May's Haven, LLC

Based on record review and interview, the manager failed to ensure before or at the time of acceptance, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of three residents sampled. The deficient practice posed a risk as the facility admitted R1 without knowing if R1 required a higher level of care. Findings include: 1. A review of R1's (accepted in 2023) medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 2. In an interview, E1 acknowledged documentation to include whether R3 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not submitted.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical records, for three of three residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, and the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a service plan (dated in May 2023) for directed care services. The service plan stated the following services were to be provided to R1: -Oral care; -Nail care; -Hair care/shaving; -Dressing; -Bathing; and -Toileting. 2. A review of R1's medical record revealed an activities of daily living document for July 1-31, 2023. However, the following services were not documented as provided from July 1-26, 2023: -Oral care; -Nail care; -Hair care/shaving; -Dressing; and -Toileting. 3. A review of R2's medical record revealed a service plan (dated in June 2023) for directed care services. The service plan stated the following services were to be provided to R2: -Oral care; -Nail care; -Hair care/shaving; -Dressing; -Bathing; -Toileting; and -Transferring. 4. A review of R2's medical record revealed an activities of daily living document for July 1-31, 2023. However, the following services were not documented as provided on July 1-26, 2023: -Oral care; -Nail care; -Hair care/shaving; -Dressing; -Toileting; and -Transferring. 5. A review of R3's medical record revealed a service plan (dated in July 2023) for directed care services. The service plan stated the following services were to be provided to R3: -Oral care; -Nail care; -Hair care/shaving; -Dressing; -Bathing; -Toileting; -Transferring; and -Walking/Mobility. 6. A review of R3's medical record revealed documentation of services provided to R3 was not available for review. 7. The Compliance Officer observed E1 and E2 create an ADL sheet for R3, and then observed them document on E3's ADL sheet for July 19, 2023 and July 20, 2023. 8. In a interview, E1 acknowledged services provided were not being documented in R1's, R2's, and R3's medical records and the Department was provided false or misleading documentation.