Rosarian Assisted Living

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two residents reviewed. The deficient practice posed a health and safety risk if the facility was unable to meet the needs of the resident. Findings include: 1. A review of R2's medical record revealed no documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2's acceptance date, this documentation was required. 2. During an interview, E2 acknowledged R2 did not provide documentation signed by a medical practitioner or a registered nurse stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 3. Technical assistance was provided on this Rule during the inspection conducted on August 7, 2023.

Based on record review, observation, and interview, the manager failed to ensure medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a health risk to the resident. Findings include: 1. A review of R2's medical record revealed a current written service plan dated August 4, 2024. This service plan indicated R2 received medication administration. 2. A review of R2's medical record revealed a signed medication order dated January 22, 2025. This medication order stated, “Docusate sodium 100mg tablet take one tablet every other day”. 3. A review of R2's medical record revealed a June 2025 medication administration record (MAR). This MAR stated, “Colace (Docusate sod) 100mg" however, indicated Colace was not administered June 1st to present. 4. During an observation of R2's medications, “Colace (Docusate sod) 100mg" was available. 5. During an interview, E2 reported that E2 did not administer "Colace (Docusate sod) 100mg" in compliance with the signed medication order.

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. The deficient practice posed a health and safety risk to the resident if a caregiver did not know if a medication was administered. Findings include: 1. A review of R1's service plan dated January 12, 2025, revealed R1 received medication administration. 2. A review of R1’s medical record revealed a signed doctor's order, dated January 10, 2025. This order indicated two tablets of Gabapentin 100mg were to be administered every eight hours. 3. A review of R1’s June 2025 medication administration record (MAR) revealed Gabapentin 100 mg two tablets were administered twice a day at 8 am and 5 pm. 4. The Compliance Officers observed R1’s medication organizer, which revealed three tablets of Gabapentin 100mg were placed in the morning and night slots. 5. In an interview, E2 reported E2 placed three tablets of Gabapentin 100mg in the morning and night slots. E2 reported when it was time to administer the third dosage E2 took the extra Gabapentin 100mg out of the medication organizer and administered it for the third time that day. 6. In an interview, E2 and E3 acknowledged medication administered to R1 was not accurately documented in the resident's medical record.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention" (dated in November 2022). However, the program did not include initial training and continued competency training requirement. 2. A review of E2's personnel record revealed documentation of fall prevention and fall recovery training completed in February 2022. However, documentation E2 completed continued competency training was not available. 3. A review of E3's personnel record revealed documentation of fall prevention training. However, documentation E3 completed fall recovery training was not available. 4. In an interview, E1 acknowledged the facility's fall prevention and fall recovery training program did not include the initial training and continued competency training requirement, E2 did not complete a continued competency training, and E3 did not complete a fall recovery training.

Based on documentation review, record review, and interview, the health care institution failed to ensure an individual authorized by policies and procedures to administer an opioid, documented in the resident's medical record the identification of the resident's need for the opioid and the effect of the opioid administered, for one of two residents sampled. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Policy and Procedures of Opioid" (dated in November 2022). The policy and procedure stated, "The Caregiver, RN, or Manager administering the opioid shall: I. Identify the resident's pain before the opioid is administered II. Monitor the resident's response to the opioid, and III. Document in the resident's MAR a. The pain level before the opioid was administered and b. The effect of the opioid administered." 2. A review of R2's medical record revealed a medication administration record (MAR) from July 30, 2023 -present. The MAR stated "Hydrocodone Acetaminophen 5 -325, take two tablets by mouth three times daily" and indicated two tabs were administered at 8:00 AM, 12:00 PM, and 5:00 PM on July 30, 2023 to August 6, 2023. However, documentation was not available showing the identification of R2's need for the opioid and the effect of the opioid administered. 3. A review of R2's medical record revealed documentation stating R2 had an end of life condition or an active malignancy was not available for review. 4. In an interview, E1 acknowledged the caregiver did not document in R2's medical record the identification of R2's need for the opioid and the effect of the opioid administered.