Gold Star Care Home.

“Based on record review and interview, for one of two residents reviewed, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation signed and dated by a Physician, Registered Nurse Practitioner, Registered Nurse, or Physician Assistant which included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. The deficient practice posed a safety risk if residents were not appropriately assessed on acceptance. Findings include: 1. In record review, R2's medical record (received directed care services) did not include documentation, signed and dated, which included whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on the resident's date of acceptance, this documentation was required. 2. During an interview, E1 acknowledged the resident's record did not include the required signed and dated documentation by a Physician, Registered Nurse Practitioner, Registered Nurse, or Physician Assistant , which indicated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 3. This is a repeat deficiency from the compliance inspection conducted on September 27, 2022.”

“Based on observation, record review, and interview, for one of two residents who were unable to walk, and receiving directed care services, the manager failed to ensure the resident's primary care provider (PCP) or other medical practitioner (MP) examined the resident at the onset of the condition, reviewed the facility's scope of services, and signed and dated a determination stating the resident's needs could be met by the facility. The deficient practice posed a risk to residents if the resident's PCP or MP did not acknowledge and sign the documentation acknowledging the resident's needs could be met by the facility, within the facility's scope of services. R9-10-814.B.2.B includes the following: 2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: a. The resident or resident's representative requests that the resident be accepted by or remain in the assisted living facility; b. The resident's primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition; ii. Reviews the assisted living facility's scope of services; and iii.Signs and dates a determination stating that the resident ' s needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility; and c. The resident's service plan includes the resident's increased need for personal care services. Findings include: 1. In observation, R2 was observed in bed during the inspection. 2. In record review, R2's service plan (received directed care services), dated September 25, 2023, documented, "[R2] is in bed all the time... caregiver do everything... paralysis left leg..." R2's record did not include documentation, signed and dated, by the resident's PCP or MP acknowledging the resident's needs could be met by the facility, and did not include documentation the resident or resident's representative requested to be accepted in the assisted living facility. Based on the residents acceptance date, this documentation was required. 3. During an interview, E1 acknowledged a determination for R2 was signed by a registered nurse; however, the document was required to be signed by a PCP or MP. 4. This is a repeat deficiency from the compliance inspection conducted on September 27, 2022.”

“Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a health and safety risk to residents and employees if the disaster plan was not up-to-date to adequately meet the needs of the residents during a disaster. Findings include: 1. In documentation review, the facility's disaster plan did not include documentation the disaster plan was reviewed in the last 12 months. The last documented reviw was dated October 29, 2021. 2. During an interview, E1 reported being unaware if the disaster plan had been reviewed, and acknowledged the facility did not have documentation the disaster plan was reviewed, as required.”

“Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents included all individuals on the premises, except for a resident whose medical record contained documentation that evacuation from the facility would cause harm to the resident. The deficient practice posed a health and safety risk to residents and employees if the employees were unable to implement the evacuation plan. Findings include: 1. In documentation review, the facility's employee and resident evacuation drills were documented as conducted on November 1, 2022, and May 1, 2023. The documentation indicated R2 participated in the evacuation drills and required full assistance in wheelchair, 2. In observation, R2 was observed in bed during the inspection. 3. In record review, R2's service plan (received directed care services) September 25, 2023, documented, "[R2] is in bed all the time... caregiver do everything... paralysis left leg..." 4. During an interview, E1 reported R2 was confined to a bed or chair. E1 reported R2 was not evacuated during the evacuation drills. E1 acknowledged the evacuation drill documentation is required to include the names of the residents not evacuated. E1 acknowledged all persons on the premises are to be evacuated except a resident whose record had documentation the evacuation would cause harm, and acknowledged R2's record did not include this documentation.”

“Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'ba F and 120\'ba F. Findings include: 1. During an environmental inspection with E1, hot water temperatures were measured in resident bathrooms. The hot water temperature measured at 126.4 in one bathroom, located in a hallway between resident bedrooms, and observed to be used by residents. The water temperature measured at 127.9 in the master bathroom, occupied by resident. 2. During an interview, E1 reported the facility checked water temperatures; however, acknowledged the hot water temperatures were above the required 95\'ba F and 120\'ba F.”