Silver Bells Adult Care Home

Based on record review and interview, for one of three resident records reviewed, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible. The deficient practice posed a risk if documentation in a resident's medical record was altered and illegible. Findings include: 1. In record review, E3's medication administration record, dated December 2023, included illegible ink markings for Trazadone medication 50mg, documentation entered on dates December 9-11, and for Trazadone medication 25, mg, documentation entered on December 1 - 13, 4pm. 2. During an interview, E1 reported there was a mix up in the documentation of the Trazadone medication administration, and acknowledged the original entries were written over with a pen, and made illegible.

Based on record review, observation, and interview, for one of three residents reviewed, who received medication administration, the manager failed to ensure a resident's medical record included the dosage of a medication administered to a resident. The deficient practice posed a risk if documentation of a medication administered to a resident did not include the dosage administered to the resident, ensuring the resident was administered the correct dosage per the resident's medication orders. Findings include: 1. In record review, R2's medication administration record (MAR), dated December 2023, included documentation R2 received Mirtazapine, daily at 8pm, Haldol twice daily, Triamcinolone twice daily, Citalopram daily, Omeprazole daily, Furosemide daily, and Hydrocodone twice daily, as ordered. However, the MAR did not include documentation of the dosage of the medications that were administered to R2. 2. In observation, R2's medications were observed on site. 3. During an interview, E1 and E2 acknowledged the resident's MAR did not include documentation of the dosage of the medications administered to R2.

Based on observation and interview, the manager failed to ensure a bathroom which was accessible from a common area contained paper towels in a dispenser or a mechanical hand dryer. The deficient practice posed a potential infection control risk. Findings include: 1. During an environmental inspection, the compliance officer observed two bathrooms accessible from a common area had paper towel dispensers; however, the dispensers were empty, and did not contain paper towels. The bathrooms were observed to have hand towels hanging in the bathroom. 2. During an interview, E1 and E2 acknowledged the bathrooms did not contain paper towels in a dispenser or a mechanical hand dryer.

Based on observation, record review, documentation review, and interview, for one of three residents reviewed, who received opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record; an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident's health and safety if the facility did not appropriately assess and monitor opioid administration for a resident. Findings include: 1. In observation, R2 had Hydrocodone/APAP Norco medication (a schedule II controlled substance), on site and stored by the facility. The Hydrocodone/APAP medication bottle indicated 30 tablets of the medication was dispensed on December 12, 2023. The Compliance Officer observed 27 pills remained in the bottle. 2. In record review, R2's medical record (received directed care and medication administration services) included a medication order for Hydrocodone/APAP Norco; take one tab po 2 x day. R2's medication administration record dated December 2023, indicated R2 received the medication daily December 6 - 14, 2023. R2's record did not include documentation of an identification of the need for the medication, and the monitoring of the effect of the opioid administered. 3. In documentation review, a facility policy, titled, Opioid Prescribing & Treatment, documented, "...document when and how much opioid medication was administered in order to keep track of how much is left... Identify the resident's pain before the ... opioid is administered... Monitor the resident's response to the opioid... " 4. During an interview, E1 and E2 reported the Hydrocodone medication was administered to R2 for pain, and acknowledged the caregivers did not document an identification of the need for the opioid medication, and the monitoring of the effect of the medication administered..

Based on observation, record review, documentation review, and interview, for one of three residents reviewed, who received a controlled substance, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility. Findings include: 1. In observation, R2 had Hydrocodone/APAP Norco medication (a schedule II controlled substance) and Lorazepam Intensol oral concentrate (a Schedule IV controlled substance), on site and stored by the facility. The Hydrocodone/APAP medication bottle indicated 30 tablets of the medication was dispensed on December 12, 2023. The Compliance Officer observed 27 pills remained in the bottle. The Lorazepam medication bottle revealed 6 ml of medication remained in the bottle. 2. In record review, R2's medical record (received directed care and medication administration services) included a medication order for Hydrocodone/APAP Norco; take one tab po 2 x day, and Lorazepam, 2mg, take 0.25ml-0.5ml under the tongue QHS. R2's medication administration record dated December 2023, indicated R2 received the medications, as ordered. R2's record did not include an inventory of the medications. 3. In documentation review, a facility policy, titled "Medications..." documented, "... As soon as possible, medication will be inventoried and placed in the resident's labeled medication bin... Narcotics will be controlled and stored by the facility... Daily narcotic administration will be recorded on each resident MR. As needed narcotic administration will be recorded on the Narcotic Administration Record separate for each resident to ensure proper inventory..." 4. During an interview, E1 and E2 acknowledged an inventory of the resident's controlled substances was not maintained.

Based on observation, record review, and interview, for one of three caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services. The deficient practice posed a health and safety risk to residents, if a caregiver did not have the documented skills and knowledge to provide care and services for a resident. Findings include: 1. In observation, E4 was observed working as a caregiver during the inspection, and was the only certified caregiver on site. 2. In record review, E4's personnel record (hired on November 19, 2023, did not include documentation the caregiver's skills and knowledge were verified and documented before the caregiver provided services to the residents. 3. During an interview, E1 and E2 reported E4 worked at the facility and was a live in caregiver. E1 and E2 acknowledged E4's personnel record did not include documentation E4's skills and knowledge were verified and documented, before providing care and services for residents.

Based on observation and interview, the manager failed to ensure food stored by the facility was free from spoilage, and was safe for human consumption. Findings include: 1. During an environmental inspection, the surveyor observed expired dry foods stored by the facility. The foods included: four packages of Ramen noodles, dated February 8, 2023, Pudding mix, dated November 21, 2021, Gravy mixes, dated July 19, 2021, September 31, 2021, and January 10, 2022. 2. During an interview, E1 acknowledged the facility stored expired food on the premises.

Based on documentation review, record review, observation, and interview, for one of five employees reviewed, the manager failed to establish and document a job description for an employee. The deficient practice posed a risk to the health and safety of residents, if the facility did not establish a job description which covered the duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers. Findings include: 1. In observation, the Compliance Officer observed E5 was on site, and worked at the facility during the compliance inspection. 2. In record review, E5's personnel record (hired on November 21, 2023) included a job description, titled "Caregiver Job Description." E5's personnel record did not include documentation E5 completed a caregiver training program, or had a caregiver certificate. 3. During an interview, E1 and E2 reported E5 was a cook and a housekeeper, and was not a caregiver. 4. In documentation review, a review of the facility's policies and procedures revealed the facility did not have a job description for E5's position as a cook and housekeeper. 5. During an interview, E1 and E2 acknowledged the facility did not establish and document policies and procedures covering a job description for a cook and a housekeeper, who was working at the facility, as required pursuant to R9-10-803.C.1.a.