Orange Grove Senior Care LLC

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility 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. A review of Department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officer observed an exit door in the north hallway had a door alarm, however, however, the alarm was not functioning. 3. In an interview, E1 acknowledged there was a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility which did not control or alert employees of the egress of a resident from the facility.

Based on 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 two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, updated April 11, 2024, for directed care services, including medication administration. 2. A review of R1's medical record revealed an order, dated February 19, 2024 , for "Metoprolol Tartrate 25 MG Oral Tablet 0.5 tab po bid, hold for systolic bp< 110 or pulse < 60." 3. A review of R1's medical record revealed a medication administration record (MAR) dated May 2024. The MAR indicated, "Metoprolol 25 mg 1 tab, give 1/2 tab P.O. BID hold for BP < 110 or HR <60," had been administered to R1 at 8 AM and 5 PM on each day between May 1, 2024 and the day of the on-site inspection, May 20, 2024. The MAR indicated the medication had not been held on any day in May 2024. 4. A review of R1's medical record revealed a Blood Pressure Log dated May 2024. The log documented R1's blood pressure at 8 AM and at 9 AM on each day in May 2024, however, the log did not include documentation of R1's blood pressure at 5 PM on any day on May 2024. Additionally, the log included the following entries indicating Metoprolol should have been held or some other action should have been taken: - "5/2, 8 AM, 97/69/106"; - "5/4, 8 AM, 105/67 p69"; - "5/8, 8 AM, 108/73/94"; - "5/13, 8 AM, 48/71/93"; - "5/15, 8 AM, 93/61/94"; - "5/17, 8 AM, 109/72/88"; - "4/18, 8 AM, 129/106 P58"; and - "4/20, 8 AM, 94/74/106." 5. In an interview, E1 acknowledged R1's partial vitals record and MAR indicated a medication had not been administered to R1 in compliance with a medication order.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for two of four residents sampled. Findings include: 1. A review of R2's medical record revealed a documented residency agreement, signed by the resident's representative. However, the residency agreement had not been signed or dated by the manager. 2. A review of R4's medical record revealed a documented residency agreement, signed by the resident's representative. However, the residency agreement had not been signed or dated by the manager. 3. In an interview, E1 acknowledged the manager had not signed and dated the residency agreements provided for R2 and R4.

Based on documentation review, record review and interview, the manager failed to ensure a written service plan was completed no later than three working days after the resident's date of acceptance, for one resident sampled receiving respite care services. Findings include: 1. A review of the facility's policies and procedures, last reviewed in January 2023, revealed a policy titled, "Respite Care." This policy stated, "If a resident receives respite care services, the manager or their designee will ensure that a written service plan is:...completed no later than three working days after the resident's date of acceptance." 2. A review of R3's medical record revealed a residency agreement. The residency agreement stated R3 would be admitted for a fixed ten day period and would not establish month to month tenancy at the facility. 3. A review of R3's medical record revealed R3's written service plan was not available for review. Based on R3's date of acceptance and discharge, a service plan was required. 4. In an interview, E1 reported R3 had received respite care services. 5. In an interview, E1 acknowledged a service plan had not been completed within three working days after a resident was admitted for respite services.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of four residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan dated April 2, 2023, for directed care services. The service plan included provision of the following services: - "Shower, Complete Assist, M, Th. 1 bed bath & 1 shower a week. Hospice does bed bath and showers"; - "Dressing, Complete Assist, done morning and bedtime"; - "Grooming, Morning, Complete Assist"; - "Oral Care, Complete Assist, Morning & bedtime"; - "Toileting, Complete Assist, Clean, Inc: Bladder/Bowel"; - "Basic Skin Care..Use lotion all over body every day, after every shower, and PRN"; - "Food Intake: Monitor food intake at each meal. Help feed [R3] can't always handle the fork..."; - "Fall Risk: Encourage daily exercise and movement."; - "Skin breakdown risk:.. Monitor bony prominence's daily for redness."; and - "Sundowning, Keep the home brightly lit in afternoon, encourage daily exercise in mornings, allow for short morning nap, lower external stimuli in afternoon." 2. A review of R2's medical record revealed a two page document titled, "Activities of Daily living record," dated May 2023. The first page documented services provided to R2 during the month of May 2023. However, the first page had been left blank from May 2, 2023, through May 5, 2023, during which time no services were documented to have been provided to R2. The second page included sections for caregivers to sign on each shift indicating they had followed the service plan for R2. However, the second page had been left blank from two shifts on May 3, 2023, through on shift on May 6, 2023. 3. A review of R2's medical record revealed R2 had not been out of the facility in May 2023 and had received medications at the facility on every day in May 2023 including May 2 through May 6, 2023. 4. In an interview, E1 acknowledged documentation of services provided to R2 between May 2, 2023, and May 6, 2023 had not been provided for review.

