June and Frank Sackton Assisted Living Apartments

Based on documentation review, observation, record review, and interview, the manager failed to establish, and document policies and procedures for administering an opioid that covered how, when, and by whom a patient's need for opioid administration is assessed; how, when, and by whom a patient receiving an opioid is monitored; and how, when, and by whom the actions taken according to subsections (F)(1)(c) and (d) are documented. The deficient practice posed a safety risk to residents if the opioid rules were not understood and implemented by staff administering medications. Findings include: 1. In documentation review, a facility policy, titled, "Opioids Policy," dated April 1, 2024, did not cover how, when, and by whom a patient's need for opioid administration is assessed; how, when, and by whom a patient receiving an opioid is monitored; and how, when, and by whom the actions taken according to subsections (F)(1)(c) and (d) are documented. 2. In observation, the facility stored opioid medication in a medication cart for residents, who received opioid medication administration. 3. In record review, R4's medication record indicated R4 received Tramadol medication (a class IV controlled substance) in October and November, 2024. 4. During an interview, E1 and O1 reported the facility established and documented policies and procedures for administering opioid medication; however, were unable to locate the policies and procedures. No further documentation was provided for review.

Based on interview and record review, for two of three residents reviewed, the manager failed to ensure a resident was treated with dignity, respect, and consideration. Findings include: 1. During an interview, R2 reported an incident occurred with E5, where E5 spoke in a rude manner, and refused to assist R2 sufficiently during toileting. R2 reported "E5 doesn't have the caring that is required for people who do this job." 2. In record review, R2's medical record included a report which documented an investigation of the incident, and the termination of E5's employment. 3. In record review, R3's medical record included a report which documented R3 had a toileting accident, and requested assistance from E4 to shower and get cleaned up before lunch. E4 told R3 "you cannot have a shower until tomorrow." E3 reported feeling old and diminished. E4 was terminated from employment. 4. During an interview, E1 and O1 acknowledged R2 and R3 reported incidents of mistreatment by a caregiver, the facility reported this, as required, and conducted an investigation. The employees referenced were terminated.

Based on observation, record review, and interview, for two of four caregivers reviewed, the manager failed to ensure that before providing assisted living services, a caregiver received orientation specific to the duties to be performed by the caregiver. The deficient practice posed a health and safety risk to residents if a caregiver did not receive the required orientation. Findings include: 1. In observation, E5 was observed working as a caregiver during the inspection. 2. In record review, the personnel records for E4 and E5 did not include documentation the caregivers received orientation before providing services. 3. During an interview, E1 and E2 reported E4 and E5 worked at the facility as caregivers (provided by an outside agency), and were not hired by the facility. E1 reported E5 worked at the facility on the day of the inspection, and acknowledged the personnel records for E4 and E5 did not include documentation the caregivers received orientation before providing services to residents.

Based on observation, record review, and interview, for two of four caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health 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 care and services for a resident. Findings include: 1. In observation, E5 was observed working as a caregiver during the inspection. 2. In record review, the personnel records for E4 and E5 did not include documentation the caregiver's skills and knowledge were verified and documented before the caregivers provided services to the residents. 3. During an interview, E1 and E2 reported E4 and E5 worked at the facility as caregivers (provided by an outside agency), and were not hired by the facility. E1 reported E5 worked at the facility on the day of the inspection, and acknowledged the personnel records for E4 and E5 did not include documentation the caregivers skills and knowledge were verified and documented, as required.

Based on record review and interview, for three of four caregiver records reviewed, the manager failed to ensure a caregiver provided documentation of cardiopulmonary resuscitation training (CPR) certification specific to adults, which included a demonstration. The deficient practice posed a health and safety risk to residents if caregivers did not have CPR training which included a demonstration of the employee's ability to perform CPR. Findings include: 1. In record review, the personnel records for E4, E5, and E10 included documentation of CPR certification provided by NationalCPRFoundation, which was an online training program, and did not include a demonstration of an individual's ability to perform CPR. 2. During an interview, E1 and E2 reported E4, E5 and E10 worked as caregivers at the facility. E1 reported being unaware the CPR training program was an online program, and acknowledged the CPR training received by the employees did not include the required demonstration of the employees' ability to perform CPR.