Inspection Report — ARROWHEAD SENIOR LIVING

Inspection Details

Inspection #

INSP-0099720

Inspection Date(s)

3/4/2025

Status

Complete

Inspection Type

Complaint;Compliance (Annual)

Worksheet Type

Assisted Living Home

Certificate Number

AL10052H

Location Type

—

Initial Comments

The following deficiency was found during the compliance inspection and investigation of complaint #00105846 and #00106236 conducted on March 4, 2025:

Statement of Deficiency

1 deficiency found

Deficiency #1

R9-10-808 ✓ Plan Provided

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Rule

R9-10-808.C.1.g. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and

Evidence

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of three residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services. This service plan stated "Catheter care...caregiver to empty bag twice a day and as needed". However, in review of the Activities of Daily Living (ADLs) sheet, there was only documentation of this service being provided once a day for February 2025. 2. In an interview, E1 reported the catheter bag is emptied according to the service plan. E1 acknowledged R1's medical record did not include documentation of the above listed service.

Plan of Correction

Responsible Person

Francis Colinayo, Manager

Temporary Correction Date

2025-03-05

Permanent Correction Date

2025-03-05

Permanent Solution

On march 4, 2025, the manager corrected the R1’s prior ADL documents by adding a late entry second page to include the BID and PRN catheter care and drainage bag emptying. On March 4, 2025, the manager edited the permanent ADL document to reflect BID catheter care and emptying the drainage bag. To prevent recurrence of this documentation omission, the manager met with each caregiver (March 4th and 5th, 2025) and discussed the omission and reinforced the importance of thorough documentation of all ADLs and resident care and if questions, will check the providers orders and clarify with the manager. The manager will compare Service plans to the ADL documentation for accuracy each month and PRN. Updates in the service plan are generally every 3–6 months and if there is a change in residents condition.

Monitoring

The manager will compare Service plans to the ADL documentation for accuracy each month and PRN. Updates in the service plan are generally every 3–6 months and if there is a change in residents condition.