TERRA POINTE MEMORY CARE

Based on documentation review and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Findings include: 1. A review of the facility's policies and procedures (dated October 28, 2023) revealed a policy and procedure on how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual was not available for review. 2. In an interview, E1 reported when a resident experiences a sudden, intense, or out-of-control behavior, residents may be taken to a calm room, have one-on-one time with a caregiver, notifications made to the resident's medical practitioner, and the facility follows the guidance of the medical practitioner. However, this procedure was not documented in a policy. 3. In an interview, E1 acknowledged a policy and procedure on how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual was not available for review.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for two of six 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 medical record revealed a current service plan for directed care services (dated in 2023). The service plan stated the following service was to be provided to R1: -"[R1] requires moderate assistance with using the bathroom and incontinence care. Team members will physically assist resident to the restroom and provide moderate assistance with changing incontinent products. ... 3 Times/Day." 2. A review of R1's medical record revealed an activities of daily living (ADL) sheet for August 2023. The ADL sheet stated "[R1] requires moderate assistance with using the bathroom and incontinence care. Team members will physically assist resident to the restroom and provide moderate assistance with changing incontinent products. ... 3 Times/Day" was not documented as provided three times a day on the following dates: -August 10, 2023; -August 24, 2023; and -August 26, 2023. 3. In an interview, E1 reported R1 will sometimes use the toilet and not tell any of the personnel members. 4. In an interview, E1 acknowledged a caregiver or assistant caregiver did not document the services provided in R1's medical record. 5. A review of R5's medical record revealed a service plan (dated in 2022, level of care unknown). The service plan stated the following services were to be provided to R5: -"[R5] requires moderate assistance with taking care of skin integrity. Team members will physically apply lotion to care for resident skin ... 2 Times/Day;" -"[R5] requires moderate assistance with using the bathroom and incontinence care. Team members will physically assist resident to the restroom and provider moderate assistance with changing incontinence products, if applicable. ... 3 Times/Day;" -"[R5] requires minimal assistance. Resident attempts to dress self but may need repetitive verbal cues, minimal physical assistance (tying shoes, getting clothes from closet, putting on jacket or sweater) ... 2 Times/Day;" and -"Team members will provide moderate assistance with showers, twice weekly and as needed." 6. A review of R5's medical record revealed an ADL sheet for November 2022. The ADL sheet stated "[R5] requires moderate assistance with taking care of skin integrity. Team members will physically apply lotion to care for resident skin ... 2 Times/Day" was not documented as provided two times a day on the following dates: -November 6, 2022; -November 11, 2022; and -November 16, 2022. 7. A review of R5's medical record revealed an ADL sheet for November 2022. The ADL sheet stated "[R5] requires moderate assistance with using the bathroom and incontinence care. Team members will physically assist resident to the restroom and provide moderate assistance with changing incontinence products, if applicable. ... 3 Times/Day" was not documented as provided three times a day on the following dates: -November 6, 2022; -November 11, 2022; and -November 16, 2022. 8. A review of R5's medical record revealed an ADL sheet for November 2022. The ADL sheet stated "Team members will provide moderate assistance with showers, twice weekly and as needed" was documented as "1" on the following dates: -November 3, 2022 and November 10, 2022. The ADL stated "Task Completed? 2-Yes 1-No" and "System Response available for all questions: RU- Resident Not Available RR-Resident Refused." 9. In an interview, E1 reported the "1" documented on R5's ADL sheet could have been the resident's refusal of the service. 10. In an interview, E1 acknowledged a caregiver or assistant caregiver did not document the services provided in R5's medical record.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a mediation order, for one of six residents sampled who received medication administration. 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 R3's medical record revealed a current service plan for directed care services (dated in 2023). The service plan revealed R3 received medication administration. 2. A review of R3's medial record revealed a medication order for "Nortriptyline HCl 25mg Cap Give 3 capsule orally in the afternoon" (dated August 14, 2023). 3. A review of R3's medical record revealed a medication administration record (MAR) for August 2023. The MAR stated "Nortriptyline HCl 25mg Cap Give 3 capsule orally in the afternoon." R3's MAR revealed Nortriptyline was documented as administered at 8:00PM on the following dates: -August 15-28, 2023. 4. In an interview, E11 reported 8:00PM was considered the evening and not the afternoon. E11 reported E11 would have to double check R3's medication orders for Nortriptyline. 5. In an interview, E1 acknowledged medication was not administered in compliance with a medication order.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed five ambulatory residents on the premises. 2. The Compliance Officer observed an unlocked room in the nurse's station area. The Compliance Officer observed a personnel member walk away from the nurse's station area. The Compliance Officer observed the following: -One large bucket containing what appeared to be various tablets and capsules; and -One pharmacy provided multi-dose packaging for bubble pack for "Loperamide 2mg." 3. In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.