Annie's Care Home

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 two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated July 11, 2023. This service plan stated the following services were needed: "Dressing - Requires assistance - Twice daily and as needed" "Check resident's skin at every shower, bath, and PRN" "Resident is encouraged to drink 6-8 cups of water per day" "Resident is checked on every 3-4 hours at night time and as needed during the day..." However, documentation was not available indicating these services were provided August 1st - present. In addition, the service plan stated "Toileting - Requires total care - Daily as needed". However, documentation was not available indicating this service was provided August 14th - present. 2. Review of R2's medical record revealed a current written service plan for directed care services dated July 6, 2023. This service plan stated the following services were needed: "Check resident's skin at every shower, bath, and PRN" "Resident is encouraged to drink 6-8 cups of water per day" "Resident is checked on every 3-4 hours at night time and as needed during the day..." However, documentation was not available indicating these services were provided August 1st - present. 3. In an interview, E1 and E2 acknowledged R1's and R2's medical records did not include documentation of the above listed services and reported the services were provided as indicated in the service plan. 4. Technical assistance was provided on this Rule during the compliance inspection conducted May 20, 2022.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated July 11, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated August 15, 2023. This medication order stated "Fluticas-Salmet 250/50 INH 2 sprays QD". 3. Review of R1's medical record revealed an August 2023 medication administration record (MAR). This MAR stated "Fluticas-salmet 250/50 INH 2 spray QD" and indicated the medication was administered at 8am and 8pm August 1st - present. 4. During an observation of R1's medication, Fluticasone was observed. 5. In an interview, E1 and E2 reported the medication was administered two times a day per the MAR and acknowledged R1's medication was not administered in compliance with the available medication order.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "Disaster Plan For Relocating Residents." A document titled "Disaster Plan - Annual Review" revealed the disaster plan was last reviewed January 2, 2022. 2. In an interview, E1 and E2 acknowledged the facility's disaster plan was not reviewed within the last 12 months.