Innovative Care Assisted Living Facility, LLC

Based on observation, documentation review, and interview, the manager failed to establish, document, and implement a policy and procedure to protect the health and safety of a resident that cover methods by which an assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide which is a health and safety risk. Findings include: 1. The compliance officer observed residents residing at the facility. 2. The compliance officer requested and was not provided with the facility's policy and procedure that cover the methods by which the facility was aware of the general whereabouts of a resident. 3. In an interview, E2 acknowledged there was no policy and procedure that covered the whereabouts of all the assisted living residents.

Based on documentation review and interview, the manager failed to establish and document a policy and procedure as part of the policies and procedure required in R9-10-803(C)(1)(h) to ensure the manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services; which posed a health and safety risk. Findings include: 1. Review of the facility's documentation revealed the facility had not established, documented, and implemented as needed a policy and procedure regarding back-up staffing to provide assisted living services to a resident. The facility had three residents residing at the facility. 2. In an interview, E2 acknowledged the facility had no policy and procedure that covered back-up staffing.

Based on record review and interview, the manager failed to ensure that a service plan for a resident receiving personal care services included skin maintenance, which posed a health and safety risk; for two of two sample residents' records that were reviewed. Findings include: 1. Review of R1's current service plan that was dated March 19. 2023 stated the resident required personal care and medication administration services. The service plan did not state how the facility was going to maintain the resident's skin to prevent any skin issues. 2. Review of R3's current service plan that was dated March 23. 2023 stated the resident required personal care and medication administration services. The service plan did not state how the facility was going to maintain the resident's skin to prevent any skin issues. In an interview, E2 reported that R3 had an active G-tube and R3 had a trach removed and now is in the process of the stoma healing. E2 acknowledged the service plan did not address the skin around the G-tube and the treatment of the stoma and how these areas were being cared for to prevent any skin issues. 3. In an interview, E2 acknowledged R1's and R3's service plans failed to document the care of the residents' skin to maintain and prevent skin issues. Technical assistance was provided during the compliance inspection on June 9, 2022.

Based on record review and interview, the manager failed to ensure that a service plan for a resident receiving directed care services included skin maintenance, which posed a health and safety risk; for one of one sample resident record that was reviewed. Findings include: 1. Review of R2's current service plan that was dated March 26. 2023 stated the resident required directed care and medication administration services. The service plan did not state how the facility was going to maintain the resident's skin to prevent any skin issues. 2. In an interview, E2 acknowledged R2's service plan failed to document the care of the resident's skin to maintain and prevent skin issues. Technical assistance was provided during the compliance inspection on June 9, 2022.

Based on record review and interview, the manager failed to ensure that a resident's medication organizer was only filled by the manager or a caregiver who had been designated and was under the direction of a medical practitioner, for one of three sample residents' records reviewed. Findings include: 1. Review of the sampled residents records revealed there was no signed medical practitioner's order designating the unlicensed caregivers to pre-fill the resident's medication organizers for R1. 2. During an interview, E2 acknowledged that facility's unlicensed caregivers were filling the resident's medication organizer without a designated written order from a medical practitioner.