B and H Adult Care Home

Based on record review and interview, the manager failed to ensure that before or at time of acceptance of an individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1) Review of R2's medical record revealed a form titled "Pre-Admission Determination." This document did not include whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints. 2) In an interview, E2 and E4 acknowledged R2's medical record did not contain documentation that included if R2 required continuous medical services, continuous or intermittent nursing services, or restraints at the time of acceptance or within 90 days before R2 was accepted into the facility.

Based on observation, record review, and interview, the manager failed to ensure a written service plan included a summary of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of three residents reviewed. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1) During an environmental tour of the facility, the Compliance Officer observed R2 in bed. 2) Review of R2's medical record revealed a written service plan for personal care dated January 5, 2025. This service plan indicated R2 was "ambulatory with unsteady gait" and "able to transfer self from bed to wheelchair, commode, chair, etc." 3) Review of R2's medical record revealed a signed document titled "Certification for Non-Ambulatory Resident to Reside in this Residential Facility" dated December 10, 2024. This document stated R2 was "...confined to a bed or chair because of an inability to ambulate even with assistance..." 4) During an interview, E2 reported R2 was non-ambulatory upon admission and acknowledged R2's service plan did not include documentation of R2's medical or health problems.

Based on observation, interview, and record review, the manager failed to ensure the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to the resident. Findings include: 1) During an environmental inspection of the facility with E3, the Compliance Officer observed R3 lying in bed. R3's bed had half bedrails along the side at the head of the bed and at the foot of the bed. The Compliance Officer observed a mattress placed on the floor next to R3's bed. 2) In an interview, E3 reported the bedrails were placed in the upright position to prevent R3 from "diving out of bed." 3) A review of R3's medical record revealed a current service plan for directed care services dated March 13, 2025. The service plan stated R3 was bedbound and "requires full assist with all activities of daily living (ADL's) from the caregiver..." 4) In an interview, E2 reported R3 did not get out of bed at all, could not move the rails up or down, and could not move around them, and acknowledged the situation may cause the resident to suffer physical injury.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of facility documentation revealed no documented policy for fall prevention and fall recovery. 2. A review of E1's, E2's and E4's personnel records revealed no documentation of continued competency training in fall prevention and fall recovery training. 3. A review of E3's and E5's personnel records revealed no documentation of fall prevention and fall recovery training. 4. In an interview, E1 acknowledged the facility failed to establish a policy and procedure on fall prevention and fall recovery that included initial training and continued competency. E1 reported the new policy and procedure manual E1 recently purchased, but had not yet picked up, will include compliance to fall prevention and fall recovery training. E1 acknowledged E1's, E2's, and E4's personnel records did not include documentation of continued competency in fall prevention and fall recovery training. E1 acknowledged E3's and E5's personnel record did not include initial training in fall prevention and fall recovery.

Based on observation, interview, and documentation review, the manager failed to ensure policies and procedures were established, documented, and implemented covering job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk as there were no policies and procedures to reinforce and clarify the health care institution's standards. Findings include: 1. When the Compliance Officer arrived at the facility, E3 was observed at the facility. 2. In an interview, E1 reported E3 was the cook. 3. Review of the facility's policies and procedures revealed no policy and procedure for a cook. 4. In an interview, E1 reported E3 worked as a cook, and did not assist with any patient care. E1 acknowledged a policy and procedure was not available covering job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for a cook.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed and updated at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure manual dated January 11, 2020. 2. In an interview, E1 reported E1 was waiting to pick up the updated facility policies and procedures from the individual that is contracted with the facility to review and update the facility policies and procedures as needed. E1 acknowledged the facility's policy and procedure manual had not been reviewed at least once every three years.

