Inge's Uniquely Warm Assisted Living Home

Based on record review and interview, the manager failed to ensure that a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints for one of four residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1's acceptance date, this document was required. 2. In an interview, E1 acknowledged R1's medical record did not contain documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on record review and interview, the manager failed to ensure a written service plan included a summary of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for two of four residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. A review of R1's medical record revealed a written service plan for personal care dated July 17, 2025. However, this service plan did not include documentation of R1's medical or health problems. 2. A review of R2's medical record revealed a written service plan for directed care dated July 10, 2025. However, this service plan did not include documentation of R2's medical or health problems. 3. In an interview, E1 acknowledged that R1's and R2's service plans did not include documentation of R1's and R2's medical or health problems.