Mary & Pete's Assisted Living

Based on record review and interview, the manager failed to ensure a resident had a written service plan that included a description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. Findings include: 1. A review of R1’s medical record revealed a service plan, dated November 10, 2024, for personal care services, which reflected R1’s “Medical Diagnosis and History” as “Chronic ulceration of skin of sites w/ necrosis of the bone. Atypical flutter, presence of cardiac pacemaker, altered mental status, unspecified.” The service plan included a section titled “Integumentary,” which read,” No Issues,” and “Keep resident’s skin clean and dry, apply hydrating lotion, check resident’s skin at every shower, bath, and PRN, ensure good hygiene and nutrition.” In addition, the service plan contained a section titled "Hospice Services," which identified Arista Hospice as R1's provider. The section indicated R1 was seen by a "CNA...2 times per Week and as needed." The section also indicated R1 was seen by a hospice provider "1 time per Week and as needed." 2. A review of R1’s medical record revealed a document titled “IDG Meeting Review,” documenting notes and diagnoses from R1’s hospice provider, signed on February 5, 2025. The document notes indicated R1 was admitted to hospice for a primary diagnosis of “protein calorie malnutrition” and identified R1’s “Primary” diagnosis as “Unspecified severe protein-calorie malnutrition Start Effective Date: 11/06/2024.” Furthermore, the document identified a "Start of Care Date" of November 4, 2024, six days prior to the formation of R1's service plan. 3. In an interview, E1 advised all caregivers were aware of R1’s medical conditions, including R1’s primary diagnosis. E1 acknowledged R1’s service plan did not include an accurate description of R1’s medical issues.

Based on documentation review, record review and interview, the manager failed to ensure a caregiver documented the services provided in a resident's service plan for one of two residents sampled. Findings include: 1. A review of facility staff schedules revealed the facility operated two shifts per day, 7 a.m. to 7 p.m., and 7 p.m. to 7 a.m. 2. A review of R2’s medical record revealed a service plan, dated September 17, 2024, for directed care services. The service plan contained sections titled “Transferring,” which indicated R2 required “total care, daily,” and “Dressing,” which indicated, “Requires total care, twice daily.” The service plan also included a section titled “Mobility,” which indicated “Bed Ridden” and “Requires Positioning: Yes 2 Hour(s).” In addition, the service plan contained a section titled “Strategies to ensure resident’s personal Safety,” which indicated “Resident is checked on every 3-4 hours at night time…” 3. A review of R2’s medical record revealed a document used for tracking activities of daily living (ADLs) for October 2024 and November 2024. The document included sections for documenting the services “Transfers” and "Dressing.” While the record reflected documentation indicating the service “Transfers” was provided every shift during October 2024 and November 2024, the record did not include a section for documenting the service “Mobility” every two hours. In addition, evidence that this service was provided was unavailable for review. Further, evidence of documentation R2 was provided the service “Dressing” twice daily was unavailable for review. 4. In an interview, E1 agreed caregivers were not documenting the services provided in a resident’s service plan as required.

Based on record review and interview, the manager failed to ensure an entry in a resident’s medical record was not changed to make the initial entry illegible. Findings include: 1. A review of R2’s medical record revealed a document titled “Individual Control Drug Record,” used for documenting and tracking the administration of a controlled substance. The record included a column titled “Date,” which contained documentation of dates of administration and receipt of a controlled substance. Entries on November 7, 2024 and November 8, 2024, were written over correction tape, which made the original date entries illegible. In addition, the document contained a column titled “Balance,” used for documenting and reconciling the amount of controlled substance on hand after administration. Entries on October 25, 2024; November 14, 2024; November 17, 2024; and November 20, 2024 were written over the original entry, making the original entry illegible. 2. In an interview, E1 agreed entries into a resident’s medical record were changed to make the original entry illegible.

Based on record review and interview, the manager failed to ensure a medication was administered to a resident under the direction of a medical practitioner for one of two residents sampled. Findings include: 1. A review of R1’s medical record revealed a service plan for personal care services, which included medication administration. Further review revealed a document used by medical providers to authorize “staff trained in medication administration…to administer medications and treatments that I may prescribe for my patient.” The document identified the name of R1’s physician; however, it was not signed by the physician identified but rather a registered nurse. 2. In an interview, E1 advised R1 was being administered medication as ordered. E1 agreed medication was being administered to R1 without the specific direction of a medical practitioner as required.