Grace Hill Assisted Livings, LLC

Based on observation,, documentation review, record review, and interview, for three of five personnel reviewed, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident if a caregiver did not know how to implement procedures for fall prevention and fall recovery. Findings include: 1. In observation, E3 was on site, were working as a caregiver, during the inspection. 2. In documentation review, the compliance officer requested to review the facility's documentation of a Fall Prevention and Fall Recovery Program. No documentation was made available for review. 3. In record review, the personnel records for E3 (hired January 4, 2023), and E4 (hired May 5, 2023), did not include documentation the personnel received training on fall prevention and fall recovery. 4. During an interview, E1 reported the personnel had received training on fall prevention and fall recovery; however, acknowledged the personnel records did not include documentation the personnel received training.

Based on record review and interview, for one of three residents reviewed, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services provided to the resident. The deficient practice posed a risk to the health and safety of a resident if the service plan did not specify the amount, type, and frequency of services to be provided by caregivers, as required by a resident. Findings include: 1. In observation, R2 was observed to be in bed during the inspection, and unable to reposition self. R2 was observed to receive repositioning by E3. The compliance officer observed R2 had a sacral wound, and observed E3 packed and re-bandaged the wound. 2. In record review, R2's medical record included documentation R2 had a stage 1 wound on the buttocks that progressed to a stage 4 wound. The record included the following documentation: - Team Care Plan, dated October 12, 2023: Diagnoses.... Pressure Ulcer of sacral region, unstageable "03-02-2023.." - Hospice of the West "Physician's Orders," (signed by O1), "3/17/2023... Give Doxycycline 200mg twice a day for 7 days for wound infection... wound care for unstageable sacral wound as follows: cleanse wound with wound cleanser, pat dry, apply medihoney to affected area, cover with island dressing. Change 3x week and PRN for soiling... Patient to be out of bed for 1 hour for meals 3 times daily in bed on side all other time for wound management. - June 21, 2023, Hospice of the West, "Physician's Orders" signed by O1, "Wound care as follows for Stage 4 sacral wound: cleanse with wound cleanser, pack with dampened gauze, apply dermaseptin to sinus tract at 6 o clock and pressure area at 12 o clock. Cover with and pad. Change 3 times weekly and PRN for soiling..." 3. In record review, R2's medical record included a service plan dated "12/20/21, 6/20/22, 12/20/22, 3/20/23 6/20/23, 9/20/23." The service plan indicated R2 went received Personal Care Services from December 20, 2021- September 20, 2023, and then received Directed Care Services beginning December 20, 2022. The service plan indicated R2's condition changed (no date) from being continent to incontinent, from having a catheter to having no catheter, from a regular diet to soft food and thickened liquids. The service plan indicated R2 received Home Health and Hospice services. A section titled, "Wound Care," had a checked box for "Hospice RN," and "Caregiver." The service plans did not include the amount type and frequency of services provided to care for the resident's wound. 4. R2's medical record included a service plan dated September 21, 2023, for directed care, medication administration and Hospice services. The service plan documented R2 had a "Decubitus ulcer..." The service plan indicated the frequency of hospice agency visits; however, did not include the amount, type and frequency of services provided for the resident's wound. 5. During an interview, E1 and E3 reported the careg

Based on record review, observation, and interview, for one of three residents reviewed, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication that was administered. The deficient practice posed a health and safety risk. Findings include: 1. In observation, the facility had controlled substances/medications for R2 stored in the kitchen refrigerator, to include Morphine (66 syringes) and Lorazepam (9 syringes). 2. In record review, R2's medical record included a document titled, "Physician's Orders...." dated September 14, 2023, which included an order for Morphine Sulfate 10mg PO, give 10 mt every hour as needed, and an order for Lorazepam (a schedule IV controlled substance, 0.5 mg po 2, give 0.05 every two hours as needed. However, the document was not signed by a Medical Practitioner. 3, In record review, R2's medications administration record (MAR) dated October, 2023, included documentation the Morphine was administered on October 1, 2, 3, 7, 8, 9 (x3), 10, and 11, and September 9, 11, 12, 14 (x2), 18 (x2), and the Lorazepam on October 2, 7, 9, 10, and September 9, 2023. 4. During an interview, E1 and E3 reported the Morphine and Lorazepam medications were administered to R2. E1 reviewed R1's medical record, and acknowledged the documentation of a physician's order for the medications was not available for review.

