Lt Assisted Living LLC

Based on documentation review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program which included the frequency of submitting a documented report required in subsection (2) to the governing authority. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Quality Management Policy and Procedure.” The policy stated, “The Manager or Designee shall document monthly... Maintain a line graph for each of the above to identify trends form [sic] month to month... An Assurance checklist will be performed by manager/caregiver/designee on a regular basis for at least once every 3month [sic]. ” 2. A review of the facility’s quality management documentation revealed a report dated March 1, 2025. However, documentation of the monthly tracking and line graph was not available for review. 3. In an interview, E1 reported E1 was unaware of the additional quality management requirements outlined in the facility's policies and procedures. E1 acknowledged the report required in subsection (2) was not submitted to the governing authority at the frequency established by the facility’s policies and procedures.

Based on record review and interview, the manager failed to ensure that a resident’s medical record contained documentation of medication administered to the resident that included the date and time of administration, for one of two residents sampled. Findings include: 1. A review of R1’s medical record revealed signed medication orders for the following medications: Gabapentin 600 milligrams (mg), 1 tablet by mouth (po) three times a day (tid); and Insulin Aspart 100 units / milliliters (mL), Inject subcutaneously before meals / tid per sliding scale. 2. A review of R1’s medication administration record (MAR) for June 2025 revealed R1 was administered the following medications on June 10, 2025, at 12:00 PM: Gabapentin 600 mg, 1 tablet po; and Insulin Aspart 100 units/mL, 0 units administered subcutaneously per sliding scale. However, the MAR documentation was provided to the Compliance Officer for review at approximately 10:30 AM. 3. In an interview, E2 reported R1 was administered the medication at approximately 10:30 AM, due to R1’s request for medication. 4. In an interview, E1 acknowledged R1’s medical record did not include documentation of the accurate date and time of administration of medications to R1.

Based on observation, documentation review, and interview, the manager failed to ensure policies and procedures were available to employees. The deficient practice posed a risk as policies and procedures reinforce and clarify the health care institution's standards, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested to review the facility's policies and procedures for the assisted living facility at 10:20 am. However, the facility's policies and procedures were not provided for review. 2. In an interview, E1 reported looking for, but not being able to find the policies and procedures binder. E1 acknowledged the policies and procedures were not available to employees.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every six months, for one of two resident reviewed receiving personal care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. Review of R2's medical record revealed a current written service plan for personal care services dated October 10, 2023. However, a service plan after October 10, 2023 was not available for review. 2. In an interview, E1 reported thinking that R2 had a more recent service plan, but could not produce it for review. E1 acknowledged R2 received personal care services and the service plan was not updated at least once every six months.

Based on record review, observation and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a service plan for directed care services dated May 20, 2024. This service plan stated the following services were needed: -"Bathing: CG assist, shower, complete bath 2X week/PRN; wash hair, with shower; peri care, daily and PRN, after each disposable change"; -"Brush teeth, Daily and PRN"; -"Cleans nails PRN"; -"Shave daily"; and -"Skin care PRN, Check pressure areas PRN". 2. Review of the electronic Activities of Daily Living Log (ADL) for R1 revealed no services were documented. 3. The Compliance Officer observed that the services appeared to have been provided to R1. 4. Review of R2's medical record revealed a service plan for personal care services dated October 10, 2023. This service plan stated the following service was needed: -"Brush dentures, Daily and PRN" 5. Review of the electronic ADL for R2 revealed the no documentation showing that R2's dentures had been brushed. 6. In an interview, R2 reported that R2's dentures were brushed by caregivers. 7. In an interview, E1 reported that the electronic system was new, and caregivers were still learning to use it. E1 acknowledged that services provided by the caregiver were not documented in the resident's medical record.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, 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 authorized to provide directed care services. 2. During the facility tour, the Compliance Officer observed a back door leading to the parking lot. The door was equipped with a device to alert caregivers when the door was opened, however, the device was switched off. 3. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a room with a sign on the door labeling it "Med Room" which contained 10 resident's medications in baskets on a shelf. However, this room was unlocked. 2. In an interview, E1 reported access to that area of the home was usually locked. However, the door was unlocked at time of inspection. 3. In an interview, E1 acknowledged the medication was not stored in a locked area.

Based on observation and interview, the manager failed to ensure at least one bathroom accessible from a common area contained toilet tissue for each toilet. Findings include: 1. The Compliance Officer observed one bathroom accessible from a common area. However, the bathroom did not contain toilet tissue. 2. In an interview E1 acknowledged the bathroom accessible from a common area did not contain toilet tissue.

Based on observation and interview, the manager failed to ensure the bathroom accessible from the common area contained paper towels in a dispenser or a mechanical air hand dryer. Findings include: 1. The Compliance Officer observed one bathroom accessible from a common area. However, the bathroom did not contain paper towels or a mechanical air hand dryer. 2. In an interview, E1 acknowledged the bathroom accessible from the common area did not contain paper towels in a dispenser or a mechanical air hand dryer.