Moonlight Manor Assisted Living Home.

“Based on record review and interview, the manager failed to provide the emergency responder with 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 an incident report dated April 28, 2025. 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.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of four caregivers. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Review of E4’s personnel record revealed E4 worked as a caregiver and had a hire date of July 10, 2010. The personnel record revealed a first aid and CPR training card with an expiration date of February 27, 2025. There was no additional documentation available to review. 2. Review of March 2025 personnel schedule revealed E4 worked the 7 am – 7:30 pm shift on Mondays. 3. In an interview, E1 acknowledged that E4's personnel record did not have current documentation of first aid and CPR training.”

“Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative for one of three residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. Review of R1's medical record revealed a current written service plan for personal care services dated April 21, 2025. However, this service plan did not include a signature and date from the resident or representative. 2. In an interview, E1 acknowledged that R1's service plan did not include a signature and date from the resident or representative. This is a repeat deficiency from the compliance inspection conducted on May 4, 2022.”

“Based on record review and interview, the manager failed to ensure that when a resident had an incident that resulted in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for one of three residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed an incident report dated April 28, 2025. This document indicated R1 was not feeling well, and 911 was called. R1 was transported to the emergency room. 2. There was no documentation to demonstrate that the primary care physician or the resident's power of attorney (POA) was notified of this occurrence.  3. In an interview with E1, E1 acknowledged the primary care physician and POA were not notified and revealed there was no further documentation available for review.”

“Based on record review and interview, the manager failed to ensure a resident medical record contained documentation of a medication administered to a resident that included the date and time of administration; the name, strength, dosage, and route of administration; the name and signature of the individual administering the medication; and an unexpected reaction a resident had to the medication, for one of three residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed no documentation of a September 2024 medication administration record (MAR). Based on the resident's date of acceptance, this documentation was required. 2. In an interview, O1, E1, and E2 acknowledged R1 received medication administration and the September 2024 MAR was not available for review.”

“Based on documentation review, record review, and interview, the manager failed to ensure an caregiver or assistant caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for two of two sampled caregiver and assistant caregivers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. A review of E2's (hired as a caregiver) and E3's (hired as an assistant caregiver) personnel records revealed no documented verification of E2's and E3's skills and knowledge. 2. In an interview, E1 and E4 acknowledged E2's and E3's personnel records did not contain documented verification of skills and knowledge.”

“Based on an observation and interview, the manager failed to ensure a means of exiting the facility 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 the environmental inspection of the facility, the Compliance Officer observed nine of the ten resident bedrooms had a door leading from the residents' rooms to a patio outside of the residents' rooms. The Compliance Officer observed the doors had no mechanism to alert employees of the egress of a resident from the facility. 2. In an interview, E4 acknowledged nine of the ten bedrooms for residents of the facility had patios and the doors had no mechanism to alert the staff of a resident leaving the facility.”

“Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures were implemented for discarding medication and discarding expired medication. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Policy and Procedure." The policy stated, "For residents who are not capable of managing their own medications, the following policy and procedures apply: ....8) Expired medications and medications which have been permanently discontinued will be returned to the responsible party, or if there is no responsible party, to the pharmacy for disposal." 2. During a facility tour, the surveyor observed a bottle of "Morphine Sulfate Oral Solution 100milligrams (MG)", two bottles, three boxes and three bags of prefilled syringes Qty 20 of "Lorazepam Intersol Oral Concentrate 2mg", three bags Qty 5 of "Acetaminophen Sup 650mg." in a refrigerator in the medication closet. 3. In an interview, E1 and E4 acknowledged the medication had not been disposed of. E1 and E4 reported the medications were for residents who were no longer at the facility for over four months.”

“Based on observation and interview, the manager failed to ensure that garbage and refuse were removed from the premises at least once a week. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed in several residents bedrooms and in the resident bathrooms small trash can filled with garbage, such as briefs, toilet paper, women's sanitary pads. 2. In an interview E4 acknowledged the garbage cans were overfilled with trash.”