BROOKDALE EAST ARBOR

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of four residents sampled.

Findings include:

1. A review of R1's medical record revealed a current service plan listing the services required by R1.

2. A review of facility incident reports revealed R1 had been sent to the hospital on August 29, 2024 and had not returned to the facility as of the date of the on-site inspection, September 11, 2024.

3. A review of R1's medical record revealed a form titled, "Resident Personalized Service Plan Signature Sheet," dated July 2024 through September 2024. However, the form included the following errors:
- On August 29, 2024, the form indicated services had been provided to R1 on the Evening and Nights shift;
- On August 30, 2024, the form indicated services had been provided to R1 on all three shifts;
- On August 31, 2024, the form indicated services had been provided to R1 on all three shifts;
- On September 1, 2024, the form indicated services had been provided to R1 on the Days and Evening shifts;
- On September 2, 2024, the form indicated services had been provided to R1 on the Evening shift;
- On September 8, 2024, the form indicated services had been provided to R1 on the Days and Evening shifts; and
- On September 9, 2024, the form indicated services had been provided to R1 on the Days and Evening shifts.

However, R1 was not present in the facility on any of these days and times and could not have received the documented services.

4. A review of R3's medical record revealed a service plan was current at the time of R3's discharge on October 27, 2023 and listed all services required by R3.

5. A review of R3's medical record revealed a form titled, "Resident Personalized Service Plan Signature Sheet," dated October 2023 through December 2023. However, the form included the following errors:
- On October 6,7,12,13,14,15 and October 21, 2023, R3 had not received any services on the Days shift, however, the form had been left blank and did not include a code or other explanation why services had not been provided;
- On October 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,20,and October 21, 2023, R3 had not received any services on the Evening shift, however, the form had been left blank and did not include a code or other explanation why services had not been provided;
- On October 9,10,11,12,22 and October 23, 2023, R3 had not received any services on the Nights shift, however, the form had been left blank and did not include a code or other explanation why services had not been provided;
- On October 28, 2023, after R3 had discharged, the form indicated services had been provided to R3 on the Nights shift;
- On October 29, 2023, after R3 had discharged, the form indicated services had been provided to R3 on all three shifts;
- On October 30, 2023, after R3 had discharged, the form indicated services had been provided to R3 on the Evening shift, and a mark in the evening shift section had been written over, obscuring the original mark;
- On October 31, 2023, after R3 had discharged, the form indicated services had been provided to R3 on the Days shift, and a mark in the Evening shift section had been written over, obscuring the original mark;
- On November 1, 2023, after R3 had discharged, the form indicated services had been provided to R3 on the Days shift.

4. In an interview, E1, E2, and E3 acknowledged the services provided to R1 and R3 had not been accurately documented in each 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 two sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication, and false or misleading information was provided to the department.

Findings include:

1. A review of R3's medical record revealed a service plan dated September 22, 2023 for Personal Care services including medication administration.

2. A review of R3's medical record revealed a list of medication orders, dated October 16, 2023 , which included:
- "Start 09/22/2023, Hydralazine HCL Oral Tablet 25 MG. Dose: 2 Tab(s), Frequency: BID Instructions: Take two tabs by mouth two times a day for hypertension - hold for SBP below 140."

3. A review of R3's medical record revealed an electronic medication administration record (MAR) dated October 2023. The MAR indicated the following:
- On October 6, 2023, at 0800, R3's blood pressure was documented to be 133/88, however, Hydralazine was administered to R3;
- On October 8, 2023, at 0800, R3's blood pressure was documented to be 132/88, however, Hydralazine was administered to R3;
- On October 9, 2023, at 0800, R3's blood pressure was documented to be 122/70, however, Hydralazine was administered to R3;
- On October 27, 2023, at 0800, R3's blood pressure was documented to be 139/69, however, Hydralazine was administered to R3;
- On October 8, 2023, at 1700, R3's blood pressure was documented to be 118/78, however, the Hydralazine was administered to R3;

4. In an interview, E1, E2, and E3 acknowledged medications had not been administered to R3 in compliance with a medication order.

Based on record review, observation, and interview, the manager failed to ensure medication stored by the facility was stored in a separate locked area used only for medication storage.

Findings include:

1. A review of R2's medical record revealed a service plan, updated July 19, 2024, for Personal care services including medication administration.

2. During an environmental inspection of the facility, the Compliance Officer observed a medicine cabinet in R2's private bathroom did not have a lock. Inside the medicine cabinet, the Compliance Officer observed containers of "Triple Antibiotic Ointment and Pain Relief" and, "Refresh Tears Lubricant Eye Drops." The medicine cabinet also included non-medication hygiene items, such as lotion, saline, and floss picks.

3. In an interview, E1, E2, and E3 acknowledged medication required to be stored by the facility was not stored in a separate locked area used only for medication storage.

Based on observation and interview, the manager failed to ensure the premises were free from a situation that may cause a resident to suffer physical injury.

Findings include:

1. During an environmental tour, the Compliance Officer observed the door to R4's room had been left unlocked and the room was not occupied at the time of the inspection. In an unlocked cabinet in the R4's private bathroom, the Compliance Officer observed a bottle of toilet bowl cleaner. In an unlocked closet in R4's bedroom, the Compliance Officer observed two containers of , "Swiffer Wet Jet" floor cleaner.

2. In an interview, E1 reported R4 received directed care services. E1, E2, and E3 acknowledged the premises were not free from a situation that may cause a resident to suffer physical injury.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant, for two of four residents sampled. The deficient practice posed a risk if a resident was not assessed and determined to be within the scope of an assisted living facility prior to receiving services.

Findings include:

1. A review of R1's medical record revealed a document titled, "Physician/Healthcare Provider Plan of Care," dated May 3, 2023, and signed by a physician and documenting R1's level of care and needs. However, the document was not dated within 90 calendar days before R1's date of admission.

2. A review of R3's medical record revealed a document titled, "Physician/Healthcare Provider Plan of Care," dated April 29, 2022, and signed by a physician and documenting R3's level of care and needs. However, the document was not dated within 90 calendar days before R3's date of admission.

3. In an interview, E1 acknowledged R1's and R3's medical records did not contain documentation that was dated within 90 days before the individual was accepted by the assisted living facility and was signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant.

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated at least once every three months for a resident receiving directed care services, for one of one resident sampled who received directed care services. The deficient practice posed a risk if the service plan did not reinforce and clarify services to be provided to a resident.

Findings include:

1. A review of R1's medical record revealed a service plan dated February 24, 2023, indicating R1 received directed care services. However, a subsequent reviewed or updated service plan was not available for review.

2. In an interview, E1 acknowledged R1's service plan was not reviewed and updated at least once every three months as required.