Leisure Living

Based on record review and interview, the healthcare institution failed to document in the patient’s medical record an identification of the patient’s need for the opioid before the opioid was administered to one of the two residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R1’s medical record revealed a signed medication order, dated January 25, 2025, for Oxycodone 10 milligrams (mg), 1 tablet by mouth (po) three times a day (tid). 2. A review of R1’s medication administration record (MAR) for February 2025 and March 2025 revealed a form titled “Narcotics Record.” The form revealed R2 was administered Oxycodone 10 mg 1 tablet po at 7:00 AM, 1:00 PM, and 7:00 PM February 23, 2025 - present. However, the form did not include documentation of R1’s need for the opioid. 3. In an interview, E1 acknowledged that the facility did not document R1’s need for the opioid before the opioid was administered to R1.

Based on documentation review, record review, observation, and interview, the manager failed to ensure that policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk as the standards expected of employees were not followed. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Controlled or Narcotic Medications." The policy stated, "2. The caregiver will document the the time the medication is taken and include amount given and remaining quantity of narcotics on the Narcotic Record sheet or pharmacy provided Controlled Narcotics Log Sheet." 2. A review of R1's medical record revealed a medication order dated January 25, 2025, for Oxycodone 10 milligrams (mg), 1 tablet per mouth (po) three times a day (TID). 3. A review of R1's medical record revealed a form titled "Narcotics Record." The form indicated R1 had 11 Oxycodone 10 mg tablets remaining at the time of inspection. 4. While on-site for the compliance inspection, the Compliance Officers observed R1's medication organizer to contain 20 Oxycodone 10 mg tablets. 5. In an interview, E1 reported that R1's dosage of Oxycodone had recently changed in frequency, and the facility used the remaining Oxycodone tablets before using the newly received medication. E1 acknowledged the facility's policies and procedures for inventorying controlled substances were not implemented.

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a health and safety risk for residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a water temperature of 150º F in the shared bathroom for residents. 2. The Compliance Officers also observed the water temperature of the kitchen sink to be 147º F. 3. In an interview, E1 acknowledged the hot water temperatures were not maintained between 95º F and 120º F in areas used by residents.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. During the on-site compliance inspection, the Compliance Officers observed E3 at the facility, providing services to residents. 2. A review of the facility's personnel schedule did not include documentation of E3 scheduled to work at the facility in March 2025. 3. In an interview, E1 reported the facility's personnel schedule only included documentation of the licensed caregivers and the hours worked by each. 4. A review of the facility's personnel schedule for March 2025 indicated multiple caregivers were scheduled to work 7:00 AM - 7:00 PM from March 1, 2025 - March 31, 2025. However, no caregivers or assistant caregivers were documented as scheduled to work overnight in the facility. 5. In an interview, E1 reported the facility had a caregiver on shift in the facility from 7:00 PM - 7:00 AM. E1 acknowledged the facility's personnel schedule did not include documentation of the caregiver and assistant caregivers who worked each day, and the hours worked by each.

Based on observation and interview, the manager failed to ensure that a resident's medical record was protected from loss, damage, or unauthorized use. 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, the Compliance Officers observed the residents’ medical records stored in an unlockable office, accessible through the facility’s kitchen. 2. In an interview, E1 reported E1 was unable to lock the office door. E1 acknowledged the residents’ medical records were not protected from loss, damage or unauthorized use. Technical assistance was provided regarding this rule during the compliance inspection conducted on January 17, 2023.