Ana & David Assisted Living.

“Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section. Findings include: 1 . A review of R1's medical record revealed that documentation of a maintained standardized form for the emergency responder was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of four residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1 . A review of R1's medical record revealed a negative TB signs and symptoms screening and risk assessment. However, documentation of a negative TB skin test or blood test was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility that controlled 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 general or specific whereabouts of a resident. Findings include: 1. Review of department documentation revealed the facility was licensed at the directed level of care. 2. The Compliance Officers observed ambulatory residents in the facility.  3. The Compliance Officers observed a sliding glass door in a resident's room. The sliding glass door led to the backyard. The door was able to be opened without a key, and there was no alert of egress. 4. Review of the facility's policies and procedures revealed a policy titled, “Environmental and Physical Plant Safety,” which stated, “4. Exit doors and windows to the outside that a wandering resident may exit through, will be alarmed to alert employees in the event a resident is wandering.” 5. In an interview, E1 acknowledged the sliding glass door did not control or alert the egress of a resident from the facility.”

“Based on record review and interview, the manager failed to ensure that a medication administered to a resident was accurately documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order.     Findings include:     1. Review of R1’s current service plan dated October 28, 2024, showed that R1 received medication administration.      2. Review of R1’s medical record revealed the following: -A signed medication order, dated March 18, 2025, for “Guaifenesin 600 mg take 1 tablet by mouth every 12 hours”   3. Review of R1’s March 2025 medication administration record (MAR) revealed the following: -Guaifenesin 600 mg was documented as administered at 8:00 am from March 1, 2025, to March 20, 2025. However, the 8:00 pm documentation was left blank.    4. Review of R1’s medical record revealed the following: -A signed medication order, dated January 24, 2025, for “Admelog Solostar 100 unit” “Continue Admelog 8 units before breakfast; decrease Admelog to 4 units before lunch; continue Admelog 6 units before dinner; Plus below correction scale if blood sugar greater than 150; If FS 151-200 give 1 unit of Admelog; If FS 201-250 give 2 units Admelog; IF FS 251-300 give 3 units Admelog; IF FS 301-350 give 4 units Admelog; If FS 351-400 give 5 units Admelog; if FS more than 401 give 6 units Admelog.”   5. Review of R1’s blood sugar monitoring and March 2025 MAR revealed the following: -March 6, 2025, at lunch, R1’s blood sugar was at 277. A review of R1’s MAR revealed a mark that looks like a “1” and a mark that looks like a “2” written over the other mark was administered. According to the sliding scale order, three units were to be administered. -March 6, 2025, at dinner, R1’s blood sugar was at 209. A review of R1’s MAR revealed one unit was administered. However, according to the sliding scale order, two units were to be administered.   -March 9, 2025, at lunch, R1’s blood sugar was at 237. A review of R1’s MAR revealed one unit was administered. However, according to the sliding scale order, two units were to be administered. -March 11, 2025, at dinner, R1’s blood sugar was recorded at 81. A review of R1’s MAR revealed two units were administered. According to the sliding scale order, no units were to be administered. -March 13, 2025, at dinner, R1’s blood sugar was recorded at 136. A review of R1’s MAR revealed one unit was administered. According to the sliding scale order, no units were to be administered.     6. In an interview, E1 reported the medication was administered per the order. E1 acknowledged medication administered to R1 was not accurately documented in the medical record.”

“Based on observation, record review, documentation review, and interview, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers to residents. Findings include: 1. The Compliance Officers observed a bottle of mouthwash on the nightstand next to a bottle of juice in R1's bedroom. In a drawer across from R1’s bed, there was a bottle of Antacid tablets 750 mg, a bottle of pain relief cream 4% Lidocaine HCI/ Topical Analgesic.  2. Review of R1’s current service plan dated October 28, 2024, showed that R1 was “Legally Blind”. A further look into the service plan showed R1 received medication administration. 3. Review of the facility’s policy and procedures revealed a policy titled, "Environmental and Physical Plant Safety,” which stated, “39. All employees and volunteers should be monitoring the environment for potentially hazardous situations and reporting their observations to the manager immediately upon discovering such a situation.” 4. In an interview, R1 reported that R1 supplied the Antacid tablets and the mouthwash, but did not know where the pain relief cream came from. 5. In an interview, E1 acknowledged the facility did not supply the antacid tablets, pain relief cream, and mouthwash. E1 acknowledged the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.”

“Based on documentation review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery to include continued competency training in fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention" (dated in October 2021). The policy and procedure stated "Fall Prevention and Recovery Training is required upon hire and at least every twelve months thereafter." 2. A review of E1's personnel record revealed training dated August 15, 2022, in fall prevention and fall recovery. However, continued competency training since August 2022 was not available for review. 3. A review of E2's personnel record revealed training dated April 5, 2022, in fall prevention and fall recovery. However, continued competency training since April 2022 was not available for review. 4. In an interview, O1 acknowledged E1's and E2's fall prevention and fall recovery training had not been administered per the facility's fall prevention and fall recovery program to ensure continued competency.”

“Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver documented the names of individuals who observed the accident, emergency, or injury; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future, for two of two residents sampled who had an accident, emergency, or injury resulting in the resident needing medical services. Findings include: 1. A review of R1's medical record revealed a progress note dated May 29, 2023 at 5:30 PM. The note stated, "[R1] very restless and temperature 102. Called 911." However, documentation of the aforementioned incident was not available to include the names of individuals who observed the accident, emergency, or injury; the individuals notified by the caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. 2. A review of R1's medical record revealed a progress note dated June 11, 2023, at 12:00 PM. The note revealed R1 returned from the hospital with a urinary catheter. 3. A review of R3's medical record revealed a progress note dated September 14, 2023, at 5:00 PM. The note stated, "[R3] was moved to the hospital today. [R3's] daughter was speaking with [R3] on the phone in the morning and felt... [R3] felt drowsy and couldn't speak. [R3's] daughter decided to... [R3] to St. Joseph Hospital. Before [R3] left for the hospital we checked [R3's] vitals and everything was normal." However, documentation of the aforementioned incident was not available to include the names of the individuals who observed the accident, emergency, or injury; the action taken by the caregiver; the individuals notified by the caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future. 4. In an interview, O1 reported the physician believed R3 had a miniature stroke which caused the aforementioned symptoms. 5. In an interview, O1 acknowledged R1's and R3's medical records did not include documentation of the names of individuals who observed the accident, emergency, or injury; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future.”