All Care Assisted Living Home, LLC.

“Based on record review and interview, the manager failed to provide to the emergency responder a written document that included all required documentation, for one of three residents sampled. Findings include: 1. A review of R1's medical record revealed a progress report dated September 23, 2024. The progress report revealed R1 had an accident, emergency, or injury, the facility contacted an emergency responder, and R1 was taken to the hospital. However, the documented information provided to the emergency responder did not include the following: -The reason or reasons the emergency responder was requested on behalf of R1; -The name, address and telephone number of the resident's current pharmacy; -The point-of-contact information for the assisted living home, including the cell phone number and email address; and -A copy of R1's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living home to plan for R1's discharge. 2. In an interview, E1 reported E1 was not familiar with the entire statute. E1 had not yet updated the facility documentation to include the required information.”

“Based on observation, record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of three residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan dated August 2024. The service plan identified R2 was incontinent and wore briefs. However, a progress note dated August 30, 2024 indicated R2 came back from the hospital with a foley catheter. There was no written service plan reviewed and updated no later than 14 calendar days after August 30, 2024. 2. R2 was observed to have a foley catheter at the time of the survey inspection. 3. In an interview, E1 acknowledged the service plan for R2 was not updated within 14 days after a significant change in condition.”

“Based on record review and interview, for one of three residents reviewed, who received personal care services, the manager failed to ensure the service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. The deficient practice posed a health and safety risk to residents, if staff were unaware of the skin maintenance services needed by a resident. Findings include: 1. In record review, R1's medical record included a treatment order by a Podiatrist, dated May 23, 2024, which documented, "Leave initial dressing in place for two days...begin twice daily cleansing and dressing changes...cleanse with hydrogen peroxide and gauze, pat dry...apply betadine to nail bed. Cover with fresh band-aid. Continue care for 1-2 weeks until no drainage remains. Contact Dr if any questions concerns". 2. In record review, R1's service plan dated May 23, 2024, documented, "nail bed removed from right great...skin observation performed daily or with any skin changes. Staff to report any skin changes... " The service plan did not include all of the skin maintenance services required by R1. 3. During an interview, the findings were reviewed with E1 who acknowledged R1's service plan did not include the skin maintenance services provided for R1, to prevent and treat bruises, injuries, pressure sores and infections, and per instruction from the Podiatrist.”

“Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk if facility staff were unable to implement the disaster plan. Findings include: 1. A review of facility documentation revealed a disaster plan review conducted on October 14, 2022. However, documentation of a disaster plan review conducted within 12 months was not available for review. 2. In an interview, E1 acknowledged the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months.”