Based on documentation review, record review and interview, the manager failed to ensure a resident or the resident's representative was informed of the rates and charges for services before the services were initiated, for three of four residents sampled. Findings include: 1. A review of the facility's policies and procedures, last reviewed in January 2023, revealed a policy titled, "Resident Acceptance and Resident Rights." This policy stated, "A resident of the resident's representative...is informed of: i. The rates and charges for services before the services are initiated." 2. A review of R1's medical record revealed a residency agreement consisting of six pages, signed by the resident's representative and the manager's designee on the date of acceptance. The residency agreement stated, "This facility requires a non-refundable $_________ administrative fee at the time of admission." However, this section had been left blank. 3. A review of R2's medical record revealed a residency agreement consisting of six pages, signed by the resident's representative on the date of acceptance. The residency agreement had not been signed by the manager. The residency agreement stated, "This facility requires a non-refundable $_N/A_ administrative fee at the time of admission." 4. A review of R4's medical record revealed a residency agreement consisting of six pages, signed by the resident's representative on the date of acceptance. The residency agreement had not been signed by the manager. The residency agreement stated, "This facility requires a non-refundable $_________ administrative fee at the time of admission." However, this section had been left blank. 5. In an interview with E1 and E2, E2 reported there is a non-refundable administrative fee paid directly to E2 for all residents and the amount should be on the residency agreement. E1 acknowledged the residency agreements for R1, R2, and R4 did not document notification of the facility's rates and charges to the residents or their representatives before services were initiated.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a clear plastic bag of medications in a drawer under the kitchen counter. The drawer did not have a lock. The bag contained loose pills as well as, "Alka-Seltzer Boost," "Paracetamol," and "Estriol cream." 2. In an interview, E1 reported the medications belonged to an employee. E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on documentation review, record review, and interview, the manager failed to ensure an individual who administered an opioid in treating a patient documented in the patient's medical record an identification of the patient's need for the opioid before the opioid was administered and the effect of the opioid administered, for one of one residents sampled who were administered an opioid. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Opioid Prescribing and Treatment", dated May 18, 2018, which stated, "2. A numeric system, often using the numbers one through ten, can be used to measure pain or need of an opioid medication. The caregiver will ask the resident to rate the pain level before administering the medication. After the medication has taken effect, the caregiver will ask again. Both responses will be documented in the Resident Medical Record..." 2. A review of R1's medical record revealed a service plan, dated January 10, 2023, for personal care services including medication administration. 3. A review of R1's medical record revealed a signed list of medication orders dated January 5, 2023. The list included an order for, "Tramadol 50 mg tab 1 PO QID #120 5 RF." 4. A review of R1's medical record revealed a Medication Administration Record (MAR) dated May 2023. The MAR indicated R1 had received Tramadol at 8 a.m., 12 p.m., 5 p.m. and 8 p.m. on each day between May 1, 2023, and May 15, 2023. However, the MAR did not include documentation of the numeric pain rating reported by R1 before and after each dose of Tramadol administered, as required by the facility's policy and procedure. Documentation of R1's need for the opioid before the opioid was administered and documentation of the effect of the opioid was not available for review. 5. In an interview, E1 acknowledged the caregiver administering opioids to R1 had not documented the identification of the resident's need for the opioid or the effect of the opioid in the manner prescribed by the facility's policies and procedures.