Jal Assisted Living Facility, LLC

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's activities of daily living. 1. A review of R2's medical record revealed a current service plan dated March 13th, 2025, with services such as sponge baths, skin checks, skin care, fluid hydration, and room cleaning. 2. A review of R2's activities of daily living (ADL) for May 2025 showed no documentation that the services mentioned above were provided on May 5th, 6th, and 7th. A chart for incontinence care monitoring showed no documentation on May 5th, 6th, and 7th. 4. A review of R3's medical record revealed a current service plan dated April 23, 2025, with services such as sponge baths, skin checks, skin care, and room cleaning. 5. A review of R3's ADL for May 2025 showed no documentation that the above services were provided between May 1st and 7th. 6. In an interview, E1 confirmed services were provided and acknowledged the caregiver did not document the services in R2's and R3's ADLs. This is a repeat deficiency from the compliance inspection conducted on May 12, 2022.

Based on observation, record review, and interview, the manager failed to ensure the resident's or the resident's representative's consent to photographing the resident. 1. During an environmental inspection, the Compliance Officers observed cameras in the facility. 2. A review of R1, R2, and R3's medical records did not contain a photographic consent form signed by the resident or the resident's representative. 3. In an interview, E1 acknowledged R1, R2, and R3's medical records did not contain photograph consent forms signed by the resident or the resident's representative.

Based on observation and interview, the manager failed to ensure a resident's medical records were protected from loss, damage, or unauthorized use. 1. During an environmental inspection, the Compliance Officers observed resident medical records on the floor next to the dining room table. 2. In an interview, E1 acknowledged the resident's medical records were not protected from loss, damage, or unauthorized use and had temporarily moved them to the floor.

Based on documentation review and interview, the manager failed to ensure the report required in subsection (2) was maintained for at least 12 months after the date the report was submitted to the governing authority. Findings include: 1. A review of the facility's quality management documentation revealed a quality management report dated January 18, 2025. However, documentation of additional reports was unavailable for review. 2. In an interview, E1 reported the facility's 2024 quality management documentation was removed at the end of the calendar year. E1 acknowledged the report required in subsection (2) was not maintained for at least 12 months after the date the report was submitted to the governing authority.

Based on documentation review and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. A review of the facility's toxicology reference guide revealed a publishing year of 2015. However, documentation of a current toxicology reference guide was not available for review. 2. In an interview, E1 acknowledged a current toxicology reference guide was not available for use by personnel members.