Sarah's Place at Glencroft.

“Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the egress of a resident from the facility.   Findings include:   1. A review of Department documentation revealed the facility was licensed for directed care. 2. During the environmental inspection of the facility, the Compliance Officer observed that a door with an alarm was not functioning. 3. In an interview, E1 acknowledged that the door alarm was not functioning and would not alert employees of the egress of a resident.”

“Based on observation and interview, the manager failed to ensure that medication was stored in a locked room. Findings include: 1. During an environmental inspection, the Compliance Officer was able to open a door to the med room. The room contained used syringe containers on the floor. The room also contained a small fridge that had Lorazepam syringes. 2. In an interview, E1 acknowledged that the med room was unlocked and provided easy access to residents.”

“Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Findings include: 1. A review of facility documentation revealed a policy titled "Managing Abusive, Aggressive, and Combative Residents." The policy stated "9. Once the immediate situation has been handled, contact the Assisted Living Manager of the Community. The Manager will then contact the Resident's family and medical practitioner to determine the cause of the behavior and to seek a solution to prevent it from happening again." 2. A review of R3's and R4's medical record revealed a report titled "Incident #1641" for R3 and R4 dated October 19, 2024. The document revealed where R4 displayed sudden, intense or out control behavior, immediate action taken by caregivers to deescalate the situation, personal and representatives the incident was reported per instructions provided, and actions completed by the care coordinator. However, no documenation that a medical practitioner was contacted as per policy was available. 3. In an interview, E1 acknowledged that policies and procedures were not implemented to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.”

“Based on record review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to initiate an investigation of the suspected abuse, neglect, or exploitation and document the information. The deficient practice posed a risk of the suspected abuse occurring in the future. Findings include: 1. A review of R3's and R4's medical record revealed a report titled "Incident #1641" for R3 and R4 dated October 19, 2024. The document revealed a reasonable basis to believe abuse occurred on the premises, immediate action taken by caregivers to stop the suspected abuse, personnel and representatives the incident was reported to per instructions provided, and actions completed by the care coordinator. However, the report was completed by caregiver personnel and did not include an investigation being initiated by the manager. 2. In an interview, E1 reported the facility took action terminating R4's residency in the facility. E1 acknowledged that after having a reasonable basis to believe abuse occurred on the premises, the manager failed to initiate an investigation of the suspected abuse, neglect, or exploitation and document.”

“Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided assistance with activities of daily living according to the resident's service plan, for one of three residents sampled. Findings include: 1. A review of R1's medical records revealed a document titled "Direct Level of Care Service Plan" dated October 24, 2024. The service plan stated "Bathing Assistance: Total Care: Staff will provide hands on assistance with shower, wash body/hair, set up/clean up." R1's service plan revealed bathing frequency to be completed two times per week by hospice. 2. In an interview, E1 reported that R1 was removed from hospice services November 1, 2024. 3. A review of R1's medical record revealed a document titled "ADL Log" used to document completion of R1's activities of daily living to be provided. However, the ADL log revealed that bathing services were not documented as being completed. 4. In an interview, E1 acknowledged R1 had not received bathing services since from November 1 - November 7, 2024. E1 acknowledged the manager failed to ensure a caregiver or assistant caregiver provided assistance with activities of daily living according to the resident's service plan.”

“Based on record review and interview, a manager failed to ensure a resident was treated with dignity, respect, and consideration for one of three residents sampled. Findings include: 1. A review of R1's medical records revealed a document titled "Direct Level of Care Service Plan" dated October 24, 2024. The service plan stated "Bathing Assistance: Total Care: Staff will provide hands on assistance with shower, wash body/hair, set up/clean up." R1's service plan revealed bathing frequency to be completed two times per week by hospice. 2. In an interview, E1 reported that R1 was removed from hospice services November 1, 2024. 3. A review of R1's medical record revealed a document titled "ADL Log" used to document completion of R1's activities of daily living to be provided. However, the ADL log revealed that bathing services were not documented as being completed. 4. In an interview, E1 acknowledged R1 had not received bathing services since from November 1 - November 7, 2024. E1 reported that hospice had not been removed from the service plan to alert caregivers to complete bathing. E1 acknowledged the manager failed to ensure a resident was treated with dignity.”

“Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a residents needs or emergencies was available in a bedroom being used by a resident receiving directed care services or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies for three of three directed care residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection, the Compliance Officers observed resident rooms were not equipped with a bell, intercom, or other mechanical means to alert employees to resident needs or emergencies. Compliance Officers observed pull chords equipped in resident bathrooms, however, the alerts were not operational. 2. A review of R1's, R2's, and R3's medical records revealed that R1, R2, and R3 were to receive directed level of services. 3. In an interview, E1 reported facility personnel complete two hour checks for resident needs or emergencies in lieu of a bell, intercom, or mechanical means. E1 acknowledged the manager failed to ensure a bell, intercom, other mechanical means, or had implemented another means to alert employees to a resident's needs or emergencies in a bedroom being used by a resident receiving directed care services.”

“Based on record review and interview, the manager failed to ensure that the resident's orientation to the exits within 24 hours after the resident's acceptance was documented for one of three residents reviewed. Findings include: 1. A review of R2's medical record revealed documentation of R2's orientation to exits within 24 hours of acceptance was not available. 2. In an interview, E4 reported that orientation to the facility exits was conducted with R2's family at the time of move in. E4 acknowledged that R2's orientation to the exits within 24 hours after the resident's acceptance was not documented.”

“Based on record review, and interview when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the manager failed to ensure that a caregiver or assistant caregiver immediately notified the resident's emergency contact and primary care provider for two of three residents reviewed. Findings include: 1. A review of R1's medical record revealed an incident report for incident #1641. The incident report revealed R1 had been injured in the incident and contact was made with the facility's manager, director, medical director, 911, and with R1's representative. However, no documentation of contact with R1's primary care provider was available. 2. A review of R4's medical record revealed an incident report for incident #1641. The incident report documented R4 had been sent out for medical services. However, no documentation of contact with R4's primary care provider was available. 3. In an interview, E1 acknowledged that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the manager failed to ensure that a caregiver or assistant caregiver immediately notified the resident's primary care provider.”