Based on record review and interview, for one of three residents reviewed, the manager failed to ensure a resident's representative was designated for a resident who was unable to direct self-care. Findings include: 1. In record review, R2's medical record revealed a service plan dated which indicated R2 received directed "12/20/6/20/22, 12/20/22, 3/20/23 6/20/23, 9/20/23," indicated a checked box for "Directed (unable to make safe judgments, call for help or self-direct care)," initialed by E1, and dated December 20, 2022. A service plan dated September 21, 2023, indicated the resident received directed care services. 2. In record review, R2's medical record did not include documentation a representative was designated for R2. 3. During an interview, E1 reported R2 did not have any family, a representative, a guardian or a Power of Attorney.

Based on interview, observation, and record review, for one of three residents reviewed, the manager retained a resident who was unable to ambulate even with assistance, and had a stage 4 pressure ulcer, without meeting the requirements in R9-10-814(B)(2)(b). The deficient practice posed a health and safety risk if the facility was unable to meet the resident's needs. Findings include: R9-10-814(B)(2)(b) states: The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: The resident's primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition; ii. Reviews the assisted living facility's scope of services; and iii. Signs and dates a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility; 1. During an interview, E1 and E3 reported R2 was unable to ambulate even with assistance, and had a sacral wound. 2. The surveyor observed R2 in bed. 3. In record review, R2's medical record included a signed and dated determination from the FNP, dated June 20, 2022, which documented R2 was confined to a bed or chair. 4. In record review, R2's record included documentation dated, June 21, 2023, from Hospice of the West, titled, "Physician's Orders" and signed by O1, "Wound care as follows for Stage 4 sacral wound: cleanse with wound cleanser, pack with dampened gauze, apply dermaseptin to sinus tract at 6 o clock and pressure area at 12 o clock. Cover with and pad. Change 3 times weekly and PRN for soiling..." 5. In an interview, E1 acknowledged R2 was unable to walk, even with assistance, and had a stage 4 wound, and the facility had not obtained a signed and dated determination from the resident's primary care provider or medical practitioner, at the onset of the condition and every six months, as required..

Based on record review and interview, for one of three residents reviewed, and receiving directed care services, the manager failed to ensure the resident's service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. The deficient practice posed a risk to the physical health of a resident if skin maintenance services were not provided. Findings include: 1. In record review, R2's medical record included a service plan dated "12/20/21, 6/20/22, 12/20/22, 3/20/23 6/20/23, 9/20/23." The service plan indicated R2 went received Personal Care Services from September 2021, to September 30, 2023, and received Directed Care Services beginning December 20, 2022. The service plan indicated R2's condition changed (no date) from being continent to incontinent, from having a catheter to having no catheter, from a regular diet to soft food and thickened liquids. The service plan indicated R2 received Home Health and Hospice services. A section titled, "Wound Care," had a checked box for "Hospice RN," and "Caregiver." The service plan documented "Weight checked monthly and PRN." The service plan did not include documentation of the resident's weight. Documented "Apply lotion and creams to maintain skin integrity. 2. In record review, R2's medical records included documentation R2 had a stage 1 wound on the buttocks beginning around January 19, 2023, and progressed to a stage IV wound. The record documentation: - Hospice of the West Nursing Visit Note (NVN) - January 19, 2023: Comprehensive... Skin: pro ?? (illegible) 1.5 x 1.5cm / distar 1x 2.. Pain management buttocks/back pain. - Team Care Plan, dated October 12, 2023: Diagnoses.... Pressure Ulcer of sacral region, unstageable "03-02-2023.." - June 21, 2023, Hospice of the West, "Physician's Orders" signed by O1, "Wound care as follows for Stage 4 sacral wound: cleanse with wound cleanser, pack with dampened gauze, apply dermaseptin to sinus tract at 6 o clock and pressure area at 12 o clock. Cover with and pad. Change 3 times weekly and PRN for soiling..." - NVN: October 13, 2023: Senile degen. of brain... sacral wound has poor color -erythema around... poor intake under 50% child sized meals... Reviewed with [E1]... - NVN: October 16, 2023: Sacral wound... Nutritional: less than half - NVN: October 20, 2023: Skin 5x5 x 0.5 - NVN: October 23, 2023: "Senile Degeneration of brain... skin coccyx... bedbound..." 3. In observation, the Compliance Officer observed R2's sacral wound, and observed E3 re pack the wound and bandage. 4. During an interview, E1 and E3 reported O2 provided wound care for R2's wound. The caregiver cleaned and repacked the wound, as needed, and if the wound became wet or soiled. E1 acknowledged R2's service plans did not include skin maintenance services provided for R2.

