Insight Guest Home

Based on record review and interview, the manager failed to ensure that a caregiver documented the services provided in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk if services provided could not be verified. Findings include: 1. Review of R1’s service plan revealed R1 received the following assisted living services: - Complete bath 2X week/ PRN - Brush Dentures Daily&/ or PRN - Clean nails PRN - Assist Dressing - Comb hair daily - Skin care PRN - Fluids encourage 6 to 8 glasses a day 2. Review of R1’s medical record revealed the assisted living services were not documented as provided for the months of February 2025 and March 2025. 3. Review of R2’s service plan revealed R2 received the following assisted living services: - Complete bath 2X week/ PRN - Brush Dentures Daily&/ or PRN - Clean nails PRN - Assist Dressing - Comb hair daily - Skin care PRN 4. Review of R2’s medical record revealed the assisted living services were not documented as provided for the month of March 2025. 5. In an interview, E2 reported the services were provided, however, E2 was unable to provide documentation of the services R1 and R2 received. 6. In an interview, E1 and E2 acknowledged R1’s services provided were not documented for the months of March and February. Also E1 and E2 acknowledged R2’s services provided were not documented for the month of March.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Review of department documentation revealed the facility was licensed for the directed level of care. 2. The Compliance Officer observed ambulatory residents in the facility. 3. The Compliance Officer observed the laundry room door unlocked and open, leading into the garage. The door leading to the garage did have an alarm, however, at the time of the inspection, the alarm was not working. Inside the garage, there was a side door that was not locked or alarmed. This side door led outside of the facility to the driveway. 4. Review of the facility’s policies and procedures revealed a policy titled, “Wandering residents," which stated, “4. Caregivers will maintain security of locks on the front door, yards and hazardous areas at all times. 5. If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security.” 5. In an interview, E1 and E2 acknowledged there were means of exiting the facility to an outside area, which did not control or alert employees of the egress of a resident from the facility. This is a repeat deficiency from the inspection conducted on August 31, 2023.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2’s medical record revealed a current written service plan dated November 2, 2024. This service plan indicated R2 received medication administration. 2. Review of R2’s medical record revealed a signed mediation order dated October 28, 2024, which stated, “Midodrine 5 mg P.O. 1 tablet BID.” 3. Review of R2’s medical record revealed a March 2025 medication administration record (MAR) which stated, “Midodrine P.O. by mouth 1 TAB TID.” 4. The Compliance Officer observed a bottle of Midodrine 10 mg with R2’s medications. 5. In an interview, E2 reported R2 received the 10mg pill of Midodrine. 6. In an interview, E1 and E2 acknowledged R2’s medication was not administered in compliance with the available medication order.

Based on record review, documentation review, and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings Include: 1. Review of R1's medical record revealed a service plan dated March 14, 2025. The service plan revealed R1 required medication administration. 2. Review of R1’s medical record revealed a February 2025 medication administration record (MAR). This MAR revealed medications were documented as administered from February 1, 2025, to February 13, 2025. However, documentation was not available showing medications were administered the rest of February. Additionally, the March 2025 MAR was not provided to the Compliance Officer. 3. Review of R2's medical record revealed a service plan dated November 2, 2024. The service plan revealed R2 required medication administration. 4. Review of R2’s medical record revealed a March 2025 MAR. This MAR revealed medications were documented as administered from March 1, 2025, to March 24, 2025. However, the 8pm medications were not documented as administered on March 24, 2025 and documentation was not available showing medications were administered the rest of March. 5. Review of the facility's policies and procedures revealed a policy titled, “Documentation in Resident Records” which stated, “2. Documentation will be completed by the caregiver or personnel completing the task, providing the service or assisting the resident.” 6. In an interview, E2 reported the medications were administered to R1 and R2 and acknowledged medications administered to R1 and R2 were not documented in the medical record.

Based on observation, documentation review, and interview, the manager failed to ensure an oxygen container was secured. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. The Compliance Officer observed one unsecured oxygen tank in the living room, three unsecured oxygen tanks in the kitchen area, four unsecured oxygen tanks in the garage, and two unsecured oxygen tanks in the backyard of the facility. 2. Review of the facility's policies and procedures revealed a policy titled, “Environmental Safety,” which stated, “17. Oxygen safety will be maintained at all times. C. Oxygen tanks will be stored in the upright position at all times.” 3. In an interview, E1 and E2 acknowledged the oxygen tanks were not secured.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed a bottle of Windex and a spray bottle of Clorox unlocked under the kitchen sink. On top of the kitchen counter, a Clorox spray bottle was observed. 2. The Compliance Officer observed a bottle of Tide laundry detergent and a spray bottle of Lysol all-purpose cleaner in the unlocked laundry room. 3. The Compliance Officer observed, in a hallway, a container of Clorox disinfecting wipes. 4. The Compliance Officer observed, unlocked under the sink of a bathroom accessible from a common area, a spray bottle of Lysol multi-purpose cleaner and Lysol disinfecting wipes. 5. The Compliance Officer observed a bottle of Spectracide Bug Stop Home Barrier unlocked in the backyard and Ortho Home Defense insect killer unlocked inside the house. 6. Review of the facility’s policies and procedures revealed a policy titled, “Environmental Safety” which stated, “6. Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas.” 7. In an interview, E1 and E2 acknowledged poisonous and toxic materials were not locked in an area inaccessible to residents.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of facility documentation revealed a policy and procedure titled "Wandering Residents" dated January 4, 2014. The policy and procedure stated: "Caregivers will maintain security of locks on the front door, yards and hazardous areas at all times. If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security." 3. During the environmental inspection of the facility, the Compliance Officer observed the front door had a keyed deadbolt installed. However, next to the front door, the Compliance Officer observed the key to the door on a chain hanging from a small hook. The Compliance Officer also observed a door leading from the facility to the back yard, with an alert installed. However, upon opening the door, the Compliance Officer heard no audible alert. Additionally, the Compliance Officer observed a door leading from the facility to the side of the house. The Compliance Officer observed a pink sticky note on the door which stated, "NO." However, the Compliance Officer observed the door had no control or alert installed. 4. In an interview, E2 reported the alert on the back door did not work. E2 further reported R1 went outside from time to time. E2 stated the facility had "always [been] this way."