Sunnyside Assisted Living LLC

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated October 31, 2024. This service plan stated the following services were needed: "repositioning q 2-3hrs" "incontinence care" In addition, R1's medical record revealed a document titled "Activities of Daily Living Chart" dated December 2024. This document indicated the following services were to be completed at 8:00 pm, midnight, and 4:00 am: Repositioning Incontinence However, documentation was not available indicating these services were provided December 18, 2024 on the 8pm-5am shift. 2. Review of R2's medical record revealed a current written service plan for personal care services dated July 13, 2024. This service plan stated the following services were needed: "repositioning q 2-3hrs" "incontinence care" In addition, R2's medical record revealed a document titled "Activities of Daily Living Chart" dated December 2024. This document indicated the following services were to be completed at 8:00 pm, midnight, and 4:00 am: Repositioning Incontinence However, documentation was not available indicating these services were provided December 18, 2024 on the 8pm-5am shift. 3. During an interview, E4 stated, "did not have the time to document and then forgot before leaving for the day". 4. During an interview, E1 and E4 acknowledged R1's and R2's medical records did not include documentation for the above listed services were provided.

Based on record review, documentation review, and interview, the manager failed to ensure policies and procedures for medication administration were implemented for the documentation of a resident's refusal to take prescribed medication in the resident's medical record. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed a medication admission record (MAR) dated December 2024. This MAR indicated the resident refused to take the following medications on the following days and times: - Fluticasone-Salmeterol 250-50 MCG 1 puff: 8 AM and 8 PM on December 1 and 2. 8 AM on December 6. - OLOPATADINE left eye 1 gtts: 8 AM on December 1, December 1-9, and December 16-17. 8 PM on December 1, December 3-5, and 15-16. - Predisolone acetate right eye 1 gtts BID: 8 AM on December 1, December 1-9, and December 16-17. 8 PM on December 1, December 3-5, and 15-16. 2. A documentation review of the facility's policies and procedures, revealed a document titled "Medications Including Opioids, Narcotics and Schedule 2, Part III-Medication Regimen, Records and Monitoring" that stated, "If a resident refuses medication it will be noted in the MAR as refused, the Physian or Medical Practioner prescribing the medication is notified and the refusal is documented in the resident's record. If such refusal occurs more than 10% of time, alternate methods will be considered to administer such medication. A doctor's order will be secured to reflect such administration procedures. Resident's Narrative Notes will include the circumstances surrounding the medication refusal. Employees will monitor the resident for any changes in condition as result of missed or refused medication and immediately report to the Manager or Manager Designee when such occur." 3. A review of R1's medical record revealed no documentation of notification to the Physian or Medical Practioner prescribing the medication and no documentation in the Resident's Narrative Notes surrounding the medication refusal. 4. In an interview, E1 acknowledged the medication policies and procedures were not implemented for a resident's refusal to take prescribed medication.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a signed medication order dated November 18, 2024 . This medication order stated "Lisinopril Tab 20 MG take 1 tab by mouth twice daily-on hold". 2. Review of R2's December 2024 medication administration record (MAR) stated "Lisinopril Tab 20 MG take 1 tab by mouth daily for htn-Hold for now". However, the MAR revealed that the medication was administered to R2 December 1st - present. 3. In an interview, E1 acknowledged R2's medication was not administered in compliance with the current 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 two of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated October 31, 2024. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated April 25, 2024 for the following medications: -"Donepezil 10 MG QD PO" -"Fluticasone-Salmeterol 250-50 MCG 1 puff BID PO" -"OLOPATADINE left eye 1 gtts BID" -"Predisolone acetate right eye 1 gtts BID" 3. Review of R1's December 2024 medication administration record (MAR) indicated the following medications were not documented as administered on the following days and times: - Donepezil 10 MG was not documented at 8 PM on December 18th. - Fluticasone-Salmeterol 250-50 MCG was not documented at 8 PM on December 17th and 18th. - OLOPATADINE left eye was not documented at 8 PM on December 2nd and 14th, at 8 AM on December 15th, at 8 PM December 17th, and at 8 AM and 8 PM on December 18th. - Predisolone acetate right eye was not documented at 8 PM on December 2nd, 6th-9th, and 14th, at 8 AM on December 15th, and at 8 AM and 8 PM on December 18th. 4. Review of R2's medical record revealed a current written service plan dated August 18, 2024. This service plan indicated R2 received medication administration. 5. Review of R2's medical record revealed signed medication orders dated October 18, 2024 for the following medications: -"Gabapentin- 100 mg 1 TAB, PO, TID" -"Methacarbamol 500mg 1 TAB, PO, QID" -"Oxycodone 10 mg 1 TAB, PO, TID" -"Senna-time 2 TABS, PO, HS" -"Ventolin HFA Inhalation aresol 90 mcg pe actuation 2 inhalation-orally TID" 6. Review of R2's medical record revealed signed medication orders dated November 18, 2024 for the following medications: -"risperiDONE Tab 0.25 mg sig: 1 tablet orally at bedtime" -"Memantine Tab 5 mg sig: Take 1 tablet by mouth twice daily" -"Atorvastatin Calcium Tab 40mg sig: Take 1 tablet by mouth at bedtime" -"Donepezil Tab 5 mg sig: Take 1 tablet by mouth at bedtime" -"Tamsulosin Cap 0.4 mg sig: Take 1 capsule by mouth at bedtime" -"traZodone Tab 100 mg sig: Take 1 tablet by mouth at bedtime" 7. Review of R2's December 2024 MAR indicated the following medications were not documented as administered on the following days and times: -Gabapentin 100 mg was not documented at 8 PM on December 18th. -Methacarbamol 500 mg was not documented at 8 PM on December 18th. -OXY 10 mg was not documented at 8 PM on December 18th. -Senna-Time Sennoside 8.6 mg was not documented at 8 PM on December 18th. -Ventolin HFA Inhalation Aerosol 90 mcg was not documented at 8 PM on December 18th. -risperiDONE Tab 0.25 mg was not documented at 8 PM on December 18th. -Memantin

Based on observation, documentation review, and interview the manager failed to ensure policies and procedures were implemented for receiving, storing, inventorying, and tracking medications. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed a plastic sandwich bag within the medication storage container of R2. The plastic sandwich bag contained approximately 22 circular orange pills and approximately 13 small circular pink pills. 2. Review of the facility's policies and procedures titled, "General Medications Prescription and non Prescription" stated, "2. Medications must be obtained from reliable legal sources such as a pharmacy or Primary Care Provider, be in the original labeled container with legible instructions printed on the label..." 3. In an interview, E1 reported the medications were in the bag when R2's family moved R2 into the facility. 4. In an interview, E1 reported E1 "thinks" E1 knew what the medications were in the plastic sandwich bag. However E1 was not certain of what the pills were and did not provide a name to the medications in the plastic bag. E1 acknowledged the policies and procedures were not implemented for receiving, storing, inventorying, and tracking medications.