Beverly Assisted Living I

Based on the record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for one of two caregivers and assistant caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of E3's personnel record revealed no documented verification of E3's skills and knowledge. 2. A review of the facility’s work schedule dated June 2024 and July 2024 reflected E3 was scheduled to work multiple days in June 2024 and July 2024. 4. In an interview, E1 reviewed E3's personnel record and acknowledged that the personnel record did not include documented verification of skills and knowledge.

Based on record review and interview, the manager failed to ensure one of three caregivers sampled of the assisted living facility had the qualifications and experience necessary to meet the needs of the residents and ensure the residents' health and safety. Findings include: 1. The Compliance Officer arrived at the facility and observed E4 to be the only staff in the facility with four other residents present. 2. In a request to review E4’s personnel record revealed that E4 did not have a personnel record available for review. There was no evidence E4 had the qualifications and experience necessary to meet the needs of the residents, and ensure the residents' health and safety. 3. In an interview, E1 acknowledged there was no evidence E4 had the skill and knowledge necessary to provide assisted living services, ancillary services, meet the needs of the residents, and ensure the residents' health and safety.

Based on observation, record review, and interview, the manager failed to ensure at least one manager or caregiver was present at an assisted living home when residents were present in the assisted living home. Findings include: 1. 1. The Compliance Officer arrived at the facility and observed E4 to be the only staff in the facility with four other residents present. 2. The surveyor requested E4's personnel record. However, no record was available for review while on-site. 3. In an interview, E1 In an interview, E1 acknowledged there was no personnel record for E4 available for review during the survey.

Based on interview and documentation review, the manager failed to ensure a personnel record was maintained for one of four sampled employees. Findings include: 1. The Compliance Officer arrived at the facility and observed E4 to be the only staff in the facility with four other residents present. 2. A review of facility personnel records revealed no documentation of a personnel record for E4. 3. In an interview, E1 reported E4 was a family friend, and there was no personnel file available for review for E4.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance an individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for two of two residents accepted after 2017. Findings include: 1. A review of R1's medical record revealed no documentation to indicate whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. Based on the resident's date of acceptance, this documentation was required. 2. A review of R2's medical record revealed no documentation to indicate whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. Based on the resident's date of acceptance, this documentation was required. 3. In an interview, E1 acknowledged R1's and R2's medical records did not include documentation to indicate whether R1 and R2 required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on observation and interview, the manager failed to ensure a bathroom accessible from a common area contained soap in a dispenser and paper towels in a dispenser or a mechanical air hand dryer. Findings include: 1. During the facility tour with E3, the surveyor observed that the two common bathrooms did not contain soap in a dispenser and paper towels or a mechanical air hand dryer. 2. During an interview, E1 and E3 acknowledged the two common bathrooms did not contain soap in a dispenser and paper towels in a dispenser or a mechanical air hand dryer.

Based on record review and interview, the manager failed to ensure a written service plan was documented for one of two sampled residents reviewed. Findings include: 1. Review of R2's medical record revealed no documentation of a written service plan. Based on R2's date of acceptance and date of termination of residency, a service plan was required. 2. In an interview, E1 acknowledged R2's medical record did not contain a service plan due to R2 being discharged, and a service plan could not be generated.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months for one of one residents who received directed care services. The deficient practice posed a risk if the service plan did not accurately reflect the services needed by the resident. Findings include: 1. A review of R1's medical record revealed a service plan for directed care services dated April 19, 2023. R1's record did not contain a more recent service plan. 2. In an interview, E1 acknowledged R1's service plan was not reviewed and updated at least once every three months.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan dated April 19, 2023 for directed level of care. R2's service plan revealed R2 required assistance with nail care daily, hair care daily, bathing twice weekly. R2's "Activities of daily living sheet" dated April 2025 showed no documentation to reflect R2 was provided assistance with nail care daily, hair care daily, and bathing twice weekly from April 1, 2025 through April 25, 2025. 2. In an interview, E1 acknowledged there was no documentation to reflect R2 was provided nail care daily, hair care daily, and bathing twice weekly for the period of April 1, 2025 through April 25, 2025.

