Sweet Home Adult Care Home LLC

Based on observation, documentation review, and interview, the manager failed to ensure policies and procedures were established, documented and implemented to protect the health and safety of a resident that covered assistance in the self-administration of medication, and medication administration. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed magnetic keys for the medication cabinet sitting on a outlet faceplate underneath the cabinet. 2 . A review of facility documentation revealed a policy titled "Medications including Opioids, Narcotics, and Schedule 2." Under "Part II-Receiving, Storing Medications" the policy stated "Only the Manager and trained caregivers shall be in possession of the keys to the medication storage area." 3 . In an exit interview, the findings were discussed with E2 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for seven of eight residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1 . A review of R1's, R4's, R5's, and R6's current service plans revealed the residents received assistance in dressing and grooming daily, as well as night checks and showers twice a week. However, a review of R1's, R4's, R5's and R6's activities of daily living (ADL) sheets for the month of December revealed no marks to indicate services were provided to the residents from December 1, 2025 to December 9, 2025 at the time of inspection. 2 . A review of R3's current service plan revealed R3 received assistance in dressing and grooming daily, as well as night checks and showers twice a week. However, documentation of an ADL sheet for the month of December was not available for review at the time of inspection. 3 . A review of R7's current service plan revealed R7 received night checks and showers twice a week. However, a review of R7's ADL sheet for the month of December revealed no marks to indicate services were provided to the residents from December 1, 2025 to December 9, 2025 at the time of inspection. 4 . A review of R8's current service plan revealed R8 received assistance in dressing and grooming daily, as well as night checks and bed baths twice a week. However, documentation of an ADL sheet for the month of December was not available for review at the time of inspection. 5 . In an exit interview, the findings were discussed with E2 and no additional information was provided. This is a repeat deficiency from the complaint investigation and compliance inspection conducted on June 12, 2023.

Based on record review and interview, the manager failed to ensure a medical record was established and maintained for each resident, for one of eight residents sampled. Findings include: 1 . A review of resident medical records revealed the medical record for R8 was not available for review at the time of inspection. 2 . In an interview, E2 reported that the binder was given to the resident's family for use to get assigned as a power of attorney. In an exit interview, the findings were discussed with E2, and no additional information was provided.

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 six of eight residents sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1 . During an inspection at the facility, the Compliance Officer asked E2 for the current medication administration record (MARs) book for the residents. E2 responded E2 would get the book and be right back. The Compliance Officer offered to accompany E2 to get the current MARs book, to which E2 reported E3 had the MARs book to send something off to a doctor. When the Compliance Officer asked where the book was located, E2 reported it was in the home. After repeated attempts of asking where the MARs book was, E3 brought the book to the Compliance Officer for review after E2 called them. 2 . A review of R1's medical record revealed signed medication orders for the following medications: -Aspirin 81 MG tablet once daily; -Cetirizine HCL 10 MG tablet once daily; -Fluticasone 50 MCG 1 spray in each nostril daily; -Metoprolol Succinate ER 25 MG 1/2 tablet once daily; -Rivastigmine 4.5 MG Capsule once daily; and -Atorvastatin 20 MG tablet once daily. Further Review of R1's medical record revealed a medication administration record (MAR) sheet for December 2025. The medications were marked as administered. However, after an interview with E2, E2 reported the medications had been marked on site during the inspection when the Compliance Officer asked for the book. 3 . A review of R3's medical record revealed signed medication orders for the following medications: -Amlodipine Besylate 5 MG tablet once daily; -Clopidogrel Bisulfate 75 MG tablet once daily; -Escitalopram Oxalate 10 MG tablet once daily; -Tamsulosin Cap 0.4 MG capsule once daily; and -Aspirin 81 MG 2 tablets once daily. However, documentation of a MARs sheet for December 2025 was not available for review at the time of inspection. 4 . A review of R4's medical record revealed signed medication orders for the following medications: -Aspirin 81 MG tablet once daily; -Esomeprazole Magnesium 40 MG capsule once daily; -Quetiapine 200 MG tablet once daily; -Metoprolol Tartrate 25 MG 1/2 tablet twice daily; -Lidocaine External Patch 4% 12 hours on, 12 hours off daily; -Donepezil 10 MG tablet once daily; -Hydralazine HCI 100 MG tablet once daily; and -Trazadone 100 MG tablet once daily. However, the MARs sheet for December 2025 was not documented as administered for the above medications from December 1, 2025 to December 9, 2025 at the time of inspection. 5 . A review of R6's medical record revealed signed medication orders for the following medications: -Lisinopril 10 MG tablet once daily; -Aspirin 81 MG tablet once daily; -Fluticasone 50 MCG 1 spray into each nostril once daily; -Hydrochlorothiazide 12.5 MG tablet once daily; and -Sertraline HCL 50 MG tablet once daily. However, the MARs sheet for

