Oasis Care Homes II

Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. Findings include: 1 . A review of facility documentation revealed a disaster plan annual review conducted on January 2. 2024. However, documentation of a disaster plan annual review conducted after January 2, 2024 was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E4 and no additional information was provided.

Based on documentation review, record review, observation, and interview, for an assisted living facility that provides medication administration, the manager failed to ensure that a medication administered to a resident was documented in the resident ' s medical record for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Medication Administration Records - MAR." The policy stated, "Each time a staff member administers medication, he or she must immediately initial the appropriate space or document electronically each dose administered to the resident. Caregiver must NEVER: - Wait until the end of a medication pass of all residents to sign the Med sheets. - Pre document (sign before giving) any medication by any method. Caregiver must: - Take caution that each section of the Medication Administration Record(s) is appropriately completed during each medication administration pass." 2. A review of R2's medical record revealed a medication order dated October 24, 2024, which included the following medications: - Vitamin B12 1,000 microgram (mcg) by mouth (PO) once a day (QD); - Docusate Sodium 100 milligrams (mg) PO twice a day (BID); - Seroquel 100 mg PO QD; - Baclofen 10 mg PO QD; - Topamax 200 mg PO BID; - Lopid 600 mg PO BID; - Seroquel 400 mg PO every afternoon/evening (QPM); - Levetiracetam 500 mg tablet (tab) PO BID; - Ferrous sulfate 325 mg Take one tab PO 3 X a week (Mon, Wed, Fri); - Vitamin D3 50 MCG (2000 unit capsule) PO QD; - Omeprazole 20 mg PO QD; - Senna 8.6 mg PO QPM as needed (PRN); - Lorazepam 0.5 mg PO QD PRN; - Ibuprofen 400 mg PO BID PRN; - Clotrimazole Cream 1% Apply on feet BID PRN; - Melatonin 10 mg PO once a day at bedtime (QHS) PRN; - Risperidone 0.5 mg tabs PO QD PRN; and - Guaifenesin-DM 100/5 milliliters (ml) syrup 10 ml PO every six hours (Q6) PRN. 3. A signed "Physician's Note" dated October 24, 2024 indicated an order to add Citalopram 10 mg PO every morning (QAM). 4. A review of R2's medical record revealed a medication administration record (MAR) for the month of November 2024. The MAR revealed the following medications were not documented as being administered on the following dates/times: - Topamax 200 mg PO BID: November 12, 2024 at 8:00 AM; - Lopid 600 mg PO BID: November 12, 2024 at 8:00 AM; and - Citalopram Hydrobromide 10 mg PO QAM: November 12, 2024 at 8:00 AM. 5. The Compliance Officers requested to see R2's mediset, at which point it was observed that the Topamax, Lopid, and Citalopram Hydrobromide had been administered on November 12, 2024. 6. In an interview, E3 stated E3 had administered the medication but failed to document it in the MAR. E1 acknowledged E1 failed to ensure that a medication administered to a resident was documented in the resident ' s medical record.

Based on record review, documentation review, and interview, the manager failed to ensure proper notifications of the incident and a report of the incident were documented for a resident who had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of R1's medical record revealed an incident report from August 20, 2022, which included all of the details required. However, there was documentation on a Medication Administration Record (MAR) of R1 also being in the hospital from August 20-28, 2023, in which no documentation of the incident or notification to the manager, RN, or resident's legal representative was available for review. 2. A review of facility documentation revealed a policy titled "Medical Emergencies/DNR Status." The policy states, "5. When a resident experiences a medical emergency...7. Staff should notify the Manager and RN of the emergency as soon as possible (e.g., after the resident's emergency medical needs have been addressed). The Manager or RN should then inform the resident's legal representative as appropriate of his/her status, and document the notification in the resident's Service Notes." 3. In an interview, E1 reported R1 did have a medical emergency on August 20, 2023, which resulted in EMS response and R2 being taken to the hospital; however, there was no incident report available for review regarding the incident. E1 acknowledged E1 failed to ensure proper notifications of the incident and a report of the incident were documented.