Ohana Adult Care Home LLC.

“Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's day of occupancy, for two of four residents reviewed. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of R2's (admitted in 2023) medical record revealed evidence of freedom from infectious TB. However, the test was completed 29 calendar days after R2's date of admission. 2. A review of R2's medical record revealed documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB was not available for review. Based on R2's acceptance date, this documentation was required. 3. A review of R4's (admitted in 2023) medical record revealed evidence of freedom from infectious TB. However, the test was completed 27 calendar days after R4's date of admission. 4. In an interview, E1 and O1 acknowledged R2 did not provide documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. 5. In an interview, E1 and O1 acknowledged R2's and R4's evidence of freedom from infectious TB was not completed before or within seven calendar days after the resident's date of occupancy.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for four of four residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's, R2's, R3's, and R4's medical records revealed current service plans describing the services to be provided by the facility personnel members to each resident. 2. A review of R1's, R2's, R3's, and R4's medical records revealed an activities of daily living (ADL) log for September 2023. R1's, R2's, R3's, and R4's ADL logs did not indicate services were provided on September 22 - 25, 2023. 3. In an interview, E1 and O1 acknowledged R1's, R2's, R3's and R4's medical records did not include documentation of services provided and reported the services were provided, however a caregiver or an assistant caregiver did not document the services provided.”

“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 four residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a medication order dated September 22, 2023. The medication order revealed Levothyroxine 175 mg, one tab, daily was discontinued. 2. A review of R2's medical record revealed a medication administration record (MAR) dated September 2023. The MAR revealed Levothyroxine 175 mg, one tab daily was given on September 24, 2023. 3. The Compliance Officer observed a medication bottle, belonging to R2, labeled for Levothyroxine 175 mg. 4. In an interview, E1 reported the medication was administered per the MAR and acknowledged R2's medication was administered although there was a medication order to discontinue the medication.”

“Based on documentation review, record review, observation, and interview, the manager failed to implement policies and procedures for discarding medication. The deficient practice posed a risk as the standards expected of employees in the policies and procedures were not followed. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Disposal of Expired Medication" (dated in August 2022). The policy and procedure stated "Medication must be disposed of when it is... discontinued by the resident's physician.... 1. Take unused, unneeded or expired prescription drugs out of their original containers. 2. Mix the prescription drugs with a undesirable substance like coffee grounds or kitty litter, and put them in impermeable, nondescript containers... 3. Throw these containers in the trash..." 2. A review of R2's medical record revealed a medication order dated September 22, 2023. The medication order revealed Losartan 50 mg, one tab, at bedtime and Levothyroxine 175 mg, one tab, daily were discontinued. 3. The Compliance Officer observed medication bottles, belonging to R2, labeled for Losartan 50 mg and for Levothyroxine 175 mg. 4. In an interview, E1 and O1 acknowledged the medications were not disposed of according to the facility's policy and procedure.”