Northwood Glen II Assisted Living

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated January 2024. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated January 5, 2024. This medication order stated "Atorvastatin 10 mg tablet take 1 PO Q day hold for SBP [systolic blood pressure] <100 or Diastolic [bottom number] <65". 3. Review of R1's medical record revealed a January 2024 medication administration record (MAR). This MAR stated "Atorvastatin 10 mg tablet take 1 PO Q day". There was no documentation of blood pressure readings to determine if medication should be given or held from January 8- January 27, 2024. The MAR documented medication was given daily. 4. During an observation of R1's medications, Atorvastatin 10 mg was observed. 5. In an interview, E1 acknowledged R1's medication was not administered in compliance with the available medication order.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a direct health and safety risk to residents who could access the medication. Findings include: 1. During an environmental inspection with E3, the Compliance Officer observed medications in the pantry area. The pantry door was opened and accessible. The pantry door had a locking device, however was not locked. 2. In an interview, E3 acknowledged medications were stored unlocked.

Based on observation, interview, documentation review, and record review, the manager failed to ensure a personnel record was established and maintained for each employee as required. The deficient practice posed a risk as required information could not be verified for E1. Findings include: 1. When the Compliance Officer arrived at the facility, E1 greeted the compliance officer at the door. E1 identified self as a caregiver and was dressed in black scrubs. 2. In a phone interview, E2 reported E1 started work approximately one week ago and replaced the former employee (E4) who worked the night shift. 3. Review of the facility's policies and procedures revealed a policy titled: "Caregiver, Assistant Caregiver and Volunteer" reviewed and signed by E3 January 1, 2023. This policy stated: "Employment requirements: 1. Full name and date of birth, 2. Current address and phone number. 3. Date of hire and termination date at the end of employment, 4. Work experience and references (at least two work related and two personal references), 5. Proof of freedom of Tuberculosis (not older than 12 months from the hiring date and updated documentation every 12 months thereafter, within 30 calendar days before or after the anniversary date), 6. Will comply with fingerprinting requirements within 3 days of employment or submitting the application to DPS within 20 days of starting date, 7. Caregiver certification as mentioned above, 8. Current First Aid and CPR training, 9. Employee orientation is completed within 48 hours from the employment started day, before providing assisted living services to the residents." 4. Review of the personnel records revealed no record for E1. 5. In an interview, E2 acknowledged a personnel record was not established for E1.