Benzen Healing Hands

Based on record review and interview, the manager failed to ensure that a resident has a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services, for two of two residents sampled. Findings include: 1. A review of R1’s service plan, dated May 20, 2024, indicated R1 required personal care services. However, documentation of an additional review was not available. 2. A review of R2’s service plan, dated July 24, 2024, indicated R2 required personal care services. However, documentation of an additional review was not available. 3. In an interview, E2 reported an additional review and update of R1’s and R2’s service plans had been completed in January 2025. However, documentation of the reviews was not available. E2 acknowledged R1’s and R2’s service plans were not reviewed and updated at least once every six months.

Based on record review, observation, and interview, the manager failed to ensure the 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. Findings include: 1. A review of R1's service plan, dated May 20, 2024, revealed R1 required the following services: Incontinence care; Assistance with dressing; Assistance with showering, once a week; Assistance with shaving, once a week; Assistance with grooming, daily (qd); Assistance with nail care, once a week; Assistance with eating; Skin care, as needed (PRN); and Medication administration. 2. A review of R1's activities of daily living (ADL) documentation, for March 2025, revealed R1 received the following services March 1, 2025 - present: Breakfast, Lunch, and Dinner provided; Three snacks taken; Shower; Tub bath; Bed bath; Shampoo; Shave; Oral care; Nail care; Comb/Brush hair; Clothing; Incontinence care; Catheter care; Urine output; Appy skin barrier; Skin condition; Bowel movement; Linen change; Assistance with ambulation; Group exercise; Recreation activities; Elevate feet when sitting; Reposition in bed, every two hours (q2h); and Night checks. 3. A review of R1's medical record revealed documentation titled "Daytime Monitoring." The form indicated R1 was observed in the following locations at the following times on March 13, 2025: Dining room, at 11:00 AM, 2:00 PM, and 8:00 PM; and Living room, at 5:00 PM. However, documentation was provided to the Compliance Officers for review at approximately 10:30 AM. 4. A review of R1's medical record revealed documentation titled "Night Time Monitoring." The form indicated R1 was sleeping at 11:00 PM on March 13, 2025. However, documentation was provided to the Compliance Officers for review at approximately 10:30 AM. 5. A review of R2's service plan, dated July 24, 2024, revealed R1 required the following services: Assistance with ambulation; Incontinence care; Assistance with dressing; Assistance with showering, once a week; Bed bath, on days showers aren't given; Shampoo, once a week and PRN; Assistance with shaving, once a week; Assistance with nail care, once a week; Assistance with eating; Skin care, as needed PRN; and Medication administration. 6. A review of R2's ADL documentation, for March 2025, revealed R2 received the following services March 1, 2025 - present: Breakfast, Lunch, and Dinner provided; Three snacks taken; Shower; Tub bath; Bed bath; Shampoo; Shave; Oral care; Nail care; Comb/Brush hair; Clothing; Incontinence care; Catheter care; Urine output; Appy skin barrier; Skin condition; Bowel movement; Linen change; Assistance with ambulation; Group exercise; Recreation activities; Elevate feet when sitting; Reposition in bed, q2h; and Night checks. 7. A review of R2's medical record revealed documentation titled "Daytime Monitoring." The form indicated R2 was observed in the fol

Based on observation, record review, and interview, the manager failed to ensure that a resident or resident's representative consented to photographs of the resident before the resident was photographed, for one of two residents sampled. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed cameras used in the facility to monitor residents' whereabouts. 2. A review of R2's medical record did not contain a photographic consent form signed by the resident or resident's representative. 3. In an interview, E2 acknowledged R2's medical record did not contain consent to photographs by the resident or resident's representative before R2 was photographed.

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies is available and accessible in a bedroom or residential unit used by a resident receiving personal care services. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed R2’s call bell to be placed behind a frame on a dresser, out of reach. 2. In an interview, R2 reported R2 was unaware of the location of R2's call bell. 3. In an interview, E2 acknowledged that a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was not available and accessible in a bedroom or residential unit being used by a resident receiving personal care services.

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility is licensed to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officers observed the back sliding door to be equipped with an alarm for egress. However, the alarm was turned off during the inspection and corrected while the Compliance Officers were on-site. 3. In an interview, E2 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for two 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 R1's medical record revealed signed medication orders for the following medications: Citalopram 20 milligrams (mg), 1 tablet by mouth (po) twice a day (bid), dated January 13, 2024; Famotidine 20 mg, 1 tablet po bid, dated December 9, 2022; Rytary 145 mg, 1 tablet po three times a day (tid), dated October 30, 2024; Sinemet 25 mg- 100 micrograms (mcg), 1 tablet four times a day (qid), dated December 9, 2024; Quetiapine 100 mg, 1 tablet po at bedtime (qhs), dated June 28, 2024; Rytary 95 mg, 1 tablet po qhs, dated October 30, 2024; and Trazodone 50 mg, 1 tablet po qhs, dated January 26, 2024. 2. A review of R1's medication administration record (MAR), for March 2025, revealed R1 was administered the following medications at the following times on March 13, 2025: Citalopram 20 mg, at 8:00 PM; Famotidine 20 mg, at 8:00 PM; Rytary 145 mg, at 12:00 PM and 5:00 PM; Sinemet 25 mg - 100 mcg, at 12:00 PM, 5:00 PM, and 8:00 PM; Quetiapine 100 mg, at 8:00 PM; Rytary 95 mg, at 8:00 PM; and Trazodone 50 mg, at 8:00 PM. However, the MAR was provided to the Compliance Officers for review at approximately 10:30 AM. 3. A review of R2's medical record revealed signed orders, dated September 19, 2024, for the following medications: Trazodone 150 mg, 1 tablet po qhs; and Buspirone HCL 15 mg, 1 tablet po every 12 hours (q12h). 4. A review of R2's MAR for March 2025, revealed R2 was administered the following medications at 8:00 PM on March 13, 2025: Trazodone 150 mg; and Buspirone HCL 15 mg. However, the MAR was provided to the Compliance Officers for review at approximately 10:30 AM. 5. In an interview, E2 acknowledged the medications administered to R1 and R2 were pre-filled and not accurately documented in R1's and R2's medical records.

Based on observation, record review, and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a health and safety risk, if medications were accessible to residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a box of Hydrocortisone 2.5% cream that R1 stored in an unlocked drawer in a shared resident's unlocked bathroom: 2. During an environmental tour of the facility, the Compliance Officers also observed a tub of Clobetasol Propionate cream USP, 0.05% stored in R2's room. The medication was stored on a lamp base on a nightstand close to R2’s bed. 3. A review of R1’s and R2's service plans revealed R1 and R2 received medication administration. 4. In an interview, E2 acknowledged medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.