Senior Care Assisted Living LLC.

“Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f.   Findings include:   1. A review of E2’s and E3’s personnel records revealed annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review.   2. A review of E2’s personnel record revealed a single-step Mantoux skin test (TST). However, a second-step TST was not available for review and a baseline screening to include a risk assessment and symptom screening, signed by an occupation health provider, was not available for review. E2’s personnel record did not contain documentation of a two-step skin test as recommended by R9-10-113.A.1.a   3. In an interview, E1 acknowledged the health care institution had not documented and implemented tuberculosis infection control activities as required in R9-10-113.A.2.a-f.”

“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 one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. 1. A review of R2's medical record revealed a service plan, dated December 13, 2024, for personal care services including medication administration. The service plan stated, "Oxygen Therapy 2LPM - Continuous... Check oxygen flow once each shift to make sure it is flowing at the rate ordered, per MAR (Medication Administration Record)." 2. A review of R2's medical record revealed a prescription dated August 9, 2024 for, "D/C Senna S BID. Start Senna S 8.5 mg/ 50 mg, Daily. Hold for loose stools." 3. A review of R2's medical record revealed a prescription dated July 10, 2024 for, "Nasal Cannula 4 Liters." 4. A review of R2's medical record revealed a medication administration record (MAR) sheet for April 2025 . The Mar included the following: For, "Senna S Tab 8.6-50 MG, Take 1 tablet by mouth once daily," the MAR documented this medication had been provided twice per day, at 8 AM and at 5 PM, on each day in April 2025; and Oxygen administration was not documented on the MAR. 5. In an interview, E1 acknowledged R2's medical record did not contain accurate documentation of the medications administered to R2. This is a repeat deficiency from the on-site compliance inspection conducted on March 14, 2024.”

“Based on observation and interview, the manager failed to ensure that foods requiring refrigeration were maintained at 41° F or below. Findings include:  1. During an environmental inspection of the facility, the Compliance officer observed a refrigerator in the kitchen contained items requiring refrigeration. However,  a thermometer in the door of the refrigerator read 52° F. The Compliance Officer observed E1 placed a second thermometer in the refrigerator. However, after approximately one half hour, both thermometers read 54° F. 2 . The Compliance Officer used a non-contact infrared thermometer to check the temperature of the air vent inside the refrigerator and observed the air was entering the refrigerator at 51° F. The Compliance Officer also observed the vertical support between the refrigerator and freezer was warm to the touch. 3. In an interview, E1 acknowledged foods requiring refrigeration had not been maintained at 41° F or below.”

“Based on record review and interview, the manager failed to ensure a residency agreement included the date of occupancy, for one of two residents reviewed. Findings include: 1. A review of R2's medical record revealed a residency agreement. However, this residency agreement did not include documentation of R2's date of occupancy. Based on R2's acceptance date, this documentation was required. 2. In an interview, E1 and O1 acknowledged R2's residency agreement did not include the date of occupancy.”

“Based on documentation review, record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two sampled residents reviewed. Findings include: 1. A review of R1's medical record revealed a service plan, dated November 13, 2023, for personal care services. The service plan included the provision of the following service to R1: - "Foley Catheter: 1) Make sure collection bag is always below the level of the bladder 2) Empty bag each shift and as necessary 3) Report any of the following to nurse or [doctor]; cloudy urine, foul odor, fever, chills, loss of appetite, confusion, and/or no urine output for more than 8 hours. 4) Clean area around catheter daily. Make sure you do not pull on the catheter. 5) Put leg bag on in the morning and large bag at night. 6) Clean catheter bags daily, when they're removed, with a solution of 50% white vinegar, allow to air dry." 2. A review of R1's medical record revealed a form titled, "Activities of Daily Living Record," (ADL) dated March 2024. The ADL documented the services provided to R1, however, the form did not include documentation of foley catheter services provided to R1. 3. In an interview, E1 and O1 acknowledged the provided medical records did not include documentation of all of the services provided to R1.”

