North Beverly Assisted Living

Based on record review, documentation review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1 . A review of E1's personnel record revealed documentation of fall prevention and fall recovery training being conducted upon hire and annually afterwards was not available for review. 2 . A review of facility documentation revealed a policy titled "Fall Prevention and Fall Recovery." The policy stated "All employees will have a class on fall prevention upon date hired and continuous training on a yearly basis by a school approved and regulated by NCIA board regarding fall prevention and recovery." 3 . In an interview, E2 acknowledged E1 had no documentation of fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure a manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis as specified in R9-10-113, for one of three personnel sampled. Findings include: 1 . A review of E2's medical record revealed documentation of a chest x-ray stating freedom from infectious tuberculosis (TB), conducted on February 6, 2023. However, documentation of two TB skin tests or a TB blood test was not available for review at the time of inspection. 2 . In an interview, E2 acknowledged E2 had no documentation of freedom from infectious tuberculosis.

Based on observation and interview, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area that 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. During an environmental inspection of the facility, the Compliance Officers observed nonfunctional door alerts in a vacant resident room and bathroom leading to the backyard. There was a screen door after each door with an alert which had a double-sided key deadbolt. However, the deadbolt for each door was unlocked. 2. During an environmental inspection of the facility, the Compliance Officers observed an occupied resident room with a door that led to the backyard. However, the door had no control or alert. 3. In an interview, E2 acknowledged the aforementioned doors leading to the backyard did not have a control or alert.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a signed medication order dated February 17, 2025. The medication on the orders included Ropinirole 0.25mg twice a day, and Calcium 500mg twice a day. However, a review of R1's Medication Administration Record (MAR) for the month of April 2025 revealed Ropinirole and Calcium not documented as administered at 5:00 PM from April 1, 2025 to April 14, 2025. 2. In an interview, E2 confirmed all residents receive medication administration. E2 acknowledged R1's medication was not documented as administered.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed in a common bathroom a locked cabinet with a magnetic key right beside it. The Compliance Officers were able to use the key to access the inside of the cabinet. The following items were in the cabinet: -A can of "Wizard" Air Freshener; -A Spray bottle with no label; -A can of Lysol Disinfectant Spray; and -A bottle of Lysol Advanced Power Clinging Gel. 2. In an interview, E2 acknowledged the poisonous or toxic materials were not maintained in labeled containers in a locked area and inaccessible to residents.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a caregiver provided valid documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of three caregivers sampled. Findings include: 1. The Compliance Officer arrived to the facility at 10:35 AM and observed E2 was the only staff present on-site. E1 arrived to the facility at 11:20 AM. 2. A review of facility documentation revealed a document titled "Delegation of Authority" dated April 1, 2023, which stated "In the absence of the Manager, the caregiver/s namely: [E1] (Night shift) and [E2] (Day Shift ) and [E4] (caregiver). Are empowered to act on the Manager's behalf in directing and supervising the operation of this Assisted Living Facility and providing care to the residents." 3. A review of the facility's work schedule reflected E2 was scheduled to work alone the following days and times: -April 5-7, 2023 from 7:00 AM to 7:00 PM; -April 12-13, 2023 from 7:00 AM to 7:00 PM; -April 19-20, 2023 from 7:00 AM to 7:00 PM; and -April 26-27, 2023 from 7:00 AM to 7:00 PM. 4. A review of E2's personnel record revealed a caregiver certification issued July 15, 2013 from "ALTP0152 Platinum Training Services, LLC." However, ALTP0152 was not assigned to Platinum Training Services LLC, and was assigned to a different caregiver training program. 5. A review of the NCIA Board website revealed ALTP0152 was assigned to Comprehensive Training Services, LLC. 6. In an interview, E1 and E2 reported being unaware E2's caregiver certification was unable to verified. E2 could not provide any other documentation of completion of a caregiver training program approved by the Department or the NCIA Board.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services provided to the resident, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan dated February 2, 2023. The service plan reflected R2 required assistance with "teeth, hair, nails...total caregiver assist with ADL's (activities of daily living), caregiver assist with dressing". However, the amount and frequency of the services was not included. 2. In an interview, E1 reviewed R2's service plan and acknowledged the service plan did not include the amount and frequency of the aforementioned services.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a document titled "ADL (activities of daily living) Chart" dated April 2023. R1's April 2023 "ADL Chart" reflected R1 received assistance with "comb/shave every day, assisting with clothing every day, skin care/lotion daily" every day from April 1, 2023 to April 25, 2023. 2. A review of R1's medical record revealed a service plan dated March 1, 2023. R1's service plan did not reflect the aforementioned services would be provided to R1. 3. A review of R2's medical record revealed a document titled "ADL Chart" dated April 2023. R2's "ADL Chart" reflected R2 received assistance with "comb/shave every day, skin care/lotion daily" every day from April 1, 2023 to April 25, 2023. 4. A review of R2's medical record revealed a service plan dated February 3, 2023. R2's service plan did not reflect the aforementioned services would be provided to R2. 5. In an interview, E1 reviewed R1's and R2's "ADL Chart[s]" and service plans and acknowledged the service plans did not include services provided to R1 and R2 according to R1's and R2's "ADL Chart[s]".

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a medication order dated March 23, 2023 for "Metroprolol Tartrate 25 mg (milligrams) one tablet by mouth twice daily and hold for systolic blood pressure less than 120." 2. A review of R2's medical record revealed a medication administration record (MAR) dated April 2023. R2's April 2023 MAR reflected R2 was administered "Metroprolol Tartrate 25 mg" on April 13, 2023. However, R2's medical record also included a document titled "Vital Sign-Weight Flow Sheet" which reflected R2's systolic blood pressure was 116 on April 13, 2023. 3. In an interview, E1 acknowledged R2's "Metroprolol Tartrate 25 mg" medication was not administered in compliance with the medication order.