Moonlight Manor Assisted Living Home

Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of a medication administered to a resident that included the date and time of administration; the name, strength, dosage, and route of administration; the name and signature of the individual administering the medication; and an unexpected reaction a resident had to the medication, for one of three residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed no documentation of a September 2024 medication administration record (MAR). Based on the resident's date of acceptance, this documentation was required. 2. In an interview, O1, E1, and E2 acknowledged R1 received medication administration and the September 2024 MAR was not available for review.

Based on documentation review, record review, and interview, the manager failed to ensure an caregiver or assistant caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for two of two sampled caregiver and assistant caregivers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. A review of E2's (hired as a caregiver) and E3's (hired as an assistant caregiver) personnel records revealed no documented verification of E2's and E3's skills and knowledge. 2. In an interview, E1 and E4 acknowledged E2's and E3's personnel records did not contain documented verification of skills and knowledge.

Based on an observation and interview, the manager failed to ensure a means of exiting the facility 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. During the environmental inspection of the facility, the Compliance Officer observed nine of the ten resident bedrooms had a door leading from the residents' rooms to a patio outside of the residents' rooms. The Compliance Officer observed the doors had no mechanism to alert employees of the egress of a resident from the facility. 2. In an interview, E4 acknowledged nine of the ten bedrooms for residents of the facility had patios and the doors had no mechanism to alert the staff of a resident leaving the facility.

Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures were implemented for discarding medication and discarding expired medication. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Policy and Procedure." The policy stated, "For residents who are not capable of managing their own medications, the following policy and procedures apply: ....8) Expired medications and medications which have been permanently discontinued will be returned to the responsible party, or if there is no responsible party, to the pharmacy for disposal." 2. During a facility tour, the surveyor observed a bottle of "Morphine Sulfate Oral Solution 100milligrams (MG)", two bottles, three boxes and three bags of prefilled syringes Qty 20 of "Lorazepam Intersol Oral Concentrate 2mg", three bags Qty 5 of "Acetaminophen Sup 650mg." in a refrigerator in the medication closet. 3. In an interview, E1 and E4 acknowledged the medication had not been disposed of. E1 and E4 reported the medications were for residents who were no longer at the facility for over four months.

Based on observation and interview, the manager failed to ensure that garbage and refuse were removed from the premises at least once a week. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed in several residents bedrooms and in the resident bathrooms small trash can filled with garbage, such as briefs, toilet paper, women's sanitary pads. 2. In an interview E4 acknowledged the garbage cans were overfilled with trash.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. Findings include: 1. Review of R1's medical record revealed a current written service plan dated July 19, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated April 20, 2023. These medication order stated the following: "Warfarin 1 mg take two tablets on Saturday and Sunday" 3. Review of R1's medical record revealed a June 2023 medication administration record (MAR). This MAR stated the following: "Warfarin 1 mg take two tablets on Saturday and Sunday" however, did not include documentation this medication was administered at 8:00 p.m. on June 17, 2023, and June 18, 2023 4. During an observation of R1's medications, the following was observed: Warfarin 1 mg was available. 5. During an interview, E1 reported the medication was administered per the medication order and acknowledged R1's medical record did not include documentation the medication was administered as stated above.