Dignified Carehome LLC

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 one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated September 11, 2025. R1's service plan reflected that R1 required an ostomy bag emptied daily and as needed. However, a review of R1's services provided between August 2025 through November 4, 2025, the activities of daily living (ADL) sheets did not document that this service was provided. There was no other documentation available for review. 2. In an interview, E2 reported R1's ostomy bag was emptied daily. However, it was not documented. E2 acknowledged that there was no documentation for this service provided.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three caregivers. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. Review of E3's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E3's hire date, this documentation was required. 4. In an interview, E1 acknowledged E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

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, at the onsite of the condition, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed a service plan dated January 26, 2024 for personal care services. The service plan revealed R1 required assistance of one or two for transfers and was bed-bound. 2. A further review of R1's medical record revealed no documentation whether R1's primary care provider or other medical practitioner examined R1, reviewed the assisted living facility's scope of services, and signed and dated a determination stating R1's needs could be met by the assisted living facility. 3. In an interview, E1 reported R1 was bedbound. E1 reported having overlooked the required documentation for R1. E1 acknowledged no documentation was included whether R1's primary care provider or other medical practitioner examined R1, reviewed the assisted living facility's scope of services, and signed and dated a determination stating R1's needs could be met by the assisted living facility

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated January 2024. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated February 2024. This medication order stated "Oxycodone 5 mg every 8 hours". 3. Review of R1's medical record revealed a February 2024 medication administration record (MAR). This MAR stated "Oxycodone 5mg every eight hours". However, only two administration times were identified for 7am and 7 pm. 4. In an interview, E1 acknowledged R1's medication was not administered in compliance with the available medication order.

Based on observation, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of four sampled caregivers. Findings include: 1. The Compliance Officer arrived to the facility at approximately 1:30 PM, and observed E1 and E2 on the premises. 2. A review of E2's personnel file revealed no documentation of completion of an approved caregiver training program for E2. The compliance officer observed E2 assisting R1 to the restroom. The compliance officer asked E2 to describe the type of duties performed at the facility. E2 stated "I dress the residents, bathing, and hand the residents their medication...E2 stated "usually meds set up in a cup from other staff and I just hand to the resident". E2 reported being an assistant caregiver. 3. In an interview, E2 acknowledged the aforementioned duties but then stated "I misunderstood what you were asking". The compliance officer spoke with E3 on the phone to review the aforementioned issue. E3 stated "I understand...we will make sure we are in compliance with the department".

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for three of three residents sampled. The deficient practice posed a risk if the Department was provided false or misleading documentation. Findings include: 1. A review of R1's (admitted in 2023) medical record did not contain a service plan as there was still time to create the plan based on R1's admit date to the facility. However, the record contained a document titled "Assisted Living Facility Daily Activity Record" that revealed all of the boxes were checked, including the following items, for May 16, 2023 through May 20, 2023, prior to the services being provided: -breakfast -lunch -dinner -bathing -skin care -dressing -night checks -repositioning 2. A review of R2's (admitted in 2023) medical record revealed a service plan dated in February 2023. The plan stated R2 was to receive assistance with activities of daily living. However, the document titled "Assisted Living Facility Daily Activity Record" revealed all of the boxes were checked, including the following items, for May 16, 2023 through May 20, 2023, prior to the services being provided: -breakfast -lunch -dinner -bathing -peri-care -oral care nail care -skin care -dressing -night checks -repositioning 3. A review of R3's (admitted in 2020) medical record revealed a service plan dated in February 2023. The plan stated R3 was to receive assistance with activities of daily living. However, the document titled "Assisted Living Facility Daily Activity Record" revealed all of the boxes were checked, including the following items, for May 16, 2023 through May 20, 2023, prior to the services being provided: -breakfast -lunch -dinner -bathing -oral care -skin care -dressing -daytime checks 4. In an interview, E1 acknowledged all of the boxes had been prefilled for May 16, 2023 through May 20, 2023 for R1, R2, and R3's "Assisted Living Facility Daily Activity Record" sheets.

Based on interview and record review, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the name and signature of the individual administering medication, for one of three residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a medication administration record for the month of May 2023. The medication administration record revealed all medications were documented as administered to R1 by E1 on May 18, 2023 which is the following day after the compliance officer's survey. 2. In an interview, E1 acknowledged the medication administration record for R1 was already signed for the following day after the compliance officer's survey.