Hope Care Assisted Living

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 three residents sampled. The deficient practice posed a risk as there was no current service plan to direct services to be provided to a resident. Findings include: 1. A review of R1's (admitted 2024) medical record revealed a current service plan for directed care services was unavailable for review. R1's medical record did contain a service plan from a previous facility which was dated November 1, 2023. 2. In an interview, E1 acknowledged R1's service plan was not created when R1 transferred to the facility in 2024. updated at least once every three months.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver provides a resident with assisted living services in the resident's service plan, and documented the services provided in the resident's medical record for two of three residents sampled. 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 current service plan was unavailable for review. However, a previous service plan, dated November 1, 2023, for Directed care services, contained a section titled "Strategies to ensure resident's personal Safety." The section indicated R1 would be "checked every 3-4 hours at night time..." 2. A review of R1's electronic medical record revealed a document titled "Vital Statistics," used for documenting activities of daily living (ADL). The ADL tracking record reflected included a section titled "Night Check," and indicated the service was documented as being provided during the month of March 2024. However, evidence the service was provided on the following dates was unavailable for review: March 9-10, 16-17, 23-24, 30-31, 2024. R1's service plan also included a section for "Dressing," which indicated R1 "requires total care," and was to receive the service "twice daily and as needed." The ADL tracking record reflected included a section titled "Change Clothing," and indicated the service was documented as being provided during the month of March 2024. However, evidence the service was provided on the following dates was unavailable for review: March 9-10, 14, 21, 23-24, 30-31, 2024. 3. A review of R3's medical record revealed a current service plan which included a section titled "Diabetes Management," which indicated R3 would receive the service, "BS check (staff) 3 times(s) Per Day." 4. A review of R3's ADL tracking record revealed a section titled, "Blood Glucose," used for documenting R3's blood sugar checks. The section contained documentation which indicated R3's blood sugar was being checked twice per day, at approximately 8:00 AM and 5:00 PM, on the following dates: March 4-8, 11-16, 18-22, 25-29, 2024 However, evidence R3 received any blood sugar checks was not available for review for the following dates: March 9-10, 17, 23-24, 30-31, 2024 Further review of R3's ADL tracking record revealed a section titled, "Whereabouts," used for documenting dates and times when R3 was not present at the facility. The section contained documentation which indicated R3 was not at the facility on the following dates and times indicated: "March 28, 2024, 10:30 AM - 3:54 PM; March 26, 2024, 10:20 AM - 4:39 PM; March 21, 2021, 10:32 AM - 4:32 PM; March 20, 2024, 12:00 PM - n/a; March 19, 2024, 10:00 AM - n/a; March 14, 2024, 10:25 AM - n/a; March 12, 2024, 10:00 AM - 4:40 PM; March 8, 2024, 11:50 AM - 4:20 PM; March 7, 2024, 10:00 AM - 4:44 PM; and March 5, 2024 10:00 AM - 4:35 PM" 5. In an interview E2

Based on record review and interview, the manager failed to ensure medication administered to a resident is administered in compliance with a medication order for three of three residents sampled. 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 R1's medical record revealed a service plan for directed care services, including medication administration. A review of R2's and R3's medical record revealed service plans for personal care services, including medication administration. R1's, R2's and R3's medical record contained an index of medications for each respective resident, signed by a registered nurse. However, evidence of a medication order, signed by a medical practitioner, in R1's, R2's or R3's medical record was unavailable for review. Further review of R1's R2's and R3's medical record revealed medication administration records which included documentation indicating each resident was being administered medications listed in their medical records. 2. In an interview E1 agreed the lists of medications in R1's R2's and R3's medical record were not signed by a medical practitioner and did not constitute a medication order.