Integrity Adult Care Home.

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a health and safety risk to the resident if a caregiver did not know if a medication was administered. Findings include: 1. Review of R2’s medical record revealed R2’s a current service plan dated December 23, 2024. This service plan revealed R2 received medication administration. 2. Review of R2’s medical record revealed a document titled, “Verbal Order Form” which was signed by a physician on May 13, 2025, and signed again on another verbal order form dated May 27, 2025. These orders stated, “Metoprolol 25 MG 1 TAB PO BID”. 3. Review of R2’s medical record revealed a medication administration record (MAR) for the month of May 2025. This MAR did not include documentation Metoprolol 25 MG was administered. 4. Review of R2’s medical record revealed a verbal order form that was received by the facility on May 22, 2025 and signed May 27, 2025. This order stated “Ceptaroxine 500 MG 1 TAB PO BID for 10 days than D/C”. 5. Review of R2’s medical record revealed a MAR for the month of May 2025. This MAR did not include documentation Ceptaroxine 500 MG was administered. 6. In an interview, E2 reported R2 received Metoprolol 25 MG and Ceptaroxine 500 MG, however, E2 did not document the medication administration in May 2025’s MAR. 7. In an interview, E2 acknowledged R2’s medical record did not include documentation that the medications were administered as ordered.”

“Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for two of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1’s medical record revealed an incident reported dated November 14, 2023 and another incident report dated December 27, 2023. The November 2023 incident report stated, “... to be taking to the hospital… the HP advice to sent [R1] because of history of C-Dif.” The December 2023 incident report stated, “Called the H.P and decided to send [R1] to ER”. 2. Review of R1’s medical record revealed the incident reports dated November 14, 2023 and December 24, 2023 did not document any action taken to prevent the accident, emergency, or injury from occurring in the future. 3. Review of R2’s medical record revealed two incident reports dated May 5, 2025 and May 27, 2025. The incident report dated May 5, 2025 stated, “Called [R2’s family member] and decide to send [R2] to ER.” The incident report dated May 27, 2025 stated, “... call [R2’s family member] and advise to send [R2] to ER.” 4. Review of R2’s medical record revealed the incident reports dated May 5, 2025 and May 27, 2025 did not document any action taken to prevent the accident, emergency, or injury from occurring in the future. 5. In an interview, E2 acknowledged R1’s and R2’s medical records did not include documentation of any action to prevent the incidents from occurring in the future.”

“Based on observation, documentation review, and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed a lock on the kitchen sink cabinet, however, the lock did not work as the cabinet door was able to be opened. The following was found under the kitchen sink cabinet: A spray canister of Weiman Stainless Steel Cleaner & Polish A Spray bottle of Windex A Spray Canister of Raid Ant & Roach Killer A bottle of Member’s Mark Commercial Oven, Grill & Fryer Cleaner A bottle of Ajax with bleach 2. The Compliance Officer observed a spray bottle of Odo Ban in a bathroom. 3. The Compliance Officer observed an open door that led into the laundry room. The laundry room door had a lock, however, the door was left open. Located inside the laundry room was a black cabinet that had the key inside the keyhole. The following was found inside of the black cabinet: A spray bottle of Shout Advanced Action Gel A bottle of Lysol Power Clinging Gel Two spray bottles of Windex Two canisters of Hot Shot insect killer A bottle of Pine-Sol 4. Review of the facility’s policies and procedures revealed a policy titled, “Environmental and Physical Plant Safety” which stated, “12. Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dining areas and medication and are inaccessible to residents.” 5. In an interview, E2 acknowledged toxic materials were stored unlocked.”