Arcadia Assisted Care Camelhead

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition. Findings include: 1. A review of R1's medical record revealed a service plan dated October 29, 2021. The service plan identified "Physician to be requested to weigh monthly and notify physician of any weight loss of more than 3lbs in one month." However, there was no written service plan reviewed and updated no later than 14 calendar days after the change in R1's physical health condition and services. 2. A review of E1's text correspondence with O1 revealed E1 identified observing significant weight loss concerns for R1 in December 2021. 3. In an interview, E1 acknowledged in December 2021, R1 experienced significant weight loss that E1 reported to R1's physician. E1 acknowledged R1's service plan identified R1 required monthly weights and to notify the physician of any weight loss exceeding three pounds. E1 acknowledged that R1's service plan was not updated until January 29, 2022. E1 acknowledged an updated service plan was not conducted to reflect R1's change in condition and service to address R1's significant weight loss.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for a resident who received personal care services. Findings include: 1. A review of R3's medical record revealed a service plan for personal care services dated June 16, 2022. No additional service plan was available for review. 2. In an interview, E1 reviewed R3's service plan. E1 confirmed that R3's June 16, 2022, service plan was the current service plan found in R3's medical record. E1 reported E1 believed R3 did have another service plan completed however E1 could not locate it. E1 acknowledged the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for a resident who received personal care services.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or resident's representative for one of the three residents sampled. Findings include: 1. Review of R1's record revealed service plans for directed care services dated July 29, 2021, October 29, 2021, and January 29, 2022. However, the service plans did not include a signature and date from the resident or resident's representative. 2. In an interview, E1 reviewed R1's medical record. E1 acknowledged that R1's service plans did not include a signature and date from the resident or resident's representative.

Based on record review, observation, and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of two residents sampled. Findings include: 1. Review of R2's medical record revealed service plans for personal care services dated March 1, 2023, and September 1, 2022. The service plan documented R2 required the following assisted living service: "Resident needs to wear helmet outside of bed. Resident is able to self transfer but occasionally requires staff. Staff to notify Physician of any changes." Review of R2's medical record revealed no documentation of R2 wearing the helmet outside of bed or any notification to R2's physician identifying any changes. 2. The compliance officer observed E1 locate R2's helmet in an empty resident bedroom. 3. In an interview, R2 reported R2 had not worn the helmet since admission. R2 reported R2 needed to wear the helmet when out of bed due to a head injury. R2 reported R2 was unaware of where the helmet was located. R2 reported R2 did not wear the helmet when out of bed due to not knowing where it was. 4. In an interview, E2 reported E2 "never seen R2 wear the helmet in the 3 years I've been working." E2 acknowledged R2 does not wear the helmet when outside of R2's bed. 5. In an interview, E1 acknowledged R2's medical record revealed R2 needs to wear the helmet outside of bed. E1 reported E1 encouraged R2 to wear the helmet. E1 acknowledged there was no documentation in R2's medical record to reveal R2's physician was notified of R2's refusal to wear the helmet as identified in the service plan. E1 acknowledged R2 was not provided the assisted living services according to R2's service plan.

Based on documentation review, record review and interview, the manager failed to ensure a resident's medical record contained documentation of a significant change in a resident's behavior, physical, cognitive, or functional condition and the action taken by a manager or caregiver to address the resident's changing needs. Findings include: 1. A review of E1's text messages reportedly between E1 and R1's public fiduciary revealed E1 identified in December 2021, a change in R1's physical health condition. E1 identified a significant weight loss concern. The text message from O1 reflected R1 weighed 144 pounds at admission to the facility and was found to be 87 pounds in March 2022. 2. A review of R1's medical record revealed no documentation in the medical record that identified action taken by a manager or caregiver to address the resident's weight loss. 3. In an interview, E1 reported E1 notified R1's physician at the time of E1's concerns with R1's weight loss. E1 acknowledged R1's medical record did not include documentation of R1's change in condition and action taken to address R1's changing needs.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated for one of two residents reviewed receiving directed care services. Findings include: 1. Review of R1's record revealed service plans for directed care services dated July 29, 2021, October 29, 2021, and January 29, 2022. These service plans revealed no documentation of R1's weight. 2. The service plan dated October 29, 2021 identified "Physician to be requested to weigh monthly and notify physician of any weight loss of more than 3lbs in one month." A review of R1's record revealed documentation from a medical practitioner stating weighing R1 was contraindicated. However, this document was not completed until February 1, 2022. 3. A review of E1's text correspondence with O1 revealed E1 identified observing significant weight loss concerns for R1 in December 2021. 4. In an interview, E1 acknowledged R1's service plan identified R1 required monthly weights and to notify the physician of any weight loss exceeding three pounds; however, the service plans did not include documentation of the resident's weight. E1 acknowledged additional documentation was not available from a medical practitioner stating weighing the identified resident was contraindicated during the time frame of the service plans identified.