INSPIRA GATEWAY

Based on records reviewed and interview, the manager failed to ensure that a resident had a written service plan that included the level of service the resident was expected to receive, which posed a health and safety risk for four of ten sampled residents. Findings include: 1. Review of R3's current service plan dated May 2, 2023 stated the resident required medication administration services, however, the level of service was not documented on the resident's service plan. In an interview E1 reported the resident required "personal" care services. 2. Review of R5's current service plan dated May 8, 2023 stated the resident required medication administration services, however, the level of service was not documented on the resident's service plan. In an interview E1 reported the resident required "personal" care services. 3. Review of R8's current service plan dated May 10, 2023 stated the resident required medication administration services, however, the level of service was not documented on the resident's service plan. In an interview E1 reported the resident required "personal" care services. 4. Review of R9's current service plan dated June 9, 2023 stated the resident was capable of storing and controlling R9's own medications, however, the level of service was not documented on the resident's service plan. In an interview E1 reported the resident required "supervisory" care services. 5. In an interview, E1 acknowledged these service plans were lacking documentation of the level of service each resident required.

Based on record review and interview, the manager failed to ensure that one of eight sampled residents who were receiving personal care services had a written service plan reviewed and updated at least once every six months, which posed a health and safety risk. Findings include: 1. Review of R5's medical record revealed that R5 required personal care services. The service plans for the past twelve months were dated: August 24, 2022, April 1, 2023, and May 8, 2023. R5's service plan was not updated at least every six months. 2. In an interview, E1 acknowledged R5's service plan had not been updated as required. E1 acknowledged R5 was receiving personal care services.

Based on record review and interview, the manager failed to ensure two of ten sampled residents' written service plans reviewed when initially developed and updated were signed and dated by the resident or resident's representative, the manager, and the nurse or medical practitioner who reviewed the service plan, as required. Finding included: 1. Review of R3's service plan that was printed on the day of the compliance inspection dated May 2, 2023 stated the resident required medication administration services. This service plan had not been signed and dated by the resident or the representative, the manager, and the nurse or medical practitioner who reviewed the service plan. In an interview, E1 reported the resident was receiving personal care services. 2. Review of R5's service plan dated May 8, 2023 stated the resident required medication administration services. This service plan had not been signed and dated by the resident or the representative, the manager, and the nurse or medical practitioner who reviewed the service plan. In an interview, E1 reported the resident was receiving personal care services. 3. In an interview, E1 acknowledged that R3's and R5's service plans had not been signed and dated as required.

Based on observation, record review, and interview, the manager failed to ensure that a service plan for a resident who is receiving personal care services included the treatment of bruises, injuries, pressure sores, and infections, which posed a health and safety risk; for two of two sampled residents. Findings include: 1. Review of R3's current service plan dated May 2, 2023 did not document the treatment of this chronic skin issue that is being treated by an outside service. 2. Review of R5's current service plan dated May 8, 2023 did not document the treatment of a pressure sore on the resident's foot since returning to the facility in April. 3. In an interview, E1 acknowledged the wounds that were being treated at the facility, however these sampled residents' service plans did not document the treatment of these wounds.

Based on record review and interview, the manager failed to ensure that for four of four sampled residents who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' needs were being met. This determination was to be completed at the time of acceptance or onset and at least once every six months throughout the duration of the residents' condition to determine if the residents' needs could be met based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services. Findings include: 1. During an interview, E1 reported that R1, R2, and R6 were unable to ambulate even with assistance since accepted to the facility, and that R7 had a change in condition a few months ago and was now unable to ambulate even with assistance. 2. Review of R1's medical record contained no documented determination completed by R1's PCP or medical practitioner within 30 days before acceptance or at the time of acceptance or onset. Base on the date of acceptance this determination was required. R1's PCP or medical practitioner should have completed a determination at least every six months throughout the duration of the resident's condition. Each determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required directed care services. 3. Review of R2's medical record contained no documented determination completed by R2's PCP or medical practitioner within 30 days before acceptance or at the time of acceptance or onset. Base on the date of acceptance this determination was required. R2's PCP or medical practitioner should have completed a determination at least every six months throughout the duration of the resident's condition. Each determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required directed care services. 4. Review of R6's medical record contained no documented determination completed by R6's PCP or medical practitioner within 30 days before acceptance or at the time of acceptance or onset. Base on the date of acceptance this determination was required. R6's PCP or medical practitioner should have completed a determination at least every six months throughout the duration of the resident's condition. Each determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required personal care services. 5. Review of R7's medical record contained no documented determination completed by R7's PCP or medical practitioner of onset. R7's PCP or medical practitioner should have completed a determination at least every six months throughout the duration of the resident's condition. Each determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. The current service plan stated the resident required personal care services. 6. In interviews, E1 acknowledged the required documentation for the determinations were not completed as required for these sampled residents who were unable to ambulate even with assistance.

Based on observation, record review, 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 in a bedroom being used by one of two sampled memory care residents receiving directed care services; which posed a health and safety risk. Findings include: 1. During a facility tour, E1 and the compliance officer observed R1 laying in bed There was no bell, intercom, or other mechanical means accessible to R1 to alert employees to the resident's needs or emergencies. 2. Review of R1's record revealed R1 was receiving directed care services and was unable to ambulate even with assistance. 3. In an interview, E1 acknowledged that R1 had no access to a call bell nor an intercom, or other mechanical means to alert employees of R1's needs.

Based on observation and interview, the manager failed to ensure there was a current drug reference guide that was available for use by personnel members which posed a health and safety risk to the resident if the caregiver was unable to reference a medication a resident was taking. Findings include: 1. During the compliance inspection the compliance officer observed the facility was providing medication administration services. The most recent facility's current drug reference guide was the Nursing 2022 Drug Handbook by Wolters Kluwer. 2. A Google search found Nursing 2023 Drug Handbook by Wolters Kluwer and also the 2024 edition. 3. In an interview, E1 and E10 acknowledged the facility's drug reference guide was not current.