Based on record review and interview, the manager failed to ensure a service plan for a resident receiving directed care services included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of one directed care residents sampled. Findings include: 1. A review of R1's medical record revealed a written service plan for directed care services dated April 19, 2023. R1's service plan did not contain documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. In an interview, E1 reviewed R1's medical record and acknowledged the service plan did not include documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, the means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During a facility tour with E1, the compliance officer observed when exiting from the patio door to the backyard, no alarm sounded to alert employees of the egress of a resident from the facility. 3. In an interview, E1 acknowledged the patio door did not control or alert employees of the egress of a resident from the facility.

Based on record review and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order, and was accurately documented in the resident's medical record, for one of four sampled residents who received medication administration. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.  Findings include: 1. A review of R1’s medical record revealed a medication order for Spironolactone 25mg one tablet daily, dated February 18, 2025. On R1’s April 2025 and March 2025 medication administration records revealed that R1 was being administered Spironolactone every Monday, Wednesday and Thursday. However, there was no other medication order available for review. 2. A review of R1’s medication organizer revealed the following medications inside: Sennoside 8.6mg, Quetiapine Fumarate 25mg, and Sulfate 325mg. However, there were no written or verbal medication orders available for review. According to the medication bottles, the above medications were filled on April 8, 2025. 3. In an interview, E1 acknowledged that medication orders were not available for the above medications and no documentation to reflect that the aforementioned medications were administered according to R1’s medication orders. This is a repeat deficiency from the compliance inspection conducted on April 8, 2022.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of the facility's disaster plan revealed there was no documentation indicating a disaster plan review was conducted every 12 months. 2. In an interview, E1 was unable to find documentation indicating a disaster plan review was conducted every 12 months. This is a repeat deficiency from the compliance inspection conducted on May 12, 2023.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility documentation revealed there was no documentation reflecting a disaster drill was conducted every three months. 2. In an interview, E1 acknowledged a disaster drill was not conducted at least every three months.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months and documented. Findings include: 1. A review of facility documentation revealed no documentation to indicate an evacuation drill was conducted every six months. 2. In an interview, E1 reported the facility had not conducted evacuation drills every six months.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner every six months stating the resident's needs were met by the facility and the resident's needs were within the facility's scope of services, for one of two directed care residents sampled. Findings include: 1. A review of R2's medical record revealed a document titled "Facility Visit Note" from hospice care dated April 7, 2023. The document stated "No significant change in patient/resident condition...Comments: [R2] bed bound now, BP 148/69". However, there was no current documentation indicating R2's medical practitioner examined R2 at least once every six months, reviewed the facility's scope of services, and signed and dated a determination stating R2's needs were being met by the facility, after R2 became bedbound. 2. In an interview, E1 reported R2 was unable to ambulate even with assistance. E1 acknowledged R2's medical record did not contain a signed and dated determination from R2's medical practitioner stating R2's needs were being met by the facility.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of the facility's disaster plan revealed there was no documentation indicating a disaster plan review was conducted at least once every 12 months. 2. In an interview, E1 was unable to provide documentation indicating a disaster plan review was conducted at least once every 12 months.

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, for one of two residents sampled. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings include: 1. A review of R2's medical record revealed a document titled "Facility Visit Note" from hospice care dated April 7, 2023. The document stated "No significant change in patient/resident condition...Comments: [R2] bed bound now, BP 148/69". 2. A review of R2's medical record revealed a service plan dated January 5, 2023. The service plan stated "Mobility: wander, walks with walker. Requires positioning: No Transfer assistance: Yes, 1 person(s)". 3. In an interview, E1 reported R2 was bedbound and could not ambulate even with assistance. E1 acknowledged R2's service plan was not updated within 14 days of a significant change in R2's physical condition.