Based on documentation review and interview, the manager failed to ensure a plan was implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures (dated January 11, 2020) revealed a policy titled, "Quality Management Plan" which stated, "Procedure: ... The frequency of submitting a documented report: The monthly report shall be completed and maintained on a quarterly basis... Quality Management Plan: a. An Assurance checklist will be performed by manager/caregiver/designee on a regular basis for at least once a month. b. A Quarterly Report will be compiled for residents having falls, medication errors, calling 911, weight loss, pressure sores, and residents admitted with C-Diff or MRSA." 2. The Compliance Officer requested to view the facility's quality management plan's supporting documents. However, the documented reports were not available for review. 3. In an interview, E1 confirmed the facility had not implemented the procedure identified in the "Quality Management Plan" policy. E1 confirmed the quarterly reports identified in the policy had not been completed. E1 acknowledged the manager failed to implement a quality management program to track, evaluate, and improve resident services.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R1's (admitted in 2023) medical record revealed a service plan for directed care services dated in July 2023. R1's service plan revealed R1 required assistance with activities of daily living including a bed bath at least two times per week and daily assistance from caregiver for toileting and incontinence care. 2. A review of R1's activities of daily living documentation dated September 2023 revealed documentation R1 received a bed bath at least two times a week and daily incontinence care from September 1, 2023 to September 10, 2023. However, documentation of R1 receiving a bed bath at least two times a week and daily incontinence care from September 11, 2023 until September 22, 2023 was not documented. 3. A review of R2's (admitted in 2023) medical record revealed a service plan for personal care services dated in July 2023. R2's service plan revealed R2 required assistance with activities of daily living including daily bathing and incontinence care. 4. A review of R2's activities of daily living documentation dated September 2023 revealed documentation to indicate R2 received daily bathing assistance and incontinence care from September 1, 2023 to September 10, 2023. However, documentation of R2 receiving daily bathing assistance and incontinence care from September 11, 2023 until September 22, 2023 was not documented. 5. In a joint interview, E1 acknowledged documentation to indicate services were provided to R1 and R2 were not documented between September 11, 2023 to September 22, 2023. E2 reported the caregivers were providing services as indicated per the resident's service plans, however the caregivers failed to document the services provided in resident's medical record.

Based on record review and interview, the manager failed to ensure a written order verifying the verbal order was obtained from the medical practitioner within 14 calendar days after receiving the verbal order if a verbal order for a resident's medication was received from a medical practitioner by the assisted living facility, for two of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of facility policies and procedures (dated January 11, 2023) revealed a policy titled "Dispensing/Refilling Medications." The policy stated, "...Written or verbal orders shall be obtained for all prescription and non-prescription (over the counter or "OTC") medications from the residents primary care provider of medical service, or as otherwise provided by law... VERBAL ORDER ... A written order verifying the verbal order is obtained from the medical practioner within 14 calendar days after receiving the verbal order. 2. A review of R1's medical record revealed a service plan (dated July 2023) for directed care services. The service plan revealed R1 received medication administration. Further review of R1's medical record revealed a verbal physician's order signed by an RN on July 13, 2023 and included the following medication, "Senna 8.6 mg; 1 tab PO qd + 1 tab qd PRN constipation." However, the document was not signed by a medical practitioner within 14 calendar days after receiving the verbal order. 3. A review of R1's medication administration record (MAR) dated September 2023, revealed R1 received "Senna 8.6 mg tab" on September 1, 2023 through September 22, 2023 at 8:00 AM. 4. A review of R2's medical record revealed a service plan (dated July 2023) for personal care services. The service plan revealed R2 received medication administration. Further review of R2's medical record revealed a verbal physician's order signed by an RN on July 31, 2023 and included the following medication, "Diazepam 2mg 1 tab PO qHS + 1 tab PO daily PRN." However, the document was not signed by a medical practitioner within 14 calendar days after receiving the verbal order. 5. A review of R2's medication administration record (MAR) dated September 2023, revealed R2 received "Diazepam 2 mg tab" on September 1, 2023 through September 21, 2023 at 8:00 PM. 6. In an interview E1 acknowledged the verbal order identified in R1's medical record and the verbal order identified in R2's medical record were not signed by a medical practioner within 14 days.