The Peaks, a Senior Living Community

Based on record review and interview, the manager failed to ensure that assistance in the self-administration of medication provided to a resident was in compliance with an order. Findings include: 1. The record for R1 contained a physician's order for Eliquis 5mg tab, take 1 tab by mouth, twice daily. 2. Record review further indicated that the medication was to be discontinued on December 7, 2024. 3. The medication administration record (MAR) for R1 indicated that the medication had continued to be administered until December 10, 2024 at 8am. 4. During an interview, E1 stated, "There was a miscommunication. We discontinued the medication as soon as we realized the error."

Based on record review and interview, the manager failed to ensure that a sample resident record contained a service plan that included the level of service the resident was expected to receive. Findings include: 1. The record for R3 contained a service plan dated November 4, 2023 that did not include the level of service the resident received. 2. During an interview, E1 acknowledged the resident record did not contain the required information.

Based on record review and interview, the manager failed to ensure that a sample resident record contained documentation of a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services. Findings include: 1. The record for R3 contained service plan reviews reflecting the following dates of completion: November 4, 2023 and August 28, 2024. 2. During an interview, E1 acknowledged the service plan documentation did not reflect that the plans were reviewed and updated at least once every six months.

Based on record review and interview the manager failed to ensure for a sample service plan, the service plan that when updated, was signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan. Findings include: 1. Review of the record for R3 (receiving medication administration), revealed that the service plan dated August 28, 2024 was not signed and dated by the resident or their representative, the manager or the nurse or medical practitioner who reviewed the service plan. 2. During an interview E1 acknowledged the required documentation was not available for review.