Marino Manor II LLC

Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. The deficient practice posed a risk as the facility was unaware of the whereabouts of a resident. Findings include: 1. A review of facility documentation revealed no policy and procedure covering this rule. The review revealed an "INCIDENT REPORT" dated May 28, 2024. The document stated: "The Lyft driver picked up [R1] for [R1's] Dental Appointment. The driver did not take [R1] inside the dental office, so [R1] got confused and went to different direction and fall. The Paramedics brought [R1] to [hospital] for treatment...It was already 3:00 pm, so we decided to check if [R1] was still in the dental office but they said [R1] did not show up. We decided to Report the indicant to the Police as missing because we don't know [R1's] Whereabout. We found out that [R1] was in the hospital when the Doctor called and notify us." 2. In an interview, E2 confirmed the facility had no policy and procedure covering this rule. E2 reported facility personnel did not know where R1 was until the physician called, confirming the incident report.

Based on documentation review, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of three total residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "MEDICATION ADMINISTRATION" which stated, "The manager or manager's designee shall ensure that a medication administered to a resident is administered in compliance with a medication order." The review also revealed a P&P titled "RESPONDING TO AND REPORTING A MEDICATION ERROR" which stated, "A medication error may be defined as any one of the following: Given with No Order - Any medication given without a physician's order." 2. In an interview, E2 reported "DC" on a medication administration record (MAR) meant the medication was not given because it was discontinued. 3. A review of R1's medical record revealed a current service plan which indicated R1 required medication administration services. The review revealed a medication order dated July 28, 2023, for the following medications: -"Allopurinol 100 mg (milligrams) Tablet 1/2 tablet by mouth once daily"; -"Furosemide 40 mg Tablet 1 tablet by mouth 2 times daily"; -"Gabapentin 300 mg capsule 1 capsule by mouth three times daily"; -"Pioglitazone HCL 30 mg Tablet 1 tablet by mouth daily"; and -"Systane (Propylene Glycol) 0.4%-0.3% ophthalmic drop, 1 drop each eye 4 times daily". The review further revealed a MAR dated May 2024 which revealed the following: -R1's "Allopurinol" was discontinued and not given after May 27, 2024; -R1's "Furosemide" was discontinued and not given after 8:00 AM on May 27, 2024; -R1's "Gabapentin" was discontinued and not given after 8:00 AM on May 27, 2024; -R1's "Pioglitazone" was discontinued and not given after 4:00 PM on May 27, 2024; -R1's "Systane" was discontinued and not given after May 27, 2024; -R1 received "Empagliflozin 10 mg" on May 28, 2024, without a signed medication order; and -R1 received "Cephalexin 500 mg" on May 27-28, 2024, without a signed medication order. 4. In an interview, E2 reported some of R1's medications were discontinued and R1 started two new medications. When the Compliance Officer asked if the facility had signed orders for the aforementioned medications, E2 stated, "No." E2 further stated, "I know that [medication orders need to be signed]."

Based on documentation review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver documented all items required by this rule, for two of three applicable sampled residents. The deficient practice posed a potential risk of re-injury. Findings include: 1. A review of facility documentation revealed an "INCIDENT REPORT" dated May 28, 2024 which indicated R1 had an accident, emergency, or injury that resulted in R1 needing medical services. However, the incident report did not include any action taken to prevent the accident, emergency, or injury from occurring in the future. The review further revealed three "Assisted Living Resident Transfer Checklist for Emergency Responders" forms. The first form, dated May 26, 2024, indicated R1 had an accident, emergency, or injury that resulted in R1 needing medical services. The other two forms, dated June 2 and 8, 2024, respectively, indicated R3 had an accident, emergency, or injury that resulted in R3 needing medical services on those dates. However, the review revealed no documentation in compliance with this rule for those three incidents. 2. In an interview, when the Compliance Officer pointed out the incident report dated May 28, 2024, did not contain any action taken to prevent the accident, emergency, or injury from occurring in the future, E2 stated, "It's not there." When the Compliance Officer asked if the facility had incident reports for the three incidents on May 26, 2024, and June 2 and 8, 2024, respectively, E2 stated, "No."