Essential Patient Care, LLC

Based on documentation review and interview, the health care institution failed to ensure a training program for all staff regarding fall prevention and fall recovery was implemented. Findings include: 1. A review of the facility’s fall prevention and fall recovery program revealed continued competency training was required annually for all employees. 2. A review of facility personnel records revealed evidence of documentation of initial fall prevention and fall recovery training for E2 and E3, provided in 2024. However, evidence of documentation of continued competency training in fall prevention and fall recovery provided in 2025 was unavailable for review. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record for two of two residents sampled. Findings include: 1. A review of R1's and R2’s medical records revealed current service plans for directed care services, which included numerous assisted living services to be provided by the facility staff. 2. A review of R1’s and R2’s medical records revealed a document used for tracking and documenting services and assistance with activities of daily living provided to R1 during February 2026. The document included sections for bathing, dressing, grooming, oral care, incontinence care, and night checks. However, the sections contained numerous gaps in documentation for all shifts during the month of February 2026. 3. In an interview, E1 indicated R1 and R2 did receive assisted living services as outlined in their respective service plan for February 2026. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a medical record included all required information per R9-10-811.C.1-24. Findings include: 1. During an on-site investigation, the Compliance Officer requested to review the medical record for R3. However, evidence of documentation of R3’s medical record was largely unavailable for review. R3’s medical record was missing evidence of documentation of the following: · the resident’s needs required in R9-10-807(B) · evidence of freedom from infectious tuberculosis as required in R9-10-807(A) · signed residency agreement · assisted living services provided to the resident · medications administered to the resident · medication orders from a medical practitioner for each medication to be administered · documentation of the resident’s orientation to exits 2. In an interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to meet the requirements in R9-10-814(B)(2), for a resident who was accepted into the facility with a stage 3 pressure sore. Findings include: 1. A review of R3’s medical record revealed skilled nursing progress notes, signed by a registered nurse, which indicated R3 had a “Pressure Injury – Stage 3” to their left heel, which was “Present Upon Admission.” 2. A request was made to review the determination required in R9-10-814(B)(2)(b)(iii); however, evidence of documentation of the determination was unavailable for review. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a Medication Administration Record (MAR), dated February 2026. The MAR documented the medications administered to R1 during the month of February 2026. The MAR included a section for documenting the administration of “Lorazepam, 0.5 Mg, 1 Tablet, PO, at 2:00 am, 8:00 am, 2:00 pm, and 8:00 pm.” However, the MAR had numerous blanks on February 1, 3, 5, 6, 7, and February 11, 2026. 2. A review of R2's medical record revealed a Medication Administration Record (MAR), dated February 2026. The MAR documented the medications administered to R2 during the month of February 2026. The MAR included a section for documenting the administration of “quetiapine 100 mg tablet, 1 Tablet, PO, at PM.” However, the MAR had been left blank on February 2, 4, 7, 8, 9, 11, 14, 18, 21, and February 22, 2026. 3. In an exit interview with E1, the findings were reviewed, and no additional information was provided.