Infinity Assisted Living 2

Based on record review and interview, the manager failed to ensure a resident had a written service plan that accurately included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed documents titled, "NURSING PROGRESS NOTES". This document included notes from the caregivers about R2. Some of the notes stated, "R2 try escaping many many many times today", "resident trying to escape all day", "client running out front door and back door and yelling and screaming", and "client up and down getting out of chair". 2. A review of R2's medical record revealed a document titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report". The document revealed it was a recertification of hospice care. The document included a note from May 24, 2023, by a registered nurse, which stated "Caregivers report R1 is trying to wander out of the front door and needs constant redirection." 3. A review of R2's medical record revealed service plans, dated March 4, 2024, December 4, 2023, and September 4, 2023, which did not include exit seeking behavior or instances of agitation. 4. E1 provided the most recent service plan initiated on June 4, 2024 which included R2's exit seeking behavior, though not the agitation. The document was not yet signed by the resident or representative. 5. In an interview E1 acknowledged the service plans did not include an accurate description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, though was in the process of correcting the service plan, though not yet signed by the resident's representative.

Based on record review, document 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 resident records reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R2's medical record revealed a directed care level service plan. 2. A review of R2's documented services on the Activity of Daily Living (ADL) form revealed a blank spot, on May 22, 2024, for the section titled, "Service Plan (Care Plan) Followed", for the "Night" shift. The box was not marked to indicate the service plan was followed by the night shift, on May 22, 2024. 3. A review of the facility's policy and procedure manual revealed a policy titled, "Provision of Services", which stated, " ... 5. Provision of services listed on the resident Service Plan are also documented on the resident Activity of Daily Living (ADL) sheet and signed by the caregiver at the end of shift or after the service is provided." 4. In an interview, E1 acknowledged R2's medical record contained no documentation the care plan services were provided by the night shift on May 22, 2024, for one of two resident ADL forms reviewed. This is a repeat citation from the on-site compliance inspection conducted on May 3, 2024.

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the posted menu was dated June 30, 2024 to July 6, 2024, the week prior to the inspection. 2. In an interview, E1 was unable to locate the menu for the current week. 3. The Compliance Officer asked E2 what was being served for dinner. E2 was unsure and looked in the refrigerator for options. 4. In an interview, E1 acknowledged a food menu had not been conspicuously posted at least one calendar day before the first meal on the food menu was served. E1 provided E2 with a menu and corrected the dates to reflect the current week. E2 was able to locate the ingredients to prepare the meal on the menu.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were clean according to policies and procedures designed to prevent, minimize, and control illness or infection. Findings include: 1. The Compliance Officer observed the facility did not smell clean. The The Compliance Officer observed the smell of urine getting stronger, while sitting in the foyer, reviewing documentation. 2. During a tour of the facility, the Compliance Officer observed the urine odor became even stronger in the hallway leading to resident rooms and the laundry room. 3. In an interview, E1 acknowledged the urine odor, though made no further comment regarding the unclean smell.

Based on record review, document review, and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for two of two resident records reviewed. 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 personal care level service plan. 2. A review of R1's medical record revealed documentation of the services provided were recorded on a document titled, "Activity of Daily Living (ADL)". 3. A review of R1's documented services on the Activity of Daily Living (ADL) form revealed a blank spot, on May 2, 2024, for the section titled, "Service Plan (Care Plan) Followed", for the "Night" shift. 4. A review of R2's medical record revealed a directed care level service plan. 5. A review of R2's documented services on the Activity of Daily Living (ADL) form revealed a blank spot, on May 2, 2024, for the section titled, "Service Plan (Care Plan) Followed", for the "Night" shift. 6. Further review of the Activity of Daily Living (ADL) forms revealed R1's, R2's, R3's, and R4's, were not marked to indicate the service plans were followed by the night shift, on May 2, 2024. R5's, R6's, and R7's forms were initialed to indicate the service plans were followed by the night shift, on May 2, 2024. 7. A review of the facility's policy and procedure manual revealed a policy titled, "Provision of Services", which stated, " ... 5. Provision of services listed on the resident Service Plan are also documented on the resident Activity of Daily Living (ADL) sheet and signed by the caregiver at the end of shift or after the service is provided. 8. In an interview, E1 acknowledged the medical records contained no documentation of the services provided by the night shift on May 2, 2024, for four of seven resident Activity of Daily Living (ADL) forms reviewed.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a direct health and safety risk to residents. Findings include: 1. The Compliance Officer observed a resident and a visiting speech therapist discuss being unable to sit outside in the backyard and asked E1 if they could sit on the front porch to conduct the therapy session. E1 unlocked the door ans allowed the resident and therapist outside. 2. During a tour of the facility, the Compliance Officer observed the backyard to be accessible to residents, through an unlocked door. The backyard was observed to have a shower chair and six metal chairs, four of which were pushed to the side and to have multiple spider webs covering them. The slats appeared to be metal and the type of chairs which need a chair pad, though there were none. The walkway was made of brick shaped pavers. A section of the bricks had weeds growing in between them, causing the walkway to be uneven and a fall hazard. 2. In an interview, E1 acknowledged the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury. E1 reported the facility was scheduled for landscaping soon.

Based on documentation review, record review, and interview, the manager failed to ensure a policy and procedure was implemented to protect the health and safety of a resident that covered cardiopulmonary resuscitation (CPR) training for applicable employees including the method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's ability to perform CPR, and including the documentation that verifies that the employee has received CPR training, for one of three personnel records sampled. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "CPR AND FIRST AID POLICY AND PROCEDURES ...B ...obtain and provide documentation of cardiopulmonary resuscitation training specific to adults, which includes a demonstration ...". 2. A review of E3's personal record revealed current proof of CPR training issued on October 1, 2021, by "NationalCPRFoundation," an online-only CPR training program. 3. In an interview, E1 acknowledged E3's personnel record did not include current documentation of CPR training which also included a demonstration of the employee's ability to perform CPR.

Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. Findings include: 1. During a tour of the facility, the Compliance Officer observed the garage door to be ajar and no handle to secure the door. The Compliance officer observed twenty boxes stacked in the garage, labeled with dates and some resident names. E2 reported the boxes contained discharged resident records. 2. In an interview, E1 acknowledged the resident's medical records were not protected from loss, damage, or unauthorized use.

Based on observation, documentation review, and interview, the manager failed to ensure an oxygen container was secured in an upright position. Findings include: 1. During a tour of the facility, the surveyor observed an oxygen container laying on a shelf and unsecured, in an unlocked resident room. 2. A review of the facilities policies and procedures revealed a policy titled, "ENVIRONMENTAL POLICY & PROCEDURES". The policy stated, "ENVIRONMENTAL STANDARDS...4. Oxygen containers are secured in an upright position, regardless of the level of oxygen in the container." 3. In an interview, E2 acknowledged the oxygen container in the room was unsecured. E2 reported the oxygen containers belonged to a company and would get the company to pick it up.