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5/23/2018 - ROUTINE HEALTH SURVEY - GLEN AT LAKE OCONEE VILLAGE, THEPRINTED: 10/24/2019 FORM APPROVED State of GA, Healthcare Facility Regulation Division State of GA Inspection Report STATE FORM 6899 HG9Z11 If continuation sheet Page 1 of 3 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: ALC000233 (X2) MULTIPLE CONSTRUCTION A.BUILDING B.WING (X3) DATE SURVEY COMPLETED 05/23/2018 NAME OF PROVIDER OR SUPPLIER GLEN AT LAKE OCONEE VILLAGE, THE STREET ADDRESS, CITY, STATE, ZIP CODE 1070 OLD SALEM ROAD GREENSBORO, GA 30642 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {L 000} Initial Comments. >>>>The purpose of this visit was to conduct the annual inspection. {L 2015} SS= D 111-8-63-.20(5)(d) Certified Medication Aide Requirements. An assisted living community using certified medication aides to administer specific medications must do all of the following: ... (d) Quarterly Drug Regimen Reviews. Secure the services of a licensed pharmacist to perform all of the following duties: 1. Conduct quarterly reviews of the drug regimen for each resident of the assisted living community and report any irregularities to the assisted living community administration. ... 2. Remove for proper disposal any drugs that are expired, discontinued or in a deteriorated condition or where the resident for whom such drugs were ordered is no longer a resident. .... 4. Monitor compliance with established policies and procedures for medication handling and storage.... 3. Establish or review policies and procedures for safe and effective drug therapy, distribution, use and control. ... This REQUIREMENT is not met as evidenced by: >>>>Based on observation, record review and staff interview, the facility failed to have the licensed pharmacist to remove drugs that are expired for 3 of 6 sampled residents (Resident #1, Resident #2, and Resident #4). Findings include: An observation of the medications on site for Resident #1, Resident #2, and Resident #4 showed the following expired medications: PRINTED: 10/24/2019 FORM APPROVED State of GA, Healthcare Facility Regulation Division State of GA Inspection Report STATE FORM 6899 HG9Z11 If continuation sheet Page 2 of 3 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: ALC000233 (X2) MULTIPLE CONSTRUCTION A.BUILDING B.WING (X3) DATE SURVEY COMPLETED 05/23/2018 NAME OF PROVIDER OR SUPPLIER GLEN AT LAKE OCONEE VILLAGE, THE STREET ADDRESS, CITY, STATE, ZIP CODE 1070 OLD SALEM ROAD GREENSBORO, GA 30642 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 1. Resident #1- Aspirin EC oral tablet Delayed release 81mg daily. Expired 11, 2017 2. Resident #2- Tylenol Oral Tablet 325mg. Two tablets every four hours as needed. Expired 1, 2018 3. Resident #4- Bisac-Evac 10mg suppository. One suppository once daily as needed. Expired 5/9/2018 and Tramadol 50 mg one (1) tablet to be given every twelve (12) hours as needed with expiration date 3/31/2018 A review of the May 2018 medication administration record (MAR) for Resident #1 showed he/she was last administered on 5/23/18 at 8:00 a.m. Resident #2 was last administered on 5/4/18 at 8:00 a.m. Resident #4 was last administered on 5/22/18 at 8:32 p.m. During an interview at 7:15 p.m. on 5/23/18, Staff B stated the night shift nurse failed to remove the expired medication from the supply and notify the pharmacist. {L 2410} SS= D 111-8-63-.24(2)(j) Residents' Files. Each resident's file must include the following information: ... (j) an inventory of valuable personal items brought to the assisted living community for use by the resident to be updated at anytime after admission if a resident or representative or legal surrogate, if any, submits to the assisted living community a new inventory of the resident's personal items; ... This REQUIREMENT is not met as evidenced by: >>>>Based on record review and staff interview, the facility failed to include an inventory of valuable personal items (PI) brought to the assisted living community by the resident for 6 of 6 residents sampled ( Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6). Findings include: A review of the files for Resident #1, admitted 5/9/17, Resident #2, admitted 3/14/18, Resident #3, admitted 5/3/18, Resident #4, admitted 5/4/17, Resident #5, admitted 6/5/17, and Resident #6, admitted 3/14/18 showed no inventory of personal items brought to the assisted living community. PRINTED: 10/24/2019 FORM APPROVED State of GA, Healthcare Facility Regulation Division State of GA Inspection Report STATE FORM 6899 HG9Z11 If continuation sheet Page 3 of 3 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: ALC000233 (X2) MULTIPLE CONSTRUCTION A.BUILDING B.WING (X3) DATE SURVEY COMPLETED 05/23/2018 NAME OF PROVIDER OR SUPPLIER GLEN AT LAKE OCONEE VILLAGE, THE STREET ADDRESS, CITY, STATE, ZIP CODE 1070 OLD SALEM ROAD GREENSBORO, GA 30642 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) During an interview at 7:30 p.m., Staff A stated the families did not return the personal inventory sheet.