Frances Residential Care #1

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled 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 R2's medical record revealed a service plan, dated October 16, 2025, for directed care services including medication administration. 2. A review of R2's medical record revealed a list of medication orders which included the following: - “Pravastatin 40MG PO QD 8pm” 3. A review of R2's medical record revealed an electronic Medication Administration Record (eMAR) dated January 2026. However, the MAR documented Pravastatin was administered at 5pm between January 1, 2026 and January 28, 2026, and had not been administered at 8pm as ordered. 4. In an exit interview, the findings were reviewed with E1. E1 stated R2’s previous orders stated to administer the medication in the evenings and did not have a specific time listed. E1 acknowledged medications had not been administered to R2 in compliance with the newest medication order.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a documented residency agreement. However, the residency agreement had not been signed and dated by the manager. 2. In an interview, E1 acknowledged the manager had not signed and dated the residency agreement for R1 before or at the time of R1's acceptance.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan was not available for review. Based on R1's admission date, a complete service plan was required. 2. In an interview, E1 acknowledged a completed service plan for R1 had not been provided for review.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for one of one residents sampled receiving directed care services. Findings include: 1. A review of R2's medical record revealed a written service plan for directed care services, dated October 21, 2023. However, required service plan updates, dated on or before January 21, 2024, April 21, 2024, and July 21, 2024, were not available for review. 2. In an interview, E1 acknowledged R2 received directed care services and each acknowledged R2's updated service plan had not been provided for review.

Based on interview and record review, the manager failed to ensure the facility did not 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 residents sampled who was confined to a bed or chair. Findings include: 1. In an interview, E1 reported that R2 received directed care services and was non-ambulatory. 2. A review of R2's medical record revealed a form titled "Determination for Residency to continue in the facility," dated April 20, 2022. The form stated R2 was non ambulatory and was signed by a doctor stating the facility was able to meet R2's needs. However, subsequent statements dated at least every six months after April 20, 2022 were not available for review. 3. In an interview, E1 acknowledged evidence R2's medical practitioner had examined R2 at least once every six months was not available for review.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a residents needs or emergencies was available in a bedroom being used by a resident receiving directed care services or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies. Findings include: 1. During a facility tour, the Compliance Officers observed bedroom #3 was occupied by two residents. However, neither resident had a bell or other mechanical means to alert the staff of their needs. 2. In an interview, E1 acknowledged the residents in bedroom #3 did not have call bells at the time of the inspection.

Based on record review and interview, the health care institution's chief administrative officer failed to implement tuberculosis (TB) infection control activities to include annual training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution, for two of two sampled employees. Findings include: 1. A review of E1's and E2's personnel records revealed documentation of TB infection control activities to include annual training and education dated August 22, 2022. However, documentation of annual training and education related to recognizing signs and symptoms of TB dated within the previous year was not available for review. 2. In an interview, E1 acknowledged the personnel records provided for R1 and R2 had not included current documentation of annual TB education.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officer observed a sliding glass door leading to a side yard and pool area did not sound an alarm when opened. The Compliance Officer observed a magnet attached to the frame of the sliding glass door, however, an alarm was not present. 3. In an interview, E1 acknowledged a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility did not control or alert employees of the egress of a resident from the facility. E1 reported a resident had removed the alarm from the sliding glass door and a new alarm needed to be purchased and installed. This is a repeat deficiency from the on-site compliance inspection conducted on April 17, 2023.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. A review of facility documentation revealed an annual assessment of the health care institution's risk of exposure to infectious tuberculosis was not available for review. 2. In an interview, E1 acknowledged that the required documentation was not available for review.