Surprise Comfort Home Care

Based on record review and interview, the manager failed to ensure that one of two sampled residents' service plan was developed with assistance and reviewed by the resident or resident’s representative and the manager. 1. A review of R2’s medical record revealed a service plan dated February 26, 2025, did not reflect that R2’s service plan was developed or reviewed by R2 or R2’s representative or the manager. 2. In an interview, E3 reviewed and acknowledged that R2’s service plan did not reflect R2’s service plan was developed with assistance and reviewed by R2 or R2’s representative or the manager.

Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer opioids identified the resident's need for an opioid before administering the opioid and monitored the resident's response to the opioid for residents who did not have an active malignancy or an end-of-life condition. Findings include: 1. Review of the facility’s policies and procedures revealed a policy titled, “ Part II- Doctor Orders, Provisions, and Handling of Narcotics, Opioids, Schedule 2 Medications, Controlled Substances,” Which stated, “9. Documentation in the NAR will include at minimum: a. Reason for the need of administration/ b. Evaluation of the resident need for this administration/ c. The amount of medication given and number of medication left in the container./ d. How effective the dose of the medication administered at half an hour, two hours and four hours after administration,” 2. Review of R2’s medical record revealed a medication order dated March 12, 2025 for “Tramadol 50 mg Take .5 (half) tab by mouth every 6 hours as needed for pain.” 3. Review of R2's medical record revealed a medication administration record (MAR) dated April 2025. The April 2025 MAR revealed, “Tramadol 50 MG TAB take ½ tab PO Q 8 hr.” The April 2025 MAR revealed Tramadol 50 MG was administered once a day, April 1, 2025 to present. 4. Review of R2’s Narcotic Administration Record (NAR) for April 2025 revealed documentation of the pain level, doses given, and doses left (which was marked as Pain). However, there was no documentation for monitoring the resident response as “30-40 min after administration”, “2 hours after administration”, and “4 hours after administration” per the policy. 5. In an interview, E3 reported R2 did not have an active malignancy or an end-of-life condition. 6. In an interview, E3 acknowledged R2’s response to the opioid was not documented per the policy.

Based on observation, record review, and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed R1 in a wheelchair with a seatbelt that secured R1 to the chair. 2. Review of R1's medical record revealed a document titled "Resident's Services (90 day assessment)" signed and dated by E1 February 23, 2024. This document stated "Yes - Resident requires restraints - When in wheel chair (seat belt) when toileting (seat belt) for safety". 3. In an interview, E2 reported R1 could not remove the seatbelt. E2 reported the seatbelt was used to prevent R1 from falling out of the wheelchair. 4. In a telephone interview, E1 reported the seatbelt was used at R1's family's request and acknowledged the seatbelt secured R1 to the wheelchair and could cause R1 to suffer physical injury.