New Beginning Homes

Based on record review and interview, the administrator did not ensure a resident's medical record contained documentation of physical health services, habilitation services, and behavioral care provided to the resident for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a current Person-Centered Service Plan (PCSP) from August 2025, which reported R1 would receive the following physical care services: Bathing - Minimal level of support; Dressing - Minimal level of support; and Grooming - Minimal level of support. 2. A review of R2's medical record revealed a document titled "ADL log." The ADL log revealed the following treatment times for "Hygiene: Brushing Teeth/Deodorant" were not documented as completed: January 5, January 10 - January 12 and January 14, 2026 at 8:00AM; and January 6 - January 7, January 10, January 13, and January 15, 2026 at 7:00PM. No documentation of bathing or dressing assistance being provided was available for review. 3 . A review of R2's medical record revealed a current Person-Centered Service Plan (PCSP) from February 2025, which reported R1 would receive the following physical care services: Bathing - Minimal level of support; Dressing - Minimal level of support; Grooming - Moderate level of support; Eating - Minimal level of support; Toileting - Moderate level of support; and Continent of Bladder - Partial requiring support. However, no documentation of support being provided to R2 was available for review. 3. During an interview E1 reported R1 and R2 had received all physical health services and staff are to complete a checklist daily to document care conducted. E1 and E5 acknowledged R1's and R2's medical record did not contain documentation of physical health services provided to R1 and R2.

Based on documentation review and interview, the administrator did not ensure policies and procedures for medication administration were reviewed and approved by a pharmacist. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Medication Administration.” However, the policy did not include documentation of having been reviewed and approved by a pharmacist. 2. In an interview, E1 acknowledged the policies and procedures for medication administration were not reviewed and approved by a pharmacist.

Based on documentation review and interview, the administrator did not ensure a disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of the facility’s documentation revealed documentation of the facility’s disaster plan being reviewed was not available for compliance officer review. 2. In an interview, E1 reported E1 was not aware the disaster plan was required to be reviewed annually. E1 acknowledged the disaster plan was not reviewed at least once every 12 months.

Based on documentation review and interview, the administrator did not ensure that a disaster drill for employees was conducted on each shift at least once every there months and documented. Findings include: 1 . A review of the facility documentation revealed a disaster drill completed on January 19, 2025 for the Morning Shift. However, no documentation of disaster drills completed on each shift every three months was available for review. 2 . In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on documentation review and interview, the administrator did not ensure an evacuation drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1 . A review of facility documentation included a staff schedule for January 2026 which revealed the facility operated with three primary shifts. 2 . A review of facility documentation revealed the following evacuation drills which included both personnel and members were conducted: January 18, 2025 during the morning shift; and March 23, 2025 during the evening shift. However, no documentation of evacuation drills for employees conducted on each shift every three months was available for review. 3 . In an interview, E1 acknowledged an evacuation drill for employees was not conducted on each shift at least once every three months and documented.

Based on observation and interview, the Administrator did not ensure ramps on the premises were secured firmly to the ground or a permanent structure. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a ramp at the front and back doors of the facility. However, the ramps were not secured firmly to the ground. 2 . In an interview, E1 acknowledged the ramps at the front and back door were not firmly secured to the ground or a permanent structure.