Rhoda's Assisted Living Home

Based on observation and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available in a bedroom being used by a resident receiving directed care services or the facility implemented another means to alert a caregiver or assistant caregiver to a resident’s needs or emergencies. The deficient practice posed a risk if the facility was unable to meet a resident's emergency needs. Findings Include: 1. In an environmental inspection, the Compliance Offices observed that R2 did not have a bell, intercom, or other mechanical means to alert employees to R2's needs or emergencies. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver’s skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services, and according to the facilities policies and procedures. The deficient practice posed a health and safety risk. Findings include: 1. A review of E2's personnel record revealed E2's skills and knowledge were not verified and documented. 2. Review of the facility’s policies and procedures revealed no policy that covered how the facility verified the skills and knowledge of caregivers and assistant caregivers. 3. In an exit interview, findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk if the facility was unable to meet a resident's emergency needs. Findings Include: 1. In an environmental inspection, the Compliance Offices observed that R1 did not have a bell, intercom, or other mechanical means to alert employees to R1's needs or emergencies. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a service plan which reflected R1 received medication administration services. 2. A review of R1's medical record revealed a medication order dated October 5, 2023 for "Trazodone 100 mg (milligrams) one tablet by mouth at night." 3. Further review of R1's medical record revealed a medication administration record (MAR) dated November 2023. R1's November 2023 MAR reflected R1 was administered "Trazodone 50 mg" at 8:00 PM from November 1, 2023 through November 30, 2023. 4. In an interview, E1 acknowledged R1's November 2023 MAR reflected R1 was administered 50 mg of "Trazodone" instead of 100 mg, as ordered. E1 reported R1's MAR was documented incorrectly.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer. The deficient practice posed a health and safety risk if the refrigerator was not maintained at a proper temperature. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a refrigerator in the kitchen. The Compliance Officer did not observe a thermometer in the refrigerator. The refrigerator contained items such as milk, eggs, cheese, and other perishable items. 2. In an interview, E1 acknowledged there was no thermometer in the facility's refrigerator.

Based on observation and interview, the manager failed to ensure a resident bathroom contained a slip-resistant surface in the shower. The deficient practice posed a fall risk for residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the facility's shared resident bathroom contained a shower. However, the shower did not contain a slip-resistant surface. 2. In an interview, E1 acknowledged the shower in the shared resident bathroom did not contain a slip-resistant surface.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a fall prevention and fall recovery program for all staff, which included initial training and continued competency training. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a fall prevention and fall recovery training program. 2. A review of E2's personnel record revealed no documentation of completion of fall prevention and fall recovery training. 3. In an interview, E1 acknowledged E2's personnel record did not contain documentation to indicate E2 completed initial training on fall prevention and fall recovery.

Based on interview and record review, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services to be provided to the resident, for one of four sampled residents. The deficient practice posed a risk if the resident's service plan did not include the accurate amount of services to be provided. Findings include: 1. A review of R1's medical record revealed a service plan dated October 4, 2023 for directed level of care. The service plan reflected R1 required assistance with incontinence care. However, the amount and frequency of incontinence care to be provided to R1 were not listed on R1's service plan. 2. In an interview, E1 confirmed R1 required assistance with incontinence care and acknowledged the amount and frequency of services were not listed on R1's service plan.