Charles Residential Care LLC III

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for two of two residents. 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 medical record revealed a service plan dated January 15, 2024. The service plan indicated R1 required assistance with incontinence care every two hours. Further review of R1's medical record revealed a document titled "Activities of Daily Living" (ADL Sheet) dated May 2024. The ADL Sheet indicated R1 received incontinence care only once daily. 2. A review of R2's medical record revealed a service plan dated May 13, 2024. The service plan indicated R2 required assistance with incontinence care every two hours. Further review of R2's medical record revealed a document titled "Activities of Daily Living" (ADL Sheet) dated May 2024. The ADL Sheet indicated R2 received incontinence care only once daily. 3. In an interview, E1 reported R1 and R2 received incontinence care more than once daily, but the services were not documented.

Based on record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of three caregivers sampled. The deficient practice posed a risk if the employee did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of R1's, R2's and R3's medical record revealed documents titled "Activities of Daily Report" and "Medication Administration Record (MAR)" dated December 2023 and January 2024. The documents reflected E3 provided services for the above residents for multiple days. 2. A review of E3's personnel record revealed no documentation of a completed skills assessment to reflect E3's skills and knowledge were verified before E3 provided physical health services. 3. In an interview, E1 acknowledged E3's skills assessment was not completed. E1 reported E3's skills and knowledge were verified, but the documentation was not completed.

Based on record review and interview, the manager failed to ensure medication was administered in compliance with a medication order, for one of two residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R2's medical revealed a medication order for "Midrodrine 5 mg (milligrams) two tablets three daily, hold if systolic blood pressure below 120." 2. A review of R2's medical record revealed a document titled "Medication Administration Record (MAR)" dated January 2024, which reflected R2 was administered "Midrodrine 5 mg tablets" at 8:00 AM, 12:00 PM, and 5:00 PM from January 12, 2024 through January 31, 2024. However, there was no documentation of R2's blood pressure being taken before "Midrodrine" was administered. 3. In an interview, E1 acknowledged R2's blood pressure was not taken and documented before R2's "Midrodrine" was administered.