Mama Care Assisted Living

Based on documentation review and interview, the manager failed to ensure that a plan was documented and implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Quality Management Plan." The policy stated: "The frequency of submitting a documented report - The monthly report shall be completed and maintained on a quarterly basis." 2. During the on-site compliance and complaint inspection, the Compliance Officers requested the facility's quality management documentation at 10:20 AM. No documentation was provided for Compliance Officer review. 3. In an interview, E3 reported the facility did not have any incidents to report. E3 acknowledged a plan was not documented or implemented for an ongoing quality management program.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge are verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services and according to policies and procedures for two of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of facility policy and procedures revealed a document titled "Staffing a Record Keeping" which stated: "Each employee hired by this facility must have the following on Employee's file 1. Application Form 2. copy of current TB skin test that reads "negative result" 3. finger print clearance card verification 4. CPR and First Aid 5. Verification of skills and Knowledge." A blank "Caregiver Skills Documentation" form was included in the policy and procedures. 2. A review of E2's and E3's personnel records revealed no documentation verifying a caregiver's or assistant caregiver's skills and knowledge. 3. A review of the facility's employee schedule for December 1, 2024 - December 11, 2024 revealed E2 was scheduled to provide services the following dates and shifts: - December 1, 2024 and December 9, 2024 day shift; - December 2, 2024 - December 8, 2024 night shift; and - December 10, 2024 - December 11, 2024 night shift. 4. A review of the facility's employee schedule for December 1, 2024 - December 11, 2024 revealed E3 was scheduled to provide services the following dates and shifts: December 1, 2024 and December 9, 2024 night shift; - December 2, 2024 - December 8, 2024 day shift; and - December 10, 2024 - December 11, 2024 day shift. 5. During an environmental inspection, Compliance Officer observed E2 and E3 provided assisted living services to residents in the home. 6. In an interview, E3 acknowledged E2's and E3's skills and knowledge were not verified and documented before E2 and E3 provided physical health services.

Based on record review, observation and interview, the manager failed to ensure medication was administered to a resident in compliance with a medication order, for one of two sample residents who received medication administration. Findings include: 1. A review of R2's medical record revealed a directed care service plan dated October, 2024 which documented R2 received medication administration. 2. A review of R2's medication administration record (MAR) for December, 2024 revealed R2 was administered the following medications December 1, 2024 - December 11, 2024: - Depakote Sprinkle 125 milligram (Mg) Cap - 1 capsule daily at lunch - 12PM; - Metformin HCL 500Mg Tablet - 1 Tablet witha a meal oraly two times a day - 8Am and 8Pm; - Galantamine Hydrobromide Tab 8 MG - Give 1 tablet by mouth two times a day For Dimentia - 8AM and 5PM; - Trazadone 50 Mg - 1/2 tab by mouth at bedtime - 8PM; - Lantus Solo Star 100 Units Sol. Pen Injector - Subcutaneously 15 Units at bedtime - 8PM; and - Hydroxycine HCL 25MG - 1 Tab Orally daily - 12Pm. 3. A review of R2's medical record revealed a medication list titled "Medication Administration" signed by a Family Nurse Practitioner (FNP) and faxed to the facility on August 25, 2024. However, page one of three was not available for review. No medication orders were provided for the following medications: - Depakote Sprinkle 125 milligram (Mg) Cap - 1 capsule daily at lunch - 12PM; - Metformin HCL 500Mg Tablet - 1 Tablet witha a meal oraly two times a day - 8Am and 8Pm; - Galantamine Hydrobromide Tab 8 MG - Give 1 tablet by mouth two times a day For Dimentia - 8AM and 5PM; - Trazadone 50 Mg - 1/2 tab by mouth at bedtime - 8PM; - Lantus Solo Star 100 Units Sol. Pen Injector - Subcutaneously 15 Units at bedtime - 8PM; - Hydroxycine HCL 25MG - 1 Tab Orally daily - 12Pm. 4. In an interview, E3 reported upon investigation R2's primary care had not received the first page of the medication list when sent for updates. E3 acknowledged R2's medication was not administered in compliance with a medication order.

Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area, labeled and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection, Compliance Officer observed ambulatory residents in the home. 3. During the environmental tour, the Compliance Officers observed the following poisonous or toxic material in the unlocked garage; - One container of "Ultra Fresh Fabric Softener"; - Three containers of "OdoBan Deodorizer, Disinfectant, Mildewstat, Virucide, and Sanitizer"; - Two cans of "WD 40"; - One container of "Prestone Brake Fluid"; - One container of "Griot's Leather 3-in-1"; - One container of "DOT Brake Fluid"; - One containter of "Peak Original Equipment Technology Antifreeze and Coolant"; and - One can of Sea Foam Motor Treatment. 4. In an interview, E3 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area, labeled and inaccessible to residents.

