Inge's Uniquely Warm Assisted Living - II.

“Based on documentation review and interview, when Adult Protective Services came out to the home on or about April 8, 2026, the manager had reasonable basis to believe abuse had occurred. The manager then failed to initiate and document the investigation of the suspected abuse. Findings include: 1. A review of facility documentation revealed there was no incident report or investigation report of the alleged potential abuse of R2. 2. In an interview, E1 stated this was E1's "first time experiencing an APS complaint," and was unaware of the requirement to document the investigation of the situation, including the actions taken by E1 to prevent the suspected abuse from occurring in the future. E1 also stated that E1 was not on-site when O1 came to the house, and therefore, only spoke to O1 briefly over the phone when O1 called E1. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and”

“B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: c. Is documented in the resident's medical record.”

“Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of one resident sampled. Findings include: 1. A review of R1's medical record revealed R1 received directed care and medication administration services. 2. A review of R1's medical record revealed a medication order dated December 19, 2024 for: Gabapentin 100 mg, 1 tab by mouth, once daily to be discontinued and Gabapentin 300 mg, one tab by mouth, once daily to begin 4. A review of R1's medication administration record (MAR) for December 2024 revealed Gabapentin 100 mg was administered to R1 daily from December 19-31, 2024 and Gabapentin 300 mg was not administered until January 1-8, 2025. 5. In an interview, E1 acknowledged E1 failed to ensure medication administered to R1 was administered in compliance with a medication order.”

“Based on observation, 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 one sampled resident who received medication administration. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R1 at the facility during the time of inspection. 2. A review of R1's medical record revealed R1 received directed care and medication administration services. 3. A review of R1's medical record revealed a medication order dated November 22, 2024 for: Trazadone 100 mg, one tab by mouth, once a day at hour of sleep 4. A review of R1's medication administration record (MAR) for December 2024 revealed Trazadone 100 mg was properly administered per the medication order; however, the MAR for January 1-8, 2025 did not document that Trazadone 100 mg was administered to R1. 5. In an interview, E1 stated, E1 is "not sure why Trazadone is not documented on the MAR but Trazadone is given every night" to R1. 6. In an interview, E1 acknowledge E1 failed to ensure a medication administered to a resident was documented in the resident's medical record.”