Artis Senior Living of Lexington

• Service and Service Coordination Requirements-

Self-Administered Medication Management (SAMM and LMA)

• EOEA reviewed six Resident Records to determine compliance with requirements for Self-administered Medication Management (SAMM).
• Documentation of actions regarding whether the Resident took or refused the medication on multiple dates and times was missing for six Residents.
• PC staff informed AGE of the Residence practice to provide medication assistance from 7:00am-8:30am but not document the results of the administration, until 10:00am using one centralized computer station, after assisting with breakfast.

Emergency Response

• Due to the entirety of the Residence being certified as a Special Care Residence (SCR) the staff conduct and document hourly safety checks of the Residents to comply with the regulation to provide timely assistance to a Resident during the hours of 7:00 p.m. and 7:00 a.m. to be aware of the Residents need in the event of an emergency needs situation.
• Documentation of hourly safety checks from March 1, 2025 through the date of the compliance review for six Residents had multiple instances where staff failed to document the hourly safety checks of the Residents during the hours required.
• Service and Service Coordination- Special Care
• AGE reviewed the Special Care Residence (SCR) operations on the date of the Compliance Review to verify that the Residence is complying with all the required safeguards.
• Documentation of the required review was incomplete for the second review of 2023 and both reviews of the 2024 calendar year reviewed.
• General Requirements for an Assisted Living Residence (ALR)-
• AGE reviewed the documentation of eight Resident Records from March 2023 through the date of the Compliance Review to determine compliance with the requirements for Screenings, Assessments and Service Plan Development and Requirements.

Screening and Assessment

• Six records were missing documentation of an initial assessment being completed by a nurse.
• Five records were missing documentation of a cognitive assessment.
• Two records were missing signatures of a Residence Representative.
• Two records were without documentation to confirm that assessments noted the name and scope of any Legal Representative.

Service Plan Development and Requirements

• Three SCR records were missing documentation that Residents have supervised access to a heating element.
• Three records were missing documentation of a service plan reflecting an assessment required at the commencement of residency.
• Five records were missing documentation of Resident goals.
• Four records were missing documentation of a service plan review required within 30 days after the commencement of residency.
• Documentation of individualized enrichment activities provided to the residents was missing in three resident records.
• Documentation of a service plan review required every six months or after a change in Resident condition, was missing for three records.
• Quality Assurance and Performance Improvement
• AGE reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Safety Assurances, and Medication Quality from March 7, 2023, through the date of the Compliance Review.

Service Planning

• Documentation of the date the audit was completed, that each service plan is identified by number or code and specific findings were missing for the 2023 and 2024 calendar year reviewed.

Resident Safety Assurances

• Documentation of a Resident Safety review was missing for the 2024 calendar year reviewed.
• Documentation of an Evidenced Informed Falls Prevention Program review being included in the annual safety review process was missing for the 2023 calendar year reviewed.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits from March 7, 2023, through the date of the Compliance Review to ensure compliance with SAMM, LMA and Residence policies.
• Documentation of the specific findings was missing for the last three quarters of 2023 and the fourth quarter of the 2024 calendar year reviewed.
• Documentation of the target date and the staff person responsible for follow-up action to findings was missing for the first three quarters of the 2024 calendar year reviewed.
• Documentation of specified outcomes was missing for the first quarter of the 2024 calendar years reviewed.

Medication administration observation

• AGE observed three Personal Care (PC) staff and two nurses providing medication assistance to eight Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA.

SAMM

• AGE observed two Resident's medication storage storage units contained family filled cassettes without a label including the Resident's name.
• AGE observed two Residents that had not received medications scheduled medication for earlier on the day of the compliance review.
• AGE observed one PC staff store and carried a Resident's medication Exemption C
• Exemption C scheduled to be administered later in the day.

LMA

• AGE observed one Resident's scheduled medication was not available for administration in the medication storage unit.
• AGE observed one Resident's medication storage unit contained medication belonging to another resident.
• AGE observed one Resident's Exemption C was missing a label indicating an open date or expiration date.
• AGE observed two Residents who had their medications crushed by the nurse were missing the required physician /prescriber orders.
• Reporting Resident-specific Emergencies- Incident Reports
• AGE reviewed the Residence records and incident reports from March 7, 2023, through the date of the Compliance Review to determine whether the Residence complied with the requirement to report qualifying incidents to AGE within 24 hours after the occurrence of the incident or accident.
• The Residence filed 38 incident reports greater than 24 hours after the occurrence of the incident or accident.
• Controlled Substances
• AGE reviewed the Controlled Substance (CS) policy and procedure for Residents who participate in SAMM / LMA.
• AGE observed one Resident's secondary controlled substance medication storage unit was unsecured as required by Residence policy.
• Resident Records- Progress Notes
• AGE reviewed six Residents' records to determine compliance with record requirements.
• Documentation of significant occurrences in the Progress Notes was missing for three Residents.
• Record Requirements- Correspondence Log
• AGE reviewed all current Correspondence Logs required to communicate information necessary to maintain the continuity of care for all Residents.
• The logs did not contain documentation on each for each 24-hour period during the 90-day period previous to the compliance review as required.
• Staffing Requirements-

Staffing Levels

• AGE reviewed the Residence records to determine compliance with Staffing Level requirements.
• Documentation to confirm the Residence conducted quarterly staffing level assessment was missing for the third quarter of 2023.

Health Screening Requirements

• AGE reviewed the personnel records of five staff members to determine compliance with Health Screening requirements.
• Five records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2023/2024 flu season.
• Training Requirements

Introductory Visit and Review

• AGE reviewed the records of six Residents to determine compliance with the requirements that a nurse reviews the Resident's service plan with all relevant personal care workers within the 48 hours after the provision of service or with any change of condition for the Resident:
• Four records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff.

Supervision

• AGE reviewed the records of four (4) Personal Care (PC) staff to determine compliance with SAMM skills and Personal Care evaluation requirements in the calendar year 2023 through the date of the Compliance Review.
• Documentation confirming the completion of SAMM and skills evaluations every six months was missing from four records for the 2024 calendar year reviewed.
• Resident Rights and Disclosures- Resident Disclosures
• AGE reviewed six Resident records to confirm compliance with the Disclosure of Rights and Services requirements.
• The required disclosure of all Rights and Services including the notification of the right to bring a Representative prior to the first meeting, was missing in four records.
• The required disclosure of the Residences' delivery of a consumer guide to the prospective Resident at the first meeting was missing in three records.