Assisted Senior Living Care LLC

Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included cognitive stimulation and activities to maximize functioning, for two of two residents sampled. Findings include: 1. A review of R1’s service plan, dated February 15, 2025, revealed R1 received directed care services. R1’s service plan also revealed a section titled, “Cognitive stimulation and strategies.” However, the section was blank. 2. A review of R2’s service plan, dated March 24, 2025, revealed R2 received directed care services. R2’s service plan also revealed a section titled, “Cognitive stimulation and strategies.” However, the section was blank. 3. In an interview, E2 acknowledged R1’s and R2’s service plans did not include cognitive stimulation and activities to maximize functioning.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that, when initially developed, was signed and dated by the resident or resident's representative, the manager, and the nurse who reviewed the service plan, for one of two residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a completed service plan, dated February 15, 2025, that was signed and dated by the nurse who reviewed the service plan, the facility's manager, and R1. However, R1's service plan revealed R1 required directed care services and was unable to sign R1's service plan. 2. A review of R2's medical record revealed a completed service plan, dated March 24, 2025, that was signed and dated by the nurse who reviewed the service plan, the facility's manager, and R2's representative. However, the service plan was dated by the manager and R2's representative on March 25, 2025, although the inspection took place on March 24, 2025. 3. In an interview, E2 acknowledged R1's and R2's service plans were not signed and dated by the resident or resident's representative, the manager, and the nurse who reviewed the service plan.

Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was accurately 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. Findings include: 1. A review of R2’s medical record revealed a medication order, dated March 5, 2025, for Lopressor 50 milligrams (mg), 0.5 tablet by mouth (po) twice a day (bid). 2. A review of R2’s medication administration record (MAR) revealed R2 was to be administered Lopressor 50 mg, 0.25 tablet po bid. However, the MAR indicated R2 received 0.25 tablet at 8:00 AM March 1, 2025 - present. 3. While on-site for the compliance and complaint inspection, the Compliance Officer observed Lopressor 50 mg tablets stored at the facility for administration to R2. 4. In an interview, E2 reported R2 was administered 25 mg, or 0.5 tablet, of Lopressor at 8:00 AM and 8:00 PM March 1, 2025 - present. However, E2 acknowledged medication administered to R2 was not accurately documented in R2’s medical record.

Based on observation and interview, the manager failed to ensure that foods requiring refrigeration were maintained at 41° F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following sauces open and stored in the facility’s unrefrigerated pantry: Kikkoman Soy Sauce; Kikkoman Teriyaki Sauce; and Kikkoman Stir Fry Orange Sauce. 2. The Compliance Officer also observed the following food products open and stored in an unrefrigerated cabinet in the facility’s kitchen: Heinz Tomato Ketchup; and Great Value Grated Parmesan Cheese. 3. In an interview, E2 reported E2 was unaware the aforementioned food products required refrigeration. E2 acknowledged that the foods requiring refrigeration were not maintained at 41° F or below.

Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a health and safety risk to residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following materials stored outside in the paved patio area: Two shopping carts; and Multiple bed frames leaning up against the side of the facility. 2. During an environmental tour of the facility, the Compliance Officer observed the facility's hose attached to the spigot on the side of the facility and lying across the paved walkway. 3. The Compliance Officer also observed the following materials stored to the side of the facility's outdoor shed: A grocery bag of trash; An unattached and broken window screen; An electric wheelchair; A mechanical wheelchair; A walker; Two portable commodes stacked on top of each other; Broken wooden boards; A discarded laundry soap container; and A broken bed frame. 4. The Compliance Officer also observed a plastic container attached to the side of the facility's external wall used to cover electrical wires to be detached from the wall and hanging open. 5. In an interview, E2 reported the facility is waiting to schedule pickup of the materials stored in the backyard. E2 acknowledged the premises and equipment used at the facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a health and safety risk for residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a water temperature of 134º F in the shared bathroom for residents. 2. In an interview, E2 acknowledged the hot water temperatures were not maintained between 95º F and 120º F in areas used by residents.