M&k Cadence Assisted Living

Based on record review, observation and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R2's medical record revealed a current written service plan for personal care services dated February 10, 2024. This service plan stated the following service was needed: "Foley Catheter: Drain twice a day, morning and evening and as needed." However, documentation was not available indicating this service was provided. 2. In an interview, R2 and E1 reported the service was provided. 3. In an interview, E1 acknowledged R2's medical record did not include documentation of the catheter care being provided.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and 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. The facility was licensed at the directed care level. 2. During an environmental inspection of the facility with E1, the Compliance Officer observed a door leading to a backyard from R3's room. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door did not have a device that alerted employees of the egress of a resident from the facility and was unlocked. 3. In an interview, E1 reported that the alarm had fallen off, and the facility was waiting for double-sided tape to be delivered to reinstall it. 4. In an interview, E1 acknowledged that the means of exiting the facility did not control or alert employee of the egress of a resident.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of three residents reviewed. The deficient practice posed a risk as medication could not be verified as administered. Findings include: 1. Review of R2's medical record revealed a current written service plan dated February 10, 2024. This service plan indicated R2 received medication administration. 2. Review of R2's June 2024 medication administration record (MAR) revealed a document for as needed (PRN) medication administration. This document assigned a number to each PRN medication administered to R2. Number 8 stated "Daytime and Night Time (Dayquil & Nyquil) 2 caps/PO/Q6hrs PRN". "8" was documented as administered to R2 at the following dates and times: -June 22 8pm; -June 23 8am; -June 23 2pm; -June 23 8pm; -June 24 2am; -June 24 8am; -June 24 2pm; -June 24 8pm; -June 25 6am; and -June 25 12N. However, the PRN MAR did not state if it was Nyquil or Dayquil administered at each time. 3. In an interview, E1 acknowledged R2's medication administration was not accurately documented in R2's medical record.