“Based on documentation review, observation, and interview, the manager failed to ensure 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, 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. A documentation review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During a facility tour, the Compliance Officer observed the front door of the facility had a door alarm taped to the top side of the door. However, the door alarm did not sound when the Compliance Officer opened the door. The surveyor observed E1 attempt to repair the door alarm and replace the batteries, however, E1 was not able to fix the front door alarm during the on-site inspection 3. During a facility tour, the surveyor observed the front yard was fenced, however, the front gate did not have a lock. 4. During a facility tour, the surveyor observed the back door did not have an alarm and had a thumb turn latch on the interior side. 5. In an interview, E1 reported the back door alarm was broken and had been removed. E1 and O1 acknowledged a resident could egress through either the front or back door without alerting a caregiver to the egress of the resident.”

“Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a service plan, dated November 13, 2023, for personal care services. The service plan indicated, "[R1] goes to dialysis on Monday, Wednesday, and Friday mornings. [R1] is appointment is at 7 AM. [R1] is picked up between 6-6:30 AM and returned between 11-11:30 AM." 2. A review of R1's medical record revealed a medication administration record (MAR) dated March 2024. The MAR indicated R1 had been provided the following medications every day at 8:00 AM to include Mondays, Wednesdays, and Fridays: - Pantoprazole Sodium, Phenytoin Sodium, Velphoro, Loratadine, Carbamazepine, Docusate Sodium, Ondansetron, and Sulfamethoxazole/Trimethoprim DS 3. In an interview, E1 reported E1 used to provide medications to R1 at 6:30 AM instead of 8:00 AM as scheduled on dialysis days. E1 reported after a recent transportation error, R1 is now going to dialysis around 9 AM and returning between 1:30-2:30 PM. E1 reported noon medications are administered after R1 returns from dialysis. E1 reported medication had been intentionally administered to R1 more than an hour before or after the scheduled time on dialysis days instead of moving R1's time of medication administration on all days to a time which would facilitate the dialysis schedule. 4. A review of R1's medical record revealed a medication administration record (MAR) dated March 2024. The MAR indicated R1 had been provided the following medication every day at 12:00 PM to include Mondays, Wednesdays, and Fridays: Carbamazepine. 6. A review of R2's medical record revealed a service plan, dated February 8, 2024, for personal care services including medication administration. 7. A review of R2's medical record revealed an order, dated October 25, 2023, for the following: "Medihoney 80% topical gel, apply topical in between affected toe every other day until gone for skin tear." 8. A review of R2's medical record revealed a list of orders, dated July 31, 2023, which included the following: "Hydralazine 25 mg tablet, take 1 tablet by oral rout every 8 hours as needed for SBP > 160. Recheck BP in one hour and call nurse practitioner if SBP > 160 after dose"; and "Diclofenac 1% Topical gel, apply 2 gram by topical route 4 times every day to the affected areas for PAIN HANDS." 9. A review of R2's medical record revealed an order, dated March 5, 2024, for the following: "D/C Medihoney." 10. A review of R2's medical record revealed a MAR, dated March 2024. However, the MAR indicated R2 had not been provided Medihoney or Diclofenac gel on any day in March, and indicated Hydralazine was discontinued. 11. A review of R2's November 2023, December 2023, January 2024, and February 2024 MAR's revealed Medihoney had not been administered on any day. 12. In an interview, E1 reported R1's hydralazine had been discontinued and provided an order as evidence. 13. A review of the order provided by E1 revealed an order, dated August 16, 2023, which stated, "Discontinue Hydrochlorothiazide." However, an order to discontinue Hydralazine was not available for review. 14. In an interview, E1 and O1 acknowledged medication had not been administered to R1 or to R2 in compliance with a medication order. This is a repeat deficiency from the on-site compliance inspection conducted on March 20, 2023.”

“Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two sampled residents who received medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a service plan, dated November 13, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed a prescription, dated March 4, 2024, which stated, "I prescribed an antibiotic - Cefpodoxime - that [R1] will take twice a day for 10 days. After that I will order another urine culture. [R1] needs to stop Protonix while [R1] takes the antibiotic, because there is an interaction between the two medications." 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated March 2024. The MAR documented the following: - "Pantoprazole Sodium Tabs, 20 MG (Protonix), take 1 tablet by mouth every morning 30 minutes before breakfast," had been administered on each day between March 1, 2024 and March 13, 2024, and had not been held as ordered; and - Cefpodoxime administration was not documented to have occurred as ordered on any day in March 2024. 4. The Compliance Officer observed R1's medications included an empty bottle of "Cefpodoxime Tab 100MG," filled on March 4, 2024. The Compliance Officer observed R1's bottle of Protonix had a red sticker on the cap with a hand written note to hold the medication. 5. In an interview, E1 and O1 reported the antibiotic order was followed, however, E1 and O1 acknowledged the provided documentation of medication administration for R1 was not accurate.”

“Based on record review and interview, the manager failed to ensure a current therapeutic diet manual was available for use by personnel members. Findings include: 1. The Compliance Officer requested the facility's therapeutic diet manual. However, a therapeutic diet manual was not provided for review. 2. A review of R2's medical record revealed a residency agreement which stated, "17....special diets will be provided only on Primary Care Provider's written order." 3. In an interview, E1 and O1 acknowledged a therapeutic diet manual had not been provided for review. Technical assistance for this rule was provided during the on-site compliance inspection conducted on March 20, 2023.”

“Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer, accurate to plus or minus 3\'b0 F, which posed a health and safety risk if the refrigerator was not maintained at a proper temperature. Findings include: 1. During the facility tour with E1, the Compliance Officer observed that there was a thermometer in a refrigerator located in the kitchen. However, the thermometer was broken and could not be read. The Compliance Officer observed the glass tube was detached from the scale, and the red ethanol inside the capillary tube was missing. 2. In an interview, E1 and O1 acknowledged the thermometer in the refrigerator was broken and could not be used to determine the temperature of the refrigerator to within 3\'b0 F. O1 immediately moved a thermometer from the freezer compartment into the refrigerator compartment. This is a repeat deficiency from the on-site compliance inspection conducted on March 20, 2023.”

“Based on documentation review, record review, and interview, the manager failed to ensure an individual who administered an opioid in treating a patient documented in the patient's medical record an identification of the patient's need for the opioid before the opioid was administered and the effect of the opioid administered, for one of one residents sampled who was administered an opioid. Findings include: 1. A review of the facility's policies and procedures, reviewed January 1, 2023, revealed a policy titled, "Opioid Policy and Procedure," which stated, "C. The Manager or Manager's Designee will ensure that the caregiver administering the opioid medication documents in the resident's medical record an identification of the resident's pain before the opioid was administered and the effect of the opioid administered." 2. A review of R2's medical record revealed a service plan, dated February 8, 2024, for personal care services including medication administration. The service plan indicated R2 did not receive hospice services. 3. A review of R2's medical record revealed a signed list of medication orders dated July 31, 2023. The list included the order, "tramadol 50 mg tablet, take 1 tablet by oral route every morning..for chronic arthritis pain." 4. A review of R2's medical record revealed a Medication Administration Record (MAR) dated March 2024. The MAR indicated R2 had been administered Tramadol on each day in March 2024. 5. A review of R2's medical record revealed a pain scale record, or other documentation of assessment and monitoring of R2 related to the administration of the opioid medication, was not available for review. 6. In an interview, E1 and O1 acknowledged the caregivers administering opioids to R2 had not documented the identification of R2's need for the opioid before every administered dose and had not documented monitoring of the effectiveness of the opioid in the manner prescribed by the facility's policies and procedures.”