Based on record review and interview, for one resident receiving directed care services, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated. The deficient practice posed a health and safety risk to a resident who had a pressure sore, eating issues and weight loss. Findings include: 1. In record review, R2's medical record included a service plan dated "12/20/21, 6/20/22, 12/20/22, 3/20/23 6/20/23, 9/20/23." The service plan indicated R2 received Personal Care Services December 20, 2021 through December 20, 2022, and then received Directed Care Services effective December 20, 2022. The service plan indicated R2's condition changed (no date) from being continent to incontinent, from having a catheter to having no catheter, from a regular diet to soft food and thickened liquids. The service plan indicated R2 received Home Health and Hospice services. A section titled, "Wound Care," had a checked box for "Hospice RN," and "Caregiver." The service plan documented "Weight checked monthly and PRN." The medical record did not include documentation R2 was weighed monthly, and the service plan and service plan updates did not include documentation of the resident's weight, which was required when R2 received directed care services. 2. In record review, R2's record included a service plan dated September 21, 2023, and received Directed care services. The service plan documented R2's weight at 106 lbs., and documented a "Decubitus ulcer..." 3.5 length x 3.5 width x .5 depth undermining 10-3 o clock." 3. In record review, a "Physician's Orders..." form signed and dated by O1, October 20, 2023, included documentation R2's weight was 94 pounds. 4. During a telephone call, O2 reported R2 lost 15 pounds and was declining. 5. During an interview, E1 reported R2 was weighed monthly by Hospice, however, acknowledged the resident's service plans did not include documentation of the resident's weight from September 20, 2021 through September 20, 2023, until the service plan dated September 21, 2023, included documentation of a weight.

Based on record review, observation, and interview, for one of three residents reviewed, the manager failed to ensure a written order verifying the verbal order was obtained from the medical practitioner within 14 calendar days after receipt of the verbal order. The deficient practice posed a health risk to the resident. Findings include: 1. In record review, R2's medical record included the following medication orders signed by O1; however, the facility did not have documentation showing written orders were obtained from the medical practitioner with 14 days. The orders stated the following: - Hospice of the West "Physician's Orders," (signed by O1), "3/17/2023... Give Doxycycline 200mg twice a day for 7 days for wound infection... wound care for unstageable sacral wound as follows: cleanse wound with wound cleanser, pat dry, apply medihoney to affected area, cover with island dressing. Change 3x week and PRN for soiling... Patient to be out of bed for 1 hour for meals 3 times daily in bed on side all other time for wound management. - June 21, 2023, Hospice of the West, "Physician's Orders" signed by O1, "Wound care as follows for Stage 4 sacral wound: cleanse with wound cleanser, pack with dampened gauze, apply dermaseptin to sinus tract at 6 o clock and pressure area at 12 o clock. Cover with and pad. Change 3 times weekly and PRN for soiling..." 2. During an interview, E1 acknowledged a written order from the medical practioner was not available for review, as required.

Based on observation, record review, documentation review, and interview, for one of three residents reviewed, the manager failed to ensure medications were administered in compliance with a medication order. The deficient practice posed a health and safety risk if the facility did not follow an order from the practitioner. Findings include: 1. In record review, R2's medical record (received directed care, medication administration and hospice services) included documentation R2 developed a "sacral wound," on January 19, 2023. 2. In record review, R2's medical record included an order, from O2, dated March 24, 2023, which documented, "Please provide soft or pureed foods... give Ensure or equivalent health drink TID..." In record review, R2's medical record, including medication administration and Activity of Daily (ADL) sheets, reviewed from January, 2023 - October, 2023, did not include documentation R2 was provided with Ensure or other health drinks. 3. In record review, R2's record included an order, from O2, dated August 11, 2023, which documented, "Change to Puree diet... may have protein supplement shake/meal replacement shake as needed if eats less that 50% meals..." In record review, R2's record, including medication administration records and Activity of Daily (ADL) sheets, reviewed from January, 2023 - October, 2023, did not include documentation R2 was provided with Ensure or other health drinks. A review of R2's ADL sheets revealed documentation R2 at 100% of meals three times daily everyday. 4. In record review, R2's record included the following documentation: - Hospice of the West Nursing Visit Note (NVN), dated February 24, 2023: ..." Heart Disease...State 1 buttocks... Nutritional" Aspiration risk, drooling, not swallowing w/intake, < 80% meals 3x/day child sized..." - NVN, dated February 27, 2023 " ...1 buttocks... Nutritional: < 75% child sized meals..." - NVN, dated March 20, 2023: "... unstageable sacral wound... Nutritional: Fair, dysphagia..." - NVN, dated May 23, 2023: "... Nutritional: fair, feeder - education re: aspiration..." - NVN, dated Juy 31, 2023: "... 100% of breakfast today..." - NVN, dated August 14, 2023: "... Nutritional: coughing w/intake, 20% intake..." - NVN, dated August 21, 2023: "...100% 3 child size meals..." - NVN, dated September 5, 2023: "... Nutritional 3 meals/day < 75%..." 5. During an interview, E1 reported protein shakes were provided for R2; however the facility ran out of shakes and Hospice reported they wouldn't cover the cost any longer. E1 reported "they said R2 didn't need it anymore." E1 reported R2 was eating the meals provided. However, E3 reported R2 ate less than half of what was provided during meals. The facility did not have Ensure or protein supplement shakes available on site for R2; however, E3 reported the facility had a box of powdered Breakfast drink (10 packets) that "was provided by R2's friend." and not given to R2. E2 acknowledged R2's medical record did not include docu