Based on documentation review, interview, record review, and observation, the manager failed to ensure an assisted living facility had a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to provide the assisted living services, behavioral care, and ancillary services in the assisted living facility's scope of services; meet the needs of a resident; and ensure the health and safety of a resident. The deficient practice posed a risk to the health and safety of residents. Findings include: 1. A review of the facility's policies and procedures, dated February 12, 2019, revealed a policy titled, "Mission Statement." The policy stated, "Services Include: 24 all levels of care provided by well-trained staff; [three] nutritious meals and 2-3 healthy snacks; various activities of choice; pastoral visits; home health care as needed; hospice care/palliative care as needed; TV in each room (optional); Grooming services available upon request; PCP [primary care provider]/NP [nurse practitioner] visits as needed." 2. A review of the facility's documentation revealed daily staffing schedules for March 2023, and April 2023. The March schedule indicated E3 worked the day shift the entire month and E2 worked the night shift for the entire month. The April schedule indicated E2 worked every shift for the entire month. No back-up caregiver or manager was included on any of the schedules. 3. In an interview, E2 reported E3's termination date was in mid-March 2023. E2 reported having difficulty hiring caregivers after E3's employment was terminated. 4. In an interview, O1 reported to believe the quality of care had deteriorated since mid-March when E3 employment was terminated with the facility. 5. A review of R2's medical record revealed a residency agreement dated in 2019, that revealed the staff sleep at night, but were available when needed. 6. During a tour, the Compliance Officer observed R3 did not have a call bell or any other means to alert staff if needed. 7. In an interview, R3 reported to call out for staff when needed or ask R3's roommate to request assistance on R3's behalf when necessary. 8. During a tour of the facility, the Compliance Officer observed the alarm on the patio door that opened to the unsecured backyard could not be heard throughout the facility when activated. 9. In an interview, E1 acknowledged it was difficult to meet the needs of the residents with only one personnel member to provide services. E1 reported hospice and home health staff assisted with the grooming needs of some of the residents a few times a week as a means of extra support.

Based on documentation review and interview, the manager failed to ensure as part of the policies and procedures required in R9-10-803(C)(1)(h), a plan was established and documented to ensure the manager or a caregiver was available as 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. The deficient practice posed a risk as there were no policies and procedures to reinforce and clarify the health care institution's standards. Findings include: 1. A review of the facility policies and procedures revealed a policy titled "Staff Schedule,"updated January 28, 2022. The policy stated, "This facility's work schedule will indicate the date, work hours and name of each person assigned to work. The following caregivers will be working based on a 12 to 24-hour shifting, depending on the resident acuity and census on a specific day or period." However, no caregivers were listed. The policy goes on to say, "...Emergency process pertaining to a staff member not appearing for a scheduled shift is as follows: Contact the facility manager or back-up staff member to come in to release the current shift." However, no back-up staff member was identified. 2. A review of the facility's daily staffing schedules (dated April 1, 2022-April 2023) revealed no back-up caregiver or manager was included. 3. In an interview, E2 reported it was difficult to find a caregiver at the present time. E2 reported only having two staff members currently. E2 reported staff would contact a temporary staffing agency if the manager or a caregiver were not available to provide the required assisted living services.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record for two of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings; 1. A review of R1's service plan dated February 4, 2023, identified the following services to be provided to R1: Shower twice per week with minimal assistance from a caregiver, providing snack to R1 between meals; communication by phone with family/power of attorney once per week and with any changes of R1's condition; eight ounces of fluid offered and encouraged with every meal and in-between meals to prevent constipation and dehydration; 2.. A review of R1's medical record revealed no documentation of services provided to R1 after March 25, 2023. 3. A review of R2's service plan, dated January 1, 2023, identified the following services to be provided: showering at least one time per week with standby assistance and providing snacks to R2 between meals. 4. A review of R2's medical record revealed no documentation of services provided to R2. Shower at least one time per day with assistance. 5. During an interview, E2 reported it was not necessary to document the services to R2 because R2 received services at the personal care level. E2 reported the services provided to R1 were documented. E2 acknowledged R2's medical record did not include the services provided to R2 after March 25, 2023. E2 reported not having time to document the services provided to R2 since March 24, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a 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 and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a health and safety risk to residents. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. During a tour, the Compliance Officer observed, when exiting the unlocked patio door to the back yard, a faint chirping sound could be heard from an alarm. However, the sound could not be heard throughout the facility. 3. In an interview, E2 acknowledged the chirping sound on the alarm could not be heard throughout the facility. E2 reported the alarm was supposed to chirp and the chirp could easily be heard throughout the facility.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a tour of the facility, the Compliance Officer observed Clorox wipes, Lysol toilet bowl cleaner, Resolve carpet cleaner, window cleaner, and Home fabric refresher in an unlocked cabinet under the kitchen sink. The surveyor observed Lysol disinfectant spray in an unlocked cabinet in R3's bathroom area. 2. In an interview, E2 acknowledged the aforementioned toxins were stored in unlocked cabinets accessible to residents.