ABSOLUTE BEST CARE

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition.

Findings include:

1. A review of R1's medical record revealed a service plan dated January 8, 2023. The service plan identified R1 received Supervisory care and self administered R1's medications. A review of R1's medical record revealed on May 15, 2023, R1 experienced a change in condition and was transitioned to medication administration. However, there was no written service plan reviewed and updated no later than 14 calendar days after the change in R1's physical health condition and services.

2. In an interview, E1 acknowledged R1 had a change in services with the change of R1 to personal care services for medication administration. E1 acknowledged an updated service plan was not conducted to reflect R1's change in condition and services.

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 the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services.

2. During the facility tour with E1, the surveyor observed a patio door that led to an outside area, in the backyard, allowed residents to be a least 30 feet away from the facility. The door leading out to the backyard did not have a means of alerting employees of the egress of residents to the outside area.

3. During an interview, E1 and E2 reported E1 and E2 were unaware the identified rule. E1 acknowledged the patio door exiting to the outside area did not have a means of alerting employees to egress. E1 acknowledged 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.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position.

Findings include:

1. During a facility tour with E3, the compliance officer observed two oxygen cylinders sitting upright, but unsecured, next to an oxygen tank in a stand located in a resident bedroom closet floor.

2. During an interview, E3 acknowledged there were two oxygen cylinders unsecured in a resident bedroom closet.

3. During an interview, E1 acknowledged the manager failed to ensure oxygen containers were secured in an upright position.