Crystal Rose.

“Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident that covered required skills and knowledge for employees and volunteers. Findings include: 1. A review of facility documentation revealed a policy titled "Caregiver's Qualifications, Job Descriptions, and Duties and Responsibilities." The policy stated, "Caregiver's skills and knowledge will be verified and documented before providing services and according to policies and procedures." 2 . In an interview, E1 acknowledged a policy covering how skills and knowledge were verified and documented was not available for review at the time of inspection.”

“Based on record review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, for one of two personnel members sampled. Findings include: 1. A review of E2's personnel record revealed documentation of skills and knowledge verified before providing services was not available for review. 2. In an interview, E1 acknowledged E2's personnel record did not contain documentation of skills and knowledge verified before providing services.”

“Based on observation and interview, the manager failed to ensure there was a means of exiting the facility, for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, that allowed the resident to be at least 30 feet away from the facility, and controlled or alerted employees of the egress of a resident from the facility. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed an alert on the front door and the back door of the facility. The front door alert was turned off, and the back door alert was not functioning on the current setting. While on-site, the Compliance Officer observed E2 turn on the alert for the front door and fix the alert on the back door so both were functional. 2 . In an interview, E1 acknowledged the alerts on the front and back door of the facility were not able to alert an employee of egress from the facility.”

“Based on record review and interview, the manager failed to ensure medication administration for a resident was documented in the resident's medical record. Findings include: 1. A review of R1's medical record revealed a signed medication list dated December 9, 2024. The following medications were listed on the order: -Aspirin 81 MG 1 tablet at bedtime; -Atorvastatin 80 MG 1 tablet at bedtime; -Divalproex Sodium 250 MG 2 tablets a day; -Famotidine 40 MG 1 Tablet a day; -Levothyroxine 112 MCG 1 tablet a day; -Losartan Potassium 25 MG 1 tablet a day; -Metoprolol Tartrate 25 MG 1/2 a tablet twice a day; -Hydroxyzine 10 MG 1 tablet twice a day; -Guanfacine 3 MG 1 tablet a day; -Zoloft 100 MG 1 and 1/2 tablets a day; -Methenamine Hippurate 1 MG 1 tablet a day; and -Methylphenidate 5 MG 1 tablet during the day and 1 tablet at night. However, a review of R1's Medication Administration Record (MAR) for February 2025 and March 2025 revealed the above medication was not documented as administered from February 27, 2025 to March 3, 2025. 2. In an interview, R1 reported R1 had received R1's medication as prescribed. 3. In an interview, E1 acknowledged R1's medication was not documented as administered from February 27, 2025 to March 3, 2025.”