North Beverly Assisted Living.

“Based on record review, documentation review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1 . A review of E1's personnel record revealed documentation of fall prevention and fall recovery training being conducted upon hire and annually afterwards was not available for review. 2 . A review of facility documentation revealed a policy titled "Fall Prevention and Fall Recovery." The policy stated "All employees will have a class on fall prevention upon date hired and continuous training on a yearly basis by a school approved and regulated by NCIA board regarding fall prevention and recovery." 3 . In an interview, E2 acknowledged E1 had no documentation of fall prevention and fall recovery training.”

“Based on record review and interview, the manager failed to ensure a manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis as specified in R9-10-113, for one of three personnel sampled. Findings include: 1 . A review of E2's medical record revealed documentation of a chest x-ray stating freedom from infectious tuberculosis (TB), conducted on February 6, 2023. However, documentation of two TB skin tests or a TB blood test was not available for review at the time of inspection. 2 . In an interview, E2 acknowledged E2 had no documentation of freedom from infectious tuberculosis.”

“Based on observation and interview, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area 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. During an environmental inspection of the facility, the Compliance Officers observed nonfunctional door alerts in a vacant resident room and bathroom leading to the backyard. There was a screen door after each door with an alert which had a double-sided key deadbolt. However, the deadbolt for each door was unlocked. 2. During an environmental inspection of the facility, the Compliance Officers observed an occupied resident room with a door that led to the backyard. However, the door had no control or alert. 3. In an interview, E2 acknowledged the aforementioned doors leading to the backyard did not have a control or alert.”

“Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a signed medication order dated February 17, 2025. The medication on the orders included Ropinirole 0.25mg twice a day, and Calcium 500mg twice a day. However, a review of R1's Medication Administration Record (MAR) for the month of April 2025 revealed Ropinirole and Calcium not documented as administered at 5:00 PM from April 1, 2025 to April 14, 2025. 2. In an interview, E2 confirmed all residents receive medication administration. E2 acknowledged R1's medication was not documented as administered.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.   Findings include:   1. During an environmental inspection of the facility, the Compliance Officers observed in a common bathroom a locked cabinet with a magnetic key right beside it. The Compliance Officers were able to use the key to access the inside of the cabinet. The following items were in the cabinet: -A can of "Wizard" Air Freshener; -A Spray bottle with no label; -A can of Lysol Disinfectant Spray; and -A bottle of Lysol Advanced Power Clinging Gel. 2. In an interview, E2 acknowledged the poisonous or toxic materials were not maintained in labeled containers in a locked area and inaccessible to residents.”