Mama Care Assisted Living.

“Based on documentation review and interview, the manager failed to ensure that a plan was documented and implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Quality Management Plan." The policy stated: "The frequency of submitting a documented report - The monthly report shall be completed and maintained on a quarterly basis." 2. During the on-site compliance and complaint inspection, the Compliance Officers requested the facility's quality management documentation at 10:20 AM. No documentation was provided for Compliance Officer review. 3. In an interview, E3 reported the facility did not have any incidents to report. E3 acknowledged a plan was not documented or implemented for an ongoing quality management program.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge are verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services and according to policies and procedures for two of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of facility policy and procedures revealed a document titled "Staffing a Record Keeping" which stated: "Each employee hired by this facility must have the following on Employee's file 1. Application Form 2. copy of current TB skin test that reads "negative result" 3. finger print clearance card verification 4. CPR and First Aid 5. Verification of skills and Knowledge." A blank "Caregiver Skills Documentation" form was included in the policy and procedures. 2. A review of E2's and E3's personnel records revealed no documentation verifying a caregiver's or assistant caregiver's skills and knowledge. 3. A review of the facility's employee schedule for December 1, 2024 - December 11, 2024 revealed E2 was scheduled to provide services the following dates and shifts: - December 1, 2024 and December 9, 2024 day shift; - December 2, 2024 - December 8, 2024 night shift; and - December 10, 2024 - December 11, 2024 night shift. 4. A review of the facility's employee schedule for December 1, 2024 - December 11, 2024 revealed E3 was scheduled to provide services the following dates and shifts: December 1, 2024 and December 9, 2024 night shift; - December 2, 2024 - December 8, 2024 day shift; and - December 10, 2024 - December 11, 2024 day shift. 5. During an environmental inspection, Compliance Officer observed E2 and E3 provided assisted living services to residents in the home. 6. In an interview, E3 acknowledged E2's and E3's skills and knowledge were not verified and documented before E2 and E3 provided physical health services.”

“Based on record review, observation and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order, for one of two sample residents who received medication administration. Findings include: 1. A review of R2's medical record revealed a directed care service plan dated October, 2024 which documented R2 received medication administration. 2. A review of R2's medication administration record (MAR) for December, 2024 revealed R2 was administered the following medications December 1, 2024 - December 11, 2024: - Depakote Sprinkle 125 milligram (Mg) Cap - 1 capsule daily at lunch - 12PM; - Metformin HCL 500Mg Tablet - 1 Tablet witha a meal oraly two times a day - 8Am and 8Pm; - Galantamine Hydrobromide Tab 8 MG - Give 1 tablet by mouth two times a day For Dimentia - 8AM and 5PM; - Trazadone 50 Mg - 1/2 tab by mouth at bedtime - 8PM; - Lantus Solo Star 100 Units Sol. Pen Injector - Subcutaneously 15 Units at bedtime - 8PM; and - Hydroxycine HCL 25MG - 1 Tab Orally daily - 12Pm. 3. A review of R2's medical record revealed a medication list titled "Medication Administration" signed by a Family Nurse Practitioner (FNP) and faxed to the facility on August 25, 2024. However, page one of three was not available for review. No medication orders were provided for the following medications: - Depakote Sprinkle 125 milligram (Mg) Cap - 1 capsule daily at lunch - 12PM; - Metformin HCL 500Mg Tablet - 1 Tablet witha a meal oraly two times a day - 8Am and 8Pm; - Galantamine Hydrobromide Tab 8 MG - Give 1 tablet by mouth two times a day For Dimentia - 8AM and 5PM; - Trazadone 50 Mg - 1/2 tab by mouth at bedtime - 8PM; - Lantus Solo Star 100 Units Sol. Pen Injector - Subcutaneously 15 Units at bedtime - 8PM; - Hydroxycine HCL 25MG - 1 Tab Orally daily - 12Pm. 4. In an interview, E3 reported upon investigation R2's primary care had not received the first page of the medication list when sent for updates. E3 acknowledged R2's medication was not administered in compliance with a medication order.”

“Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area, labeled and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection, Compliance Officer observed ambulatory residents in the home. 3. During the environmental tour, the Compliance Officers observed the following poisonous or toxic material in the unlocked garage; - One container of "Ultra Fresh Fabric Softener"; - Three containers of "OdoBan Deodorizer, Disinfectant, Mildewstat, Virucide, and Sanitizer"; - Two cans of "WD 40"; - One container of "Prestone Brake Fluid"; - One container of "Griot's Leather 3-in-1"; - One container of "DOT Brake Fluid"; - One containter of "Peak Original Equipment Technology Antifreeze and Coolant"; and - One can of Sea Foam Motor Treatment. 4. In an interview, E3 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area, labeled and inaccessible to residents.”