Living Legacy Senior Care East

Based on documentation review, record review, and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's refusal of a medication. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Refused Medication." The policy stated, "When a resident refuses a medication or treatment, document on the resident's MAR in the corresponding square for that order on the appropriate date with a "R". On the back of the MAR write the date, time, medication name and the reason the medication was not taken...If a resident consistently refuses to take a prescribed medication: personnel should ask the resident why she/he is refusing the medication and should make every effort w/in the time allocation to encourage the medication administration; and the Manager or Caregiver should attempt to address the resident's concern and may determine it is necessary to contact the resident's medical Practitioner and/or pharmacist to determine if there is a viable alternative." 2. A review of R2's medical record revealed signed medication orders dated July 11, 2024 for the following medications: - Sertraline HCl 100 milligrams (mg), 0.5 tablet po at bedtime (qhs); and - Duloxetine HCl 30 mg, 2 capsule po daily (qd). 3. A review of R2's medication administration record (MAR) for August 2024 revealed the following: -Sertraline HCL 100 mg was not listed on the MAR; and -Duloxetine HCL 30 mg was not listed on the MAR. 4. In an interview, E2 reported R2 refused the administration of Sertraline HCl 100 mg and Duloxetine HCl 30 mg August 1- present. E2 acknowledged R2's medical record did not contain documentation of R2's refusal of a medication.

Based on record review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of R3's medical record revealed R3 received directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed the sliding door that led to the patio was equipped with an alarm to alert employees of egress; however the alarm was not turned on at the time of inspection. The Compliance Officer observed a resident who was ambulatory and frequently moved in and out of the facility without assistance to smoke outside. 3. In an interview, E2 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed resident medication stored in an unlocked cabinet within the administrative office. However, the door to the office was unlocked at the time of inspection. 2. In an interview, E2 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.