A Caring Manor.

“Based on documentation review and interview, the manager failed to implement the facility's 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 Program." This policy stated, "...2. Quality Management program will consist off the following items:...2. Review and evaluate the effectiveness of the quality management program once every 12 months...the manager shall ensure the following: 1. A plan is established, documented, and implemented for an ongoing quality management program..."   2. The Compliance Officer requested to review the facility's quality management program and supporting documentation. However, no documentation was provided for review. 3.  During an interview, E1 and E2 acknowledged a quality management report was not available for review.”

“Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for one of three personnel records sampled. The deficient practice posed a risk if the employees were unable to meet residents' needs. Findings include: 1. A review of facility documentation revealed a policy titled "New Employee Orientation." The policy stated, "…before providing assisted living services to a resident, a manager…receives orientation that is specific to the duties to be performed by the manager…” 2. A review of E3's personnel record revealed no documentation of completed orientation. Based on E3's hire date orientation was required. 3. In an interview, E1 and E2 acknowledged E3's personnel record did not include documentation of orientation.”

“Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include:  1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."   2. A review of R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required.   3. In an interview, E1 and E2 acknowledged R1's medical records did not include documentation of a risk assessment of prior exposure to infectious TB or a determination if they had signs or symptoms of TB.”

“Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was dated and signed by a medical practitioner or registered nurse, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1’s medical record revealed a document titled "Admission Orders or Consent to Continue Residency." This document was signed by a medical practitioner. However, the documentation was signed after R1’s move-in date. 2. In an interview, E1 acknowledged R1’s medical record did not contain the required documentation that was dated 90 days before R1 was accepted by the facility.”

“Based on record review, observation, and interview, the manager failed to ensure a resident's medical record contained documentation of a medication administered to the resident that included the correct strength, for one of two residents reviewed. The deficient practice posed a risk as medication administration could not be verified against a medication order.   Findings include:   1. A review of R1's medical record revealed a medication order (dated February 7, 2025) which stated "Trazodone HCL Oral Tablet 100 MG; 1 tab by mouth at bedtime for chronic insomnia."   2. A review of R1's medication revealed a container of Trazodone 100 mg Tablets.   3. A review of R1's medication administration record (MAR) showed "Trazodone 50mg tablet" recorded as administered at bedtime from March 1, 2025 - April 1, 2025.   4. In an interview, E1 acknowledged R1's medical record did not contain documentation of a medication administered to the resident that included the correct strength.”

“Based on documentation review, observation, and interview, the manager failed to ensure that 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. A review of Department documentation revealed the facility was licensed to provide directed care services.   2. During the environmental tour of the facility, the Compliance Officer observed an unlocked door leading to the backyard. The backdoor was equipped with an alarm to alert employees of egress; however, the alarm was not turned on at the time of inspection. 3. In an interview, E1 and E2 acknowledged that there was no means of exiting the facility that controlled or alerted employees of the resident's egress.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk to the health and safety of residents as medications were not administered as ordered. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed a signed medication order for the following medication: -Trazodone Hydrochloride; 100mg tablet, 1 tab by mouth at bedtime for chronic insomnia 3. A review of R1’s medications revealed a bottle of Trazodone labeled 100 mg tablets. Further review revealed R1’s medication administration record (MAR) for March 2025 and April 2025 documented Trazodone; 50 mg; take one tab at bedtime for sleep..." 4. In an interview, E1 reported the medication was administered per the MAR and acknowledged R1’s medication was not administered in compliance with a medication order. This is a repeat deficiency from the inspections completed on August 18, 2023 and May 11, 2022.”

“Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication. Findings include: 1) During the environmental inspection of the facility, the Compliance Officer observed a Ziploc bag that contained insulin pens in R1’s bedroom. 2) A review of R1's medication orders revealed R1 received insulin glargine (Lantus); 20 units SubCutaneous; Once every day. 3) In an interview, E1 reported E1 administered the insulin per medication orders. 4) In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.   ”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed Lysol All Purpose Cleaner, Cascade detergent pods, Rug Doctor Pet Deep Carpet Cleaner, and Finish Jet-Dry rinse aid in an unlocked cabinet under the kitchen sink. 2. In an interview, E1 and E2 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and inaccessible to residents.”