Sun Quest Manor

Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. The Compliance Officers observed resident medical records on a counter in the kitchen and in an unlocked sideboard in the dining room. 2. In an interview, E3 acknowledged the medical records were not protected from loss, damage, or unauthorized use. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on October 6, 2023.

Based on documentation review, interview, and record review, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of two sampled residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed an incident report which revealed R1 was sent to the hospital at approximately 12:30 PM on September 8, 2024. 2. In an interview, E3 reported R1 returned to the facility from the hospital at approximately 1:30 PM on September 9, 2024. 3. A review of R1's medical record revealed a current service plan which revealed R1 was to receive medication administration. The review further revealed a medication administration record (MAR) dated September 2024. The MAR revealed R1 received Seroquel at 5:00 PM on September 8, 2024. However, R1 was in the hospital at this time. The MAR further revealed facility personnel documented other medications as administered at 8:00 PM on September 8, 2024, and at 8:00 AM on September 9, 2024, then later crossed out these instances of administration sometime before the Compliance Officer reviewed the MAR. 4. In an interview, E3 reported R1 did not receive medication administration at 5:00 PM and 8:00 PM on September 8, 2024, and at 8:00 AM on September 9, 2024. E3 stated the documentation "was an oversight."

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. A review of facility documentation revealed an incident report which indicated R9 had an accident, emergency, or injury at 3:00 AM on June 4, 2024, that resulted in R9 needing medical services. However, the incident report revealed R9's emergency contact was not notified until 7:30 AM and R9's primary care provider was not notified until 8:05 AM. The review further revealed an incident report which indicated R1 had an accident, emergency, or injury at 12:15 PM on September 8, 2024, that resulted in R1 needing medical services. However, the incident report revealed R1's primary care provider was not notified until September 9, 2024, at 9:40 AM. 2. In an interview, E3 reported E3 thought facility personnel had 24 hours to notify a resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. E3 acknowledged facility personnel did not notify R9's emergency contact and primary care provider and R1's primary care provider immediately.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort 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 egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed two sliding glass doors leading from the kitchen to the outdoors. The Compliance Officer observed the doors did not have controls or alerts installed. 3. In an interview, E3 reported the alerts must have fallen off.

Based on documentation review, interview, and record review, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed an incident report which revealed R1 was sent to the hospital at approximately 12:30 PM on September 8, 2024. 2. In an interview, E3 reported R1 returned to the facility from the hospital at approximately 1:30 PM on September 9, 2024. 3. A review of R1's medical record revealed an "ACTIVITIES OF DAILY LIVING FLOWSHEET" dated September 2024 which indicated R1 received breakfast at the facility on the morning of September 9, 2024. However, R1 was in the hospital at this time. 4. In an interview, E3 confirmed R1 did not receive breakfast at the facility on the morning of September 9, 2024. 5. A review of R1's and R2's medical records revealed current service plans which indicated a caregiver would "CHECK [R1's and R2's] NAILS DAILY AND CLEAN PRN." However, the review further revealed "ACTIVITIES OF DAILY LIVING FLOWSHEET[S]" for R1 and R2 dated September 2024 which included no documentation of caregivers having provided this service. 6. In an interview, E3 reported caregivers checked R1's and R2's nails daily and cleaned R1's and R2's nails as needed. However, E3 reported the flowsheets did not contain a place to document this service. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on October 6, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Assistance in self-administration and medication administration" which stated, "All resident medications must be secured in a locked storage area." 2. The Compliance Officer observed an unlocked box in the refrigerator in the kitchen. Inside the box, the Compliance Officer observed a variety of medications. 3. In an interview, E3 reported a caregiver forgot to lock the medication box.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver or assistant caregiver documented the individuals notified by the caregiver or assistant caregiver for an accident, emergency, or injury resulting in a resident needing medical services. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "REPORT OF UNUSUAL OCCURENCE" [sic]. The policy and procedure stated, "In the event of a Resident accident, incident or injury that results in Resident requiring medical services, the Report of Unusual Occurrence will be filled out completely to document the incident and address corrective actions to prevent future reoccurrence." 2. A review of R2's medical record revealed a document titled "REPORT OF UNUSUAL OCCURRENCE" dated June 10, 2023. The document stated R2 "WENT TO HOSPITAL." The "PERSON'S [sic] NOTIFIED" section included a field to check off whether the "Primary Care Provider" was notified, the "Date Notified," and the "Time Notified." However, each of the three fields were blank. 3. In an interview, E2 reported R2's primary care provider was notified. However, E2 reported the notification was not documented.