Anna's Carehome

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record for two of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2's medical record revealed no documentation of the services provided for September 2025. 2. A review of R3's medical record revealed no documentation of the services provided for September 2025. 3. In an interview, E1 reported that R2 and R3 received assisted living services from the caregivers. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

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 two of three reviewed residents. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A record review for R2 and R3 revealed that R2 and R3 received medication administraion. 2. An observation of the medication organizers for R2 and R3 revealed that the ordered medications were prefilled in the medication organizers. 3. A record review for R2 and R3 revealed a document titled “Medication Log” dated September 2025, which lacked documentation that medications were administered to R2 and R3. 4. In an interview, E1 reported the medication were administered to R2 and R3. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that the premises and equipment were cleaned and disinfected. The deficient practice posed an infection control risk. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed that a couch in R3's bedroom was dirty with large stains and had a strong odor of cat urine. Additionally, the Compliance Officer observed a strong odor of urine, both pet and human urine, in R3's room. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.