Arcadia Grove Assisted Living Home, LLC.

“Based on observation, documentation review, and interview, the manager failed to ensure that a rechargeable fire extinguisher was serviced at least once every 12 months. The deficient practice posed a risk if safety measures were not in place to protect residents in a fire. Findings include: 1. During the environmental tour, the Compliance Officer observed a fire extinguisher affixed to the wall in the hallway. The tag on the fire extinguisher had been marked as "NON-COMPLIANT" as of February 2023 by Metro Fire Equipment Inc. A second fire extinguisher affixed to the wall in the kitchen had also been marked as "NON-COMPLIANT" as of February 2023 by Metro Fire Equipment Inc. 2. A review of facility documentation revealed that the facility had an ongoing contract with Metro Fire, in which Metro Fire would come out to the house to conduct an inspection annually. The online system indicated the home's fire extinguishers were compliant, which was demonstrated by a green flag next to the fire extinguisher section on the account. 3. In a phone/video interview, E5 explained that it was E5's understanding that Metro Fire had conducted the required inspections, as everything in the home's online account for that particular home was marked as compliant according to Metro Fire. E2 and E5 acknowledged that the tags on the two fire extinguishers were currently marked as non-compliant. 4. In an exit interview, the findings were reviewed with E2 and E5, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, for two of three residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review R3's medical records revealed a service plan dated April 5, 2024. The service plan stated R3 was both personal level of care and directed level of care. 2. In an interview, E1 reviewed R3's service plan and acknowledged R3's service plan reflected both personal and directed. E1 reported R3 would be classified as personal level of care.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan that accurately included the amount, type, and frequency of assisted living services being provided to the resident, for three of three sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated July 22, 2024. R1's service plan stated R1 required assistance grooming and dressing daily. However, R1's service plan did not state the amount of services R1 was expected to receive. 2. A review of R2's medical record revealed a service plan dated June 24, 2024. R2's service plan stated R2 required assistance grooming and dressing daily. However, R2's service plan did not state the amount of services R2 was expected to receive. 3. A review of R3's medical record revealed a service plan dated April 3, 2024. R3's service plan stated R3 required assistance grooming and dressing daily. However, R3's service plan did not state the amount of services R3 was expected to receive. 4. In an interview, E1 acknowledged R1's, R2's, and R3's service plan did not reflect the amount of services R1, R2, and R3 were expected to receive.”

“Based on record review and interview, the manager failed to ensure an entry in a resident's medical record was authenticated, for three of three residents sampled. The deficient practice posed a risk as the Department was unable to ensure the facility's compliance. Findings include: 1. 1. R9-10-101.26. states: "Authenticate means to establish authorship of a document or an entry in a medical record by: a. A written signature; b. An individual's initials, if the individual's written signature appears on the document or in the medical record;" 2. A review of R1's medical record revealed a document titled "ADL [Activities of Daily Living] Sheet" September 2024. R1's ADL sheet reflected R1 was provided shower assistance, skin maintenance care, incontinence care, bed bath assistance and assistance with grooming twice daily. ADL sheets contained check marks and slashes to reflect the services provided to R1. However, the entries on the ADL sheets were not authenticated by the individual(s) who provided the services. 3. A review of R2's medical record revealed a document titled "ADL Sheet" September 2024. R2's ADL sheet reflected R2 was provided shower assistance, skin maintenance care, incontinence care, bed bath assistance and assistance with grooming twice daily. ADL sheets contained check marks and slashes to reflect the services provided to R2. However, the entries on the ADL sheets were not authenticated by the individual(s) who provided the services. 4. A review of R3's medical record revealed a document titled "ADL Sheet" September 2024. R3's ADL sheet reflected R3 was provided shower assistance, bed bath assistance and assistance with grooming twice daily. ADL sheets contained check marks and slashes to reflect the services provided to R3. However, the entries on the ADL sheets were not authenticated by the individual(s) who provided the services. 5. In an interview, E1 reviewed and acknowledged R1's, R2's, and R3's "ADL Sheet" reflected the entries in the resident records were not authenticated by the individual(s) who provided the services.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. Findings include: 1. During the environmental tour of the survey, the compliance observed the following poisonous or toxic material accessible in the facility's outdoor sheds: three containers of 123 fl oz of paint, three bags of polymer for concrete, two containers of 18.3 L of paint, and one container of 118fl oz of paint. There were locks on the three sheds, however two of three sheds were unlocked and accessible to residents. 2. In an interview, E1 acknowledged the poisonous or toxic materials found in the facility's backyards sheds.”