SILVER SPRINGS

Based on document review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a potential elopement risk to residents.

Findings include:

1. A review of Department documentation revealed the facility was licensed for 107 directed care level beds.

2. During the inspection, the Compliance Officer observed the premises was not secured. The Compliance Officer observed the residential units open directly to the facility grounds. The Compliance Officer observed no system to alert employees of the egress of a resident from the facility.

3. In an interview, E1 reported the facility did not accept directed care residents and was unsure why the facility had a license for directed care.

4. In an interview, E1 acknowledged the facility was authorized to provide directed care services and did not have a means to control egress or alert employees of the egress of a resident from the facility.

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 two of seven resident records reviewed.

Findings include:

1. A review of R3's medical record revealed a signed medication order, dated July 22, 2024, for Trazadone 50 mg - Take 25 mg by mouth Qhs".

2. A review of R3's medical record revealed a Medication Administration Record (MAR) dated July 2024. The MAR revealed Trazadone (half tablet) 25MG was administered at 8pm and at 9pm on July 25, 26, 27, 28, 29, and 31, 2024.

3. A review of R7's medical record revealed a signed medication order, dated July 12, 2024, for "Novolog Insulin, Inject 5 units 10 minutes before lunch unless blood sugar is below 100, hold until Dinner, check blood sugar and give 5 units if above 100."

4. A review of R7's MAR dated July 2024, revealed R7 was administered 5 units of insulin, on July 21, 2024 at 4:30pm when R7's blood sugar was 97 and on July 22, 2024 at 11:30amwhen R7's blood sugar was 95. Further review revealed on July 29, 2024 R7's blood sugar was 101 and E2 held the insulin.

5. In an interview, E1 acknowledged medications had not been administered to R3 and R7 in compliance with the medication orders.