Better Life Assisted Living 2.

“Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical records revealed no documentation stating if the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on the date of acceptance for R1, this document was required. 2. In an interview, E4 acknowledged that there was not documentation dated within 90 calendar days before R1 was accepted by the assisted living facility.”

“Based on record review and interview the manager failed to ensure that medication was administered to a resident and documented in the resident's medical record. The deficient practice posed a risk to the resident's health and safety if it could not be determined that the medication was given as ordered, and the Department was provided false and misleading information. Findings include: 1. A review of R1's medication administration record (MAR) revealed Atorvastatin calcium 40 mg 1 tablet every day. The medication was scheduled for 8 pm; however, the caregiver signed off for the medication during the morning med pass. 2. In an interview, E4 and E2 reported that E2 signed off on the MAR for a medication in the morning, which was scheduled for administration in the evening. E4 acknowledged that a medication was signed off, as administered, at the wrong time of day.”

“Based on observation and interview the manager failed to ensure that the premises used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1 . During the environmental tour of the facility the Compliance Officer observed a ramp leading from the backdoor to the backyard. However there was a gap larger than 2 inches, at the base of the ramp, that could be a trip hazard for residents or other individuals at the assisted living facility. 2 . During the environmental tour of the facility the Compliance Officer observed a paved patio area and pavers leading to the patio area that were not level with the ground and could cause a trip hazard for residents or other individuals at the assisted living facility. 3 . In an interview, E4 acknowledged that the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.”

“Based on observation and interview the manager failed to ensure that oxygen containers were secured in an upright position. Findings include: 1 . During the environmental tour of the facility the Compliance Officer observed three (3) Oxygen tanks stored in a locked hallway closet. However, the Oxygen tanks were not secured. 2 . In an interview, E4 acknowledged that there were Oxygen tanks stored in the hallway closet and not secured.”

“Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults which posed a health and safety risk for one of four personnel records reviewed who were required to complete first aid and CPR training. Findings include: 1. Review of E2's personnel record revealed that the employee was hired on March 1, 2022 to work as a caregiver, however, there was documented evidence that E2's first aid and CPR training had expired on November 1, 2023. 2. In an interview, E2 and E3 acknowledged E2's first aid and CPR had expired and E2 continued to work as a caregiver.”

“Based on record review and interview, the manager failed to ensure that one of three sampled residents who were receiving personal care services had a written service plan reviewed and updated at least once every six months, which posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed that R1 required personal care services. The only service plan for the past twelve months was dated June 15, 2023. R1's service plan was not updated at least every six months. Based on the resident's date of acceptance, this documentation was required. 2. In an interview, E3 acknowledged there was no documentation that R1's service plan had been updated as required. E3 acknowledged R1 was receiving personal care services.”

“Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked room, closet, cabinet, or self-contained unit; which posed a health and safety risk. Findings include: 1. During a facility tour, E2 and the compliance officer observed in the facility's kitchen in an unlocked cabinet above the counter that could easily be opened there were stored facility filled medication organizers containing medications for R1, R2, and R3. There were also bottles of Miralax, Finasteride, Pantoprazole DR, Acetaminophen, Gabapentin, Aspirin, Tamsulosin HCL, Tramadol HCL, Cetirizine ACL, and Lisinopril. 2. In an interview, E2 acknowledged the medications were not stored in a locked cabinet which posted a health and safety risk. The compliance officer observed E2 trying to fix the lock to get the cabinet to lock.”