Care Haven #1 Trejo, LLC

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident's date of occupancy and as specified in R9-10-113 for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings Include: 1. A review of R2’s medical record revealed a negative TB skin test; however, documentation of a baseline screening to include risk assessment and symptom screening was not available for review. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, for one of two residents sampled, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months. Findings include: 1. A review of R1’s medical record revealed a service plan, dated June 17, 2025, for directed care services. However, service plan updates dated on or before September 17, 2025, were unavailable for review. 2. In an exit interview, the findings were reviewed with E3. E3 acknowledged R1’s record did not include a written service plan update dated at least once every three months.

Based on documentation review and interview, the manager failed to ensure that a disaster plan was documented which included where residents would be relocated. Findings include: 1. A review of the facility’s documentation revealed an amended disaster and evacuation plan dated May 10, 2024; however, the disaster and evacuation plan did not provide an address as to where residents would be relocated and instead listed the same address as their facility. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of the facility’s documentation revealed an amended disaster and evacuation plan dated June 22, 2020, last reviewed on May 10, 2024. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During a tour of the facility, the Compliance Officer observed a refrigerator in the kitchen area, which was unlocked. Inside the refrigerator, the Compliance Officer observed a container of "Lorazepam Con 2mg/ml," stored in the door of the refrigerator. Inside a second unlocked refrigerator, located in a hallway next to the kitchen area, the Compliance Officer observed a container of "Lorazepam 2 MG/ML Oral Concent," as well as a container of "Morphine Sulf 100 MG/5 ML Conc." 2. In an interview, E1 acknowledged that medications were not stored in in a self-contained unit used only for medication.

Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to cover in-service education for employees for one of two employees sampled. The deficient practice posed a risk as the standards expected of employees in the policies and procedures were not followed. Findings include: 1. A review of the facility's policy and procedure manual, revealed a policy titled, "Caregiver Orientation and Continuing Education." The policy and procedure stated, " All caregivers are required to complete at least six hours of continuing education...on an annual basis." 2. A review of E3's (hired November 2014) personnel record revealed certificates indicating E3 completed five hours of continuing education in 2022 and four hours of continuing education in 2023. However, the last digit of the year issued on the certificates had been written over the prior year, so the certificates issued in 2022 appeared to have originally been issued in 2021. Similarly, the certificates issued in 2023 also appeared to have originally been issued in 2021. 3. In an interview, E1 admitted "being lazy," and writing over the dates of the continuing education certificates included in E3's personnel record. E1 advised E3 had completed the same continuing education during the same months in 2022 and 2023, however E1 did not issue new certificates for the education completed.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of medication administered to the resident that included the time of administration for one of two residents sampled. Findings include: 1. A review of R1's directed care service plan (dated April 13, 2023) revealed R1 received assistance with self-administration of medication. 2. A review of R1's medical record revealed an order dated June 12, 2023 for "Losartan 100 mg tablet, Take 1 tablet every day by oral route." 3. A review of R1's June 2023 Medication Administration Record (MAR) revealed a section for documenting administration of "Losarten 100 mg," however evidence of documentation of administration of the medication was unavailable for review. 4. In an interview, E2 acknowledged R1 had been taking their Losartan as prescribed, although it was not documented in the MAR. 5. In an interview, E1 acknoweldged the administration of R1's Losartan was not correctly documented in the June 2023 MAR.