Sunrise Assisted Living Home II

Based on record review and interview, the manager failed to ensure that when the assisted living home contacted an emergency responder on behalf of a resident, provided the emergency responder a written document that included the name, address and telephone number of the resident's current pharmacy and a copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. Findings include: 1. A review of R1's emergency medical services documentation did not include a phone number to R1's pharmacy and a copy of R1's health insurance portability and accountability act release document. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that written notification was provided to the Department of a resident’s self-injury within two working days after the resident inflicted a self-injury that required immediate intervention by an emergency services provider. Findings include: 1. A review of Department documentation revealed notification was made to the Department regarding R1's self-inflicted injury on August 27, 2025. The incident required emergency medical services. 2. A review of R1's incident report revealed the date of the related incident occurred on August 19, 2025. However, notification to the Department was not made within two working days as required. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, a caregiver or an assistant caregiver immediately notified the resident’s emergency contact and primary care provider. The deficient practice posed a health and safety risk. Findings include: 1. R9-10-101.111 stated "Immediate" means without delay. 2. A review of R1's incident report, dated August 19, 2025, revealed that there was no documentation of the time of contact for the resident's primary care doctor and emergency contact. 3. In an interview, E1 reported they contacted R1's representative and primary care doctor immediately after the incident. However, documentation of this contact was not available for review. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that written notification was provided to the Department of a resident’s self-injury within two working days after the resident inflicted a self-injury that required immediate intervention by an emergency services provider. Findings include: 1. A review of R1's medical record contained an incident report dated August 19, 2025, that revealed a self-injury that required emergency medical services. However, notification to the Department was not made within two working days as required. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1. During the environmental inspection with E2 and E3, the Compliance Officers observed a locked gate in the backyard which led to the front yard. However, the pathway to the gate had trash cans, a mattress and various other items which blocked access to the gate for egress. 2. During an interview, E2 and E3 acknowledged that the pathway from the backyard to the front of the facility was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents reviewed. The deficient practice posed a TB exposure risk to residents. Findings include: 1. Review of R1's medical record revealed a chest x-ray indicating no signs of active tuberculosis. However, documentation was not available indicating R1 had a previous positive TB skin test or blood test and without such documentation a chest x-ray is not acceptable as documentation of freedom from TB. No additional documentation of freedom from infectious TB was available for review. Based on R1's acceptance date, this documentation was required. 2. In an interview, E1 acknowledged R1 did not provide current documentation of freedom from infectious TB.

Based on documentation review, observation, and interview, the manager failed to ensure there was 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, that provided access to an outside area 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. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility with E2, the Compliance Officer observed an exit door on the north side of the facility did not have a device that alerted employees to the egress of a resident to the outside area. 3. In an interview, E1 and E2 acknowledged there was a means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.

Based on record review, observation, 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 current written service plan dated July 8, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated June 30, 2023. This medication order stated "Pantoprazole 40mg/1 tab PO QD". 3. Review of R2's medical record revealed a July 2023 medication administration record (MAR). This MAR stated the following: "Pantoprazole 40mg 1 tab PO QD" and indicated one tab was administered at 7am July 1st - present. 4. During an observation of R2's medications, Pantoprazole 20mg was observed and one tab was observed prefilled in the "Morn" slot of R2's medication organizer. 5. In an interview, E2 reported the medication was administered per the medication organizer and E1 and E2 acknowledged R2's medication was not administered in compliance with the available medication order.