The Residence at Charles Meadow

• Service and Service Coordination Requirements - Emergency Response
• AGE reviewed the Personalized Emergency Response procedures developed from May 2023 through the date of Compliance Review to provide timely assistance to a Resident in the event of an emergency needs situation.
• During the month of January 2025 there were 487 e-call response times over the ten-minute limit in accordance with the Resident's policy.
• Documentation of Personalized Emergency Response for the month of June 2024 was incomplete. AGE reviewed available documentation of June17, 2024, through June 26, 2024 to find 122 e-call response times over the ten-minute limit in accordance with the Resident's policy.
• Documentation of the Residence management monitoring the e-call system was missing for the month of June 2024.
• Documentation of Personalized Emergency Response for the month of November 2023 was missing.
• Documentation of the Residence management testing the e-call system to ensure functionality was missing for all the years reviewed
• General Requirements for an Assisted Living Residence Service Plan Development and Requirements
• AGE reviewed nine Resident Records reviewing documentation from May 2023 through the date of the Compliance Review to determine compliance with the requirements for Service Plan Development and Requirements.
• Two records were missing signature documentation of the Residence and the Resident or Legal Representative on the initial Assessment and Service Plan reviews.

Bed Rail Assessments

• AGE reviewed the Residence records of 22 Residents utilizing bed rails / U-bars or similar devices to determine compliance with the required assessment by a physical/occupational therapist every six months.
• Two records were missing documentation of a current assessment noting that the Resident can independently navigate around a bed rail/ U-bar or similar devices.
• 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 May 2023 through the date of the Compliance Review

Resident Safety Assurances

• Documentation of the target date and the staff person responsible for follow-up action to review findings were missing for the 2023 and 2024 calendar years.

Service Planning

• Documentation of the target date for follow-up action to review findings was missing for the 2023 and 2024 calendar years.

Medication Quality Plan

• AGE reviewed the Residence's quarterly medication documentation audits to ensure compliance with SAMM and LMA Residence policies.
• Documentation of specific findings, target date and the staff person responsible for follow-up action to review findings were inconsistent for all the years reviewed.

Medication administration observation

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

SAMM

• AGE observed unlabeled over the counter medication outside of the medication storage of one Resident.
• Two PC staff did not provide SAMM assistance of all scheduled medication for two Residents.
• Two PC staff did not document the observation of the Resident's actions regarding the medication (e.g. whether the Resident took or refused the medication, the date and time).
• AGE discovered the pharmacy label directions of one medication did not coincide with the directions documented on medication list for one Resident.
• AGE observed two open bottles of Exemption C in the medication storage unit of one Resident that was missing a notation of the date the bottle was opened.
• AGE observed one medication in the medication storage unit of one Resident that was missing a pharmacy label.

LMA

• The nurse did not provide LMA of all scheduled medications in the medication storage unit for one Resident.
• Age observed the nurse crush medications for a Resident without being able to verify that there was an authorized prescriber's order to crush the medication.
• AGE observed a nurse perform LMA in a manner that exceeds the scope permitted under all applicable laws, regulations and standards governing the medication administration process by a nurse, including documentation requirements.
• AGE observed the nurse administer pre-poured medication to three Residents in common areas of the SCR.
• Of the three Residents, AGE observed the nurse administered medication to of the two Residents simultaneously in the dining area, where one Resident received medications Exemption C to self-administer without nurse observation.
• AGE observed the nurse perform LMA without any Resident Records / Resident Medication Administration Records therefore the nurse did not verify, during medication administration, information including, but not limited to,
• Resident name
• Authorized prescriber's medication orders
• Medication, dose, route, time, documentation
• Resident allergies
• AGE discovered the nurse passing medications from an unsecured basket. The nurse reports that all SCR Residents scheduled and as needed (PRN) medications have been prepared by the nurse for the first shift and placed into the basket. The basket contained: four open cups of unidentifiable whole tablets crushed medications.
• Numerous bubble compartments tore from Medication on Time bubble packs to be given at various times throughout the day shift.
• AGE observed the nurse administering medication to different Residents while the basket of prepared medication is placed on a counter by the kitchen unsecured and unattended.
• AGE was informed by the nurse that documentation of medication administration will be documented after the medication passes are complete and the remaining medications in the basket are placed in an office until the next medication pass time.
• Reporting Resident-specific Emergencies – Incident Reports
• AGE reviewed the Residence records and submitted incident reports from May 2023 through the day of the Compliance Review for evidence that all occurrences of an incident or accident that has or may have a Significant Negative Effect on a Resident's health, safety or welfare were reported to AGE within 24 hours after the occurrence of the incident or accident.
• The Residence filed 27 incident reports greater than 24 hours after the occurrence of the incident or accident.
• Resident Records- Progress Notes
• AGE reviewed nine Residents' records to determine compliance with record requirements.
• Progress notes written from May 2023 to July 1, 2024, did not document all significant occurrences in the Progress Notes in five of the nine records reviewed.
• Record Requirements- Correspondence Log
• AGE reviewed the documentation maintained in the correspondence logs required every twenty-four hours to communicate information necessary to maintain the continuity of care for Residents.
• The SCR and the Traditional Correspondence logs did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.
• Health Screening Requirements
• AGE reviewed the personnel records of nine staff members to determine compliance with Health Screening requirements.
• All personnel records were missing documentation of a seasonal influenza vaccination or declination for the 2024 through 2025 seasonal period.
• Training Requirements -Introductory Visit and Review
• AGE reviewed the records of 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:
• Five records were without documentation to support that Introductory Visits were conducted with all applicable staff.