B and H Adult Care Home.

“Based on record review and interview, the manager failed to ensure that before or at time of acceptance of an individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1) Review of R2's medical record revealed a form titled "Pre-Admission Determination." This document did not include whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints. 2) In an interview, E2 and E4 acknowledged R2's medical record did not contain documentation that included if R2 required continuous medical services, continuous or intermittent nursing services, or restraints at the time of acceptance or within 90 days before R2 was accepted into the facility.”

“Based on observation, record review, and interview, the manager failed to ensure a written service plan included a summary of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of three residents reviewed. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1) During an environmental tour of the facility, the Compliance Officer observed R2 in bed. 2) Review of R2's medical record revealed a written service plan for personal care dated January 5, 2025. This service plan indicated R2 was "ambulatory with unsteady gait" and "able to transfer self from bed to wheelchair, commode, chair, etc." 3) Review of R2's medical record revealed a signed document titled "Certification for Non-Ambulatory Resident to Reside in this Residential Facility" dated December 10, 2024. This document stated R2 was "...confined to a bed or chair because of an inability to ambulate even with assistance..." 4) During an interview, E2 reported R2 was non-ambulatory upon admission and acknowledged R2's service plan did not include documentation of R2's medical or health problems.”

“Based on observation, interview, and record review, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to the resident. Findings include: 1) During an environmental inspection of the facility with E3, the Compliance Officer observed R3 lying in bed. R3's bed had half bedrails along the side at the head of the bed and at the foot of the bed. The Compliance Officer observed a mattress placed on the floor next to R3's bed. 2) In an interview, E3 reported the bedrails were placed in the upright position to prevent R3 from "diving out of bed." 3) A review of R3's medical record revealed a current service plan for directed care services dated March 13, 2025. The service plan stated R3 was bedbound and "requires full assist with all activities of daily living (ADL's) from the caregiver..." 4) In an interview, E2 reported R3 did not get out of bed at all, could not move the rails up or down, and could not move around them, and acknowledged the situation may cause the resident to suffer physical injury.”