, record review, documentation review, and interview, the manager failed to ensure the assisted living facility had a caregiver with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. The deficient practice posed a health and safety risk to the residents. Findings include: 1. During the environmental tour the Compliance Officers observed R1 was non-ambulatory. 2. Review of R1's medical record revealed a service plan for personal care dated December 12, 2023. The service plan stated "Transfer assistance: 1 person and 2 person at times." Additionally, the service plan stated "Assistive Device: Wheelchair and Hoyer lift." 3. Review of the facility's work schedule dated March 2024 revealed only one person working during each shift. 4. In an interview, E2 reported needing assistance to transfer R1 twice a day. Additionally, E2 reported E2 would call E5 to assist from the sister facility next door. 5. In an interview, E1 acknowledged not having necessary personnel documented on the schedule to meet the needs of the residents.

Based on record review and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident, for one 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 R1's medical record revealed a service plan dated December 12, 2023 for personal care services including medication administration. The service plan stated "Medication/ Treatment: Injection Insulin; Sliding Scale - No." 2. A review of R1's medical record revealed a medication order dated March 12, 2024 for "LISPRO INSULIN" and "LANTUS SOLOSTAR INSULIN." This medication order did not include an order for sliding scale insulin. 3. A review of R1's medical record revealed a March 2024 medication administration record (MAR). This MAR did not include documentation of sliding scale insulin. 4. In an interview, E1 reported R1's insulin was administered on a sliding scale and not according to the medication order. E1 acknowledged R1's medical record did not contain a medication order from a medical practitioner for a medication that was administered.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered to a resident in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a service plan dated December 12, 2023 for personal care services including medication administration. 2. A review of R1's medical record included the following list of medication orders dated March 12, 2024: - "INSULIN LISPRO 100 UNIT/ML. Directions: INJECT 30 UNITS into the skin in the morning and 30 UNITS in the noon and 30 UNITS in the evening. Inject with meals." - "LANTUS SOLOSTAR INSULIN 100 UNIT/ML. Directions: 65 UNITS in the morning and 55 Units at night." 3. A review of R1's medical record revealed a March 2024 medication administration record (MAR). This MAR stated the following: - "LISPRO INS 100 UNIT/ML INJECT 40 UNITS subcutaneously before meals," and indicated the medication was administered at 8:00 AM, 12:00 PM, and 4:00 PM. - "LANTUS SOLOSTAR 100 UNITS INJECT 70 UNITS subcutaneously every night at bedtime," and indicated the medication was administered at 8:00 PM. 4. The Compliance Officers observed the medications listed above were available. 5. In an interview, E1 reported the medications listed above were not administered and acknowledged R1's medications were not administered in compliance with the available medication order.

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 one of two residents sampled. The deficient practice posed a risk as the medical record inaccurately indicated a medication was administered, and the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a service plan dated December 12, 2023 for personal care services including medication administration. 2. A review of R1's medical record indicated the following list of medication orders dated March 12, 2024: - "INSULIN LISPRO 100 UNIT/ML. Directions: INJECT 30 UNITS into the skin in the morning and 30 UNITS in the noon and 30 UNITS in the evening. Inject with meals." - "LANTUS SOLOSTAR INSULIN 100 UNIT/ML. Directions: 65 UNITS in the morning and 55 Units at night." 3. A review of R1's medical record revealed a March 2024 medication administration record (MAR). This MAR stated the following: - "LISPRO INS 100 UNIT/ML INJECT 40 UNITS subcutaneously before meals," and indicated the medication was administered at 8:00 AM, 12:00 PM, and 4:00 PM. - "LANTUS SOLOSTAR 100 UNITS INJECT 70 UNITS subcutaneously every night at bedtime," and indicated the medication was administered at 8:00 PM. 4. The Compliance Officers observed the medications listed above were available. 5. In an interview, E1 reported the medications listed above were not administered according to the March 2024 MAR and acknowledged R1's MAR inaccurately indicated medications were administered and signed by the caregiver.

Based on observation, documentation review, and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During an environmental tour, the Compliance Officers observed four ambulatory residents on the premises. 2. The Compliance Officers observed the following medication in the kitchen refrigerator unlocked in a box: - Multiple syringes of "ATIVAN 2 MG/ML 0.25 ML." 3. A review of facility documentation revealed a policy titled "Medication and Medication Services Policies and Procedures." The policy stated "15. The procedure for storing medication ... Medication requiring refrigeration will be kept in a locked container in the refrigerator." 4. In an interview, E1 and E2 acknowledged the medication were stored unlocked.

Based on observation and interview, the manager failed to ensure the common bathroom contained a window that opened or another means of ventilation. Findings include: 1. During an environmental tour, the Compliance Officers observed the common bathroom, adjacent to resident's bedroom. The Compliance Officers observed the bathroom had an exhaust fan, however, the exhaust fan was not working. 2. In an interview, E1 and E2 acknowledged the exhaust fan was not working in the common bathroom.