True Care Assisted Home

Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed medication orders for the following medications: Amlodipine Besylate 2.5 milligrams (mg), 1 tablet by mouth (po) at bedtime (qhs); Docusate Sodium 100 mg, 2 capsules po qhs; Mirtazapine 15 mg, 1 tablet po qhs; and Trazodone HCL 50 mg, 1 tablet po qhs. 2. A review of R1's medication administration record (MAR) for March 2025, indicated R1 was not administered the following medications on March 26, 2025 and March 29, 2025 at 8:00 PM: Amlodipine Besylate 2.5 mg; Docusate Sodium 100 mg; Mirtazapine 15 mg; and Trazodone HCL 50 mg. 3. A review of R2's medical record revealed medication orders for the following medications: Mirtazapine 15 mg, 1 tablet po qhs; Senna 8.6 mg, 2 tablets po qhs; and Trazodone HCL 50 mg, 1 tablet po qhs. 4. A review of R2's MAR for March 2025, indicated R2 was not administered the following medications on March 26, 2025 and March 29, 2025 at 8:00 PM: Mirtazapine 15 mg; Senna 8.6 mg; and Trazodone HCL 50 mg. 5. In an interview, E2 reported the facility used an electronic MAR system and the facility was having internet issues at the time of the missing documentation. E2 acknowledged medications administered to R1 and R2 were not accurately documented in R1's and R2’s medical records.

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility 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. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed the front door, back door to the patio, and the door from a resident's room to the backyard were equipped with an alarm to alert employees of egress; however, the alarms were not turned on at the time of inspection. 3. In an interview, E2 acknowledged that the facility provided directed care services and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on observation and interview, the manager failed to ensure that no more than two individuals reside in a residential unit or bedroom. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed Room Six included furniture for three residents. 2. In an interview, E2 reported the facility was unaware of the requirement, and had more than two residents residing in Room Six in the past. E2 acknowledged the facility had more than two individuals residing in a residential bedroom.

Based on observation, record review, and interview, the manager failed to ensure that a caregiver was only assigned to provide the assisted living services the caregiver had the documented skills and knowledge to perform, for one of two personnel sampled. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a Hoyer Lift present at the facility to transfer R1. 2. A review of E2's personnel record revealed documentation of the verification of E2's skills and knowledge. However, the use of a Hoyer Lift was not included in the caregiver's skills sheet. 3. In an interview, E2 reported the facility used the Hoyer Lift to transfer R1. E2 acknowledged E2 was assigned to provide assisted living services E2 did not have the documented skills and knowledge to perform.

Based on observation, record review, and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided health services for two of two personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include: 1. During the on-site compliance inspection, the Compliance Officer observed E2 at the facility, providing services to residents. 2. A review of E1's personnel record revealed E1 was hired as a caregiver. 3. A review of E1's and E2's personnel records did not include documentation of the verification of E1's and E2's skills and knowledge before E1 and E2 provided health services. 4. In an interview, E2 reported E1 has provided services at the facility. E2 acknowledged E1's and E2's personnel records did not include documentation of the verification of E1's and E2's skills and knowledge before E1 and E2 provided physical health services.

Based on documentation review and interview, the manager failed to ensure that a current drug reference guide was available for use by personnel members. Findings include: 1. A review of the facility's drug reference guide revealed a publishing year of 2012. However, documentation of a current drug reference guide was not available for review. 2. In an interview, E2 acknowledged a current drug reference guide was not available for use by personnel members.

Based on documentation review and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. A review of the facility's toxicology reference guide revealed a publishing year of 2014. However, documentation of a current toxicology reference guide was not available for review. 2. In an interview, E2 acknowledged a current toxicology reference guide was not available for use by personnel members.

Based on record review, observation, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two 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 medical record revealed a service plan (dated October 1, 2024) that indicated R1 required the following services: Assistance with dressing; Assistance with eating; Encouragement to eat; and Assistance with grooming. 2. A review of R1's activities of daily living (ADL) documentation, for March 2025, revealed missing documentation of the following services on March 26, 2025: Assistance with dressing at 8:00 PM; and Assistance with grooming at 8:00 PM. 3. A review of R1's ADL documentation, for March 2025, revealed missing documentation of the following services on March 29, 2025: Assistance with dressing at 8:00 PM; Assistance with eating at 5:00 PM; Encouragement to eat at 5:00 PM; and Assistance with grooming at 8:00 PM. 4. A review of R2's medical record revealed a service plan (dated February 28, 2025) that indicated R2 required the following services: Assistance with dressing; Assistance with eating; Encouragement to eat; Assistance with grooming; and Incontinence care. 5. A review of R2's ADL documentation, for March 2025, revealed missing documentation of the following services on March 26, 2025: Assistance with dressing at 8:00 PM; and Assistance with grooming at 8:00 PM. 6. A review of R2's ADL documentation, for March 2025, revealed missing documentation of the following services on March 29, 2025: Assistance with dressing at 8:00 PM; Assistance with eating at 5:00 PM; Encouragement to eat at 5:00 PM; Assistance with grooming at 8:00 PM; and Incontinence care at 5:00 PM. 7. In an interview, E2 reported the facility used an electronic ADL system, and the facility was having internet issues at the time of the missing documentation. E2 acknowledged a caregiver failed to document the services provided in R1's and R2's medical records.