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked area, which posed a health and safety risk if medications were accessible to residents. Findings include: 1. During an environmental inspection, the surveyor observed an unlocked kitchen refrigerator had a box of Lorazepam medication (for R2)stored on a shelf. 2. During an interview, E2 and E3 observed the medication was stored in the refrigerator in an unlocked manner. E3 reported they needed a bigger medication container for the refrigerator, to be able store all refrigerated medications in a locked manner.

Based on observation, record review, and interview, for two residents reviewed and receiving controlled substances, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for. Findings include: 1. In observation, the facility had controlled substances/medications stored in the kitchen refrigerator: - Lorazepam (nine syringes) for R4, - Morphine (66 syringes) for R2 - Morphine (20 syringes) for R5, residency terminated - Lorazepam (18 syringes) for R5, residency terminated - Lorazepam (8 syringes) for R3 2. In record review, the medical records and medication administration records (MAR) were reviewed for R2 and R3. 3. In record review, R2's medical record included a document titled, "Physician's Orders...." dated September 14, 2023, which included an order for Morphine Sulfate 10mg PO, give 10 mt every hour as needed, and an order for Lorazepam (a schedule IV controlled substance, 0.5 mg po 2, give 0.05 every two hours as needed. However, the document was not signed by a Medical Practitioner. R2's medications administration record (MAR) dated October, 2023, included documentation of medication administration:Morphine (a schedule II controlled substance) on October 1, 2, 3, 7, 8, 9 (x3), 10, and 11, and September 9, 11, 12, 14 (x2), 18 (x2). Lorazepam on October 2, 7, 9, 10, and September 9, 2023. R2's record did not include an inventory for the controlled substances. 4. In record review, R3's medical record included a medication order for Morphine (a schedule II controlled substance and opioid) 10mg every hour as needed. R3's MAR dated August, 2023, included documentation R3 received the Morphine on August 16, 20, 23, and 24, 25, 30 (x2), and 31, 2023. R3's record did not include an inventory for the controlled substances. 5. During an interview, E1, E2, and E3 acknowledged the facility stored and administered controlled substances for the residents, and did not maintain an inventory of the controlled substances.

Based on observation and interview, the manager failed to ensure food stored by the facility was free from spoilage, and was safe for human consumption. Findings include: 1. During an environmental inspection, the surveyor observed a kitchen refrigerator had a bag of spoiled lettuce, and a bin with uncovered and spoiled vegetables, including one half of a red pepper. 2. During an interview, E1 and E3 acknowledged the spoiled food stored in the refrigerator.

Based on observation and interview, the manager failed to ensure that equipment and food contact surfaces were clean and in good repair. The deficient practice posed a health and safety risk to residents if food was not stored in a clean manner. Findings include: 1. During an environmental inspection, the compliance officer observed the kitchen refrigerator was not maintained in a clean manner. Two storage bins were soiled and contained food particles. One bin was uncovered and missing the cover, and had a container of food stored on top of the food in the bin. 2. During an interview, E1 and E3 acknowledged the refrigerator was not maintained in a clean manner and in good repair.

Based on documentation review, record review, and interview, for two of four employees reviewed, the health care institution failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. In documentation review, a review of facility's documents revealed the facility had not established, documented and implemented TB infection control activities, to include annual training and education related to recognizing the signs and symptoms of TB. 2. In record review, the personnel records for E3, hired on January 4, 2023), and E4 (hired on May 5, 2023) did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. During an interview, E1 acknowledged the facility had not documented and implemented annual training for employees on recognizing the signs and symptoms of TB, and E3 and E4 had not completed training and education related to recognizing the signs and symptoms of TB. 4. Technical assistance was provided on this Rule during the change of ownership inspection conducted October 21, 2022.