Lovecare Co.

“Based on record review and interview, the manager failed to ensure a resident's service plan was documented and updated at least once every three months, for one of one sampled resident receiving directed care services. Findings include: A review of R2's medical record revealed a service plan update, dated June 2, 2025, for Directed Care services. However, service plan updates, dated on or before September 2025 and December 2025, were not available for review. In an interview, E1 reported R2's service plan had been updated earlier in the week and had been misplaced. E1 attempted to locate the updated service plan during the on-site inspection, but was not able to provide the updated service plan during the inspection. In an interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in each resident's medical record, for two of two sampled residents. Findings include: A review of R1's medical record revealed a document titled "A.D.L. Flow Sheet" (ADL) dated February 2026. The ADL documented the services provided to R1 on each day in February 2026, between February 1, 2026, and the date of the inspection, February 13, 2026. However, the form had been left blank on February 1, 3, 6, 7, and February 8, 2026. A review of R2's medical record revealed a document titled "A.D.L. Flow Sheet" (ADL) dated February 2026. The ADL documented the services provided to R2 on each day in February 2026, between February 1, 2026, and the date of the inspection, February 13, 2026. However, the form had been left blank on February 1, 3, 6, 7, and February 10, 2026. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two sampled residents. Findings include: A review of R1's medical record revealed a Medication Administration Record (MAR), dated February 2026. The MAR documented the medications administered to R1 during the month of February 2026, between February 1 and the date of the on-site inspection, February 13, 2026. However, the MAR had been left blank on February 1, 3, 6, 7, 8, and February 10, 2026. A review of R2's medical record revealed a Medication Administration Record (MAR), dated February 2026. The MAR documented the medications administered to R2 during the month of February 2026, between February 1 and the date of the on-site inspection, February 13, 2026. However, the MAR had been left blank on February 1, 3, 6, 7, 8, and February 10, 2026. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the resident or resident's representative requested the resident remain in the facility and the facility obtained a written determination from a medical practitioner every six months stating they have examined the resident and the resident's needs were met by the facility and the resident's needs were within the facility's scope of services, for one of one residents reviewed who were confined to a bed or chair. The deficient practice posed a health and safety risk to the resident if the facility retained a resident who was confined to a bed or chair and the resident's needs were not met. Findings include: 1. A review of R2's (admitted in 2020)medical record revealed a current service plan for directed care services which indicated R2 was bedbound. Further review of R2's medical record revealed a document titled, "Determination for Residency to Continue in the Facility," dated March 2, 2020. The document read, "The resident is unable to ambulate even wit assistance and is confined to a bed or a chair." The document included a section for R2's or R2's Representative signature, however the section was blank. The document also included a section, signed by a primary care provider (PCP), which indicated the PCP had examined R2, reviewed the facilities Scope of Services and made a determination R2's needs could be met by the facility. However, evidence R2 had been examined every six months by a medical provider who determined R2's needs could be met by the facility was unavailable for review. Based on R2's date of admission, this documentation was required. 4. In an interview, E1 reported R2 was non-ambulatory. E1 acknowledged R2's medical record did not include the required documentation to retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance.”