SUNRISE AT RIVER ROAD

Based on documentation review and interview, the manager failed to ensure documentation of each evacuation drills included, if applicable, an identification of residents needing assistance for evacuation and an identification of residents who were not evacuated. Findings include: 1. A review of facility documentation revealed an evacuation drill, dated April 12, 2023. The document included the date and time of the evacuation drill; the amount of time taken for employees and residents to evacuate the assisted living facility; any problems encountered in conducting the evacuation drill; and recommendations for improvement. However, documentation of an identification of residents needing assistance for evacuation, and an identification of residents who were not evacuated was not available for review. The evacuation drill documentation included two resident rosters with some marks and notes, and included a resident sign out log, however, the notes written on the rosters were not clear regarding who had required assistance and who had not been evacuated. 2. A review of facility documentation revealed an evacuation drill, dated September 22, 2022. The document included the date and time of the evacuation drill; the amount of time taken for employees and residents to evacuate the assisted living facility; any problems encountered in conducting the evacuation drill; and recommendations for improvement. However, documentation of an identification of residents needing assistance for evacuation, and an identification of residents who were not evacuated was not available for review. The evacuation drill documentation included two resident rosters with some marks and notes, and included a resident sign out log, however, the notes written on the rosters were not clear regarding who had required assistance and who had not been evacuated. Additionally, the documentation included a form titled, "Sunrise Senior Living Evacuation Drill," which had sections for each resident to mark the level of assistance required by each resident to evacuate. However, the form had been left blank. 3. In an interview with E1, E2, E3, E4, E5, E6, E7, E8, and E9, the findings were presented. E5 acknowledged the documentation of the evacuation drill did not include a clear identification of residents needing assistance for evacuation and an identification of residents who were not evacuated.

R9-10-120. Opioid Prescribing and Treatment F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, including a health care institution in which an opioid may be prescribed or ordered as part of treatment, a medical director, a manager as defined in R9-10-801, or a provider, as applicable to the health care institution, shall: 1. Establish, document, and implement policies and procedures for administering an opioid as part of treatment or providing assistance in the self-administration of medication for a prescribed opioid, to protect the health and safety of a patient, that: a. Cover which personnel members may administer an opioid in treating a patient and the required knowledge and qualifications of these personnel members; b. Cover which personnel members may provide assistance in the self administration of medication for a prescribed opioid and the required knowledge and qualifications of these personnel members; c. Include how, when, and by whom a patient's need for opioid administration is assessed; d. Include how, when, and by whom a patient receiving an opioid is monitored; and e. Cover how, when, and by whom the actions taken according to subsections (F)(1)(c) and (d) are documented;

Based on record review and interview, the manager failed to establish, document, and implement policies and procedures for administering an opioid as part of treatment which covered which personnel members may administer an opioid in treating a patient and the required knowledge and qualifications of these personnel members, covered which personnel members may provide assistance in the self administration of medication for a prescribed opioid and the required knowledge and qualifications of these personnel members, included how, when and by whom a patient's need for opioid administration is assessed, included how, when and by whom a patient receiving an opioid is monitored, and covered how, when and by whom the actions taken according to subsections (F)(1)(c) and (d) would be documented. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Policy CL-0044-AZ, Opioid Management ", effective March 28, 2018. However, the policy did not cover which personnel members may administer an opioid in treating a patient and the required knowledge and qualifications of these personnel members, did not cover which personnel members may provide assistance in the self administration of medication for a prescribed opioid and the required knowledge and qualifications of these personnel members, did not include how, when and by whom a patient's need for opioid administration is assessed, did not include how, when and by whom a patient receiving an opioid is monitored, and did not cover how, when and by whom the actions taken according to subsections (F)(1)(c) and (d) would be documented. 2. In an interview, E8 reported documentation of the assessment and effectiveness of opioid medications was implemented for "as-needed" medications, however, E8 reported assessment and monitoring had not been implemented for scheduled opioids. 3. In an exit interview with E1, E2, E3, E4, E5 E6, E7, E8 and E9, the finding was presented. E8 acknowledged the facility's policy and procedure covering opioid administration did not include all of the policies required by R9-10-120.F.