Little Flower Assisted Living Home

Based on record review, documentation review, and interview, the manager failed to ensure that a medication was documented in a resident's medical record for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as documented in a resident's medication administration record. Findings include: 1. Record review of R1's medication administration record established that Tizanidine 2mg was to be administered at 8am on the morning of September 25, 2024. The medication was not documented in the medication administration record as being administered on the morning of September 25, 2024 at 8am. 2. Documentation review established a section in the facility's policies and procedures titled "Receiving, Inventorying, Tracking, And Dispensing Medications". Within this section is a subsection titled "Read the information regarding the medication in the resident medication record (i.e. the medication name, dosage and time the med)". The Tizanidine 2mg was not timed accurately according to a review of R1's medication administration record on the morning of September 25, 2024. 3. In an interview, E1 confirmed that the policies and procedures regarding "Receiving, Inventorying, Tracking, And Dispensing Medications" were not implemented correctly. E1 confirmed that the Tizanidine 2mg was administered to R1. E1 also confirmed that the following medication was not documented in R1's medication administration record on the morning of September 25, 2024: - Tizanidine 2mg

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. The Compliance Officer observed an unlocked laundry room at the facility which contained the following toxic material: - Arm & Hammer Oxi Clean 2. The Compliance Officer observed an unlocked door leading through the laundry room into the garage which contained the following toxic material: - Tide Simply Oxi 3. In an interview, E1 confirmed that the unlocked laundry room had Arm & Hammer Oxi Clean which was accessible to residents. E1 also confirmed that the garage contained Tide Simply Oxi, which was accessible to residents through an unlocked door leading to the garage through the laundry room.

Based on record review, documentation review, and interview, the manager failed to ensure that an administered medication was documented according to the date and time at which it was administered. The deficient practice posed a potential risk to the health and safety of residents. Findings include: 1. Record review established that R1 had a medication order for Morphine 20 mg/ml oral. The medication was to be administered in compliance with the following instructions: 0.25-0.5ml (5-10mg) sublingual every 1 hour as needed for pain and/or shortness of breath. The the time of administration of this medication was not documented in the medication administration record. 2. Record review established that the time for R1's medication for Morphine 20mg/ml was not recorded from August 2, 2024 to September 22, 2024. 3. On September 16, 2024, Morphine 20mg/ml was administered to R1 a total of three times. The timing of the administration was not recorded and the medication was required to be separated by a one hour frequency between administrations. 4. Documentation review established a section in the facility's policies and procedures titled "Receiving, Inventorying, Tracking, And Dispensing Medications". A subsection of this section was titled "Dispensing Medications". This section included a section titled "Read the information regarding the medication in the resident medication record (i.e. the medication name, dosage and time the med)". 5. In an interview, E1 confirmed that the time of R1's administration of Morphine 20mg/ml was not recorded from August 2, 2024 to September 22, 2024. E1 also confirmed that on September 16, 2024, Morphine 20mg/ml was administered to R1 a total of three times. The timing of the administration was not recorded and the medication was required to be separated by a one hour frequency between administrations. E1 also confirmed that documentation review established a section in the facility's policies and procedures titled "Receiving, Inventorying, Tracking, And Dispensing Medications". A subsection of this section was titled "Dispensing Medications". This section included a section titled "Read the information regarding the medication in the resident medication record (i.e. the medication name, dosage and time the med)".

Based on record review, documentation review, and interview, the manager failed to ensure that a medication was documented in a resident's medication administration record as marked by the name and signature of the individual administering the medication. The deficient practice posed a potential risk to the health and safety of residents, and the Department was provided false and misleading information. Findings include: 1. Record review established that R2's medication administration record regarding Isosorbide 60mg was marked as completed at 8am on September 26, 2024. However, the record was reviewed on September 25, 2024. 2. Documentation review established a section in the facility's policies and procedures titled "Receiving, Inventorying, Tracking, And Dispensing Medications". A subsection of this section was titled "Dispensing Medications". This section included a section titled "Read the information regarding the medication in the resident medication record (i.e. the medication name, dosage and time the med)". 3. In an interview, E1 also confirmed that record review established that R2's medication administration record regarding Isosorbide 60mg was marked as complete at 8am on September 26, 2024. However, the record was reviewed on September 25, 2024. E1 confirmed that this was false and misleading information provided to the Compliance Officer. E1 also confirmed that documentation review established a section in the facility's policies and procedures titled "Receiving, Inventorying, Tracking, And Dispensing Medications". A subsection of this section was titled "Dispensing Medications". This section included a section titled "Read the information regarding the medication in the resident medication record (i.e. the medication name, dosage and time the med)".

Based on record review, documentation review, and interview, the manager failed to ensure that a caregiver or an assistant caregiver documented the services provided in the resident's service plan in the activities of daily living record for one 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. Record review established that R2's service plan stated that R2 needed assistance with grooming. Record review established that R2 needed to be shaved two times a week according to his Activities of Daily Living record. This record was only marked as completed one time for the entire month of September 2024. It was marked completed on September 3, 2024. 2. Documentation review established a section in the facility's policies and procedures titled "Service Plan Policy". A subsection of this section contained a section titled "Service Plan Delivery" which stated the following: "The staff at the facility will provide care based upon the resident's needs and the determination of the services plan team". In addition, this section also contained a subsection which stated: "Services are delivered as specified in the service plan". 3. In an interview, E1 confirmed that R2's service plan stated that R2 needed assistance with grooming. Record review established that R2 needed to be shaved two times a week according to his Activities of Daily Living record. This record was only marked as completed one time for the entire month of September 2024. It was marked completed on September 3, 2024. E1 confirmed that the service was being provided to R2. E1 also confirmed that documentation review established a section in the facility's policies and procedures titled "Service Plan Policy". A subsection of this section contained a section titled "Service Plan Delivery" which stated the following: "The staff at the facility will provide care based upon the resident's needs and the determination of the services plan team". In addition, this section also contained a subsection which stated: "Services are delivered as specified in the service plan".