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed an alert on the front door and back door of the facility. However, neither alert was functional at the time of inspection or had a control engaged. 3. In an interview, E1 acknowledged the front and back door alerts were not functional at the time of inspection.

Based on observation and interview, the manager failed to ensure a toxic material stored by the facility was stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the following in a cabinet underneath the kitchen sink: -A bottle of "Simple Green" all-purpose cleaner; -A can of "Pledge" dusting spray; -A can of "Lysol" disinfectant spray; -A container of "LA's Totally Awesome Bleach"; and -A container of "Lysol" toilet bowl cleaner. The cabinet had latches which the Compliance Officer was able to push down to access the cabinet. 2. In an interview, E1 acknowledged toxic materials stored by the facility were not stored in a locked area and inaccessible to residents.

Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of one resident reviewed who experienced a change of condition. Findings include: 1. Review of R1's medical record revealed a current written service plan dated July 13, 2022. This service plan indicated R1 did not have any open wounds. A review of R1's medical record revealed R1 was seen by Banner Health Urgent Care for a "ulcer of heel" on November 17, 2023. A review of a Quality Home Health assessment revealed on December 2, 2022, R1 was diagnosed with a "stage 4" pressure sore on left heel. A review of R1's medical record revealed no service plan dated no later than fourteen days after the identified significant change in R1's physical condition. 2. In an interview, E2 reported R1 had a change of condition in November 2022 and required daily wound care assistance on R1's heel. E1 acknowledged R1's service plan was not updated after the identified significant change of condition. 3. In an interview, E1 acknowledged the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of one resident reviewed who experienced a change of condition.

Based on record review and interview, the manager failed to ensure a caregiver documents the services provided in the resident's medical record. Findings; 1. Review of R1's personal care service plan identified "skin care PRN, Check pressure areas PRN." A review of R1's medical record revealed R1 was diagnosed with ulcer of the heel on November 17, 2023. A review of R1's record revealed documentation to demonstrate R1 received services to address R1's ulcer of the heel began on December 1, 2022. 2. In an interview, E2 reported E2 and the facility caregivers provided R1 with wound care on the identified pressure ulcer daily since the diagnoses on November 17, 2023. E2 acknowledged the wound care services provided by the caregivers included cleaning the wound, changing the bandages and assessing the area daily. E2 acknowledged R1's medical record did not document the identified services provided until December 1, 2022. 3. In an interview, E1 acknowledged the manager failed to ensure a caregiver documents the services provided in the resident's medical record. This is a repeat deficiency from the compliance inspection conducted on June 8, 2022.

Based on record review and interview, the manager failed to ensure that a facility did not retain a resident who had a stage 4 pressure sore, unless the facility obtained a written determination from a medical practitioner stating the resident's needs are met by the facility and the resident's needs are within the facility's scope of services, which posed a health and safety risk to the resident if the facility retained a resident who had a stage 4 pressure sore, and the resident's needs are not met. Findings include: 1. Review of R1's medical record revealed a current written service plan dated July 13, 2022 for personal care services. A review of a Quality Home Health assessment revealed on December 2, 2022, R1 was diagnosed with a "Pressure ulcer of right heel, stage 4 start effective date: 12/2/22." R1's medical record did not reveal documentation from a medical practioner determining R1's needs could be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, were being met by the assisted living facility. 2. In an interview, E2 reported E2 did not recall the identified rule. E2 reported R1's medical record did not contain documentation from a medical practioner determining R1's needs could be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, were being met by the assisted living facility. 3. In an interview, E1 acknowledged the manager failed to ensure an assisted living facility authorized to provide Personal care services did not accept or retain a residents with stage 3 or stage 4 pressure sores unless the facility obtained a written determination from a medical practitioner stating the resident's needs are met by the facility and the resident's needs are within the facility's scope of services.