MARIAN ADULT CARE HOME

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of three sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information.

Findings include:

1. A review of R1's and R2's medical records revealed documentation of assisted living services (ADLs) provided to R1 and R2 for the month of August 2024. The ADLs revealed R1 and R2 received "night checks turn in bed."

2. In record review, at approximately 12:00pm, on August 27, 2024, R1's ADL form, dated August 2024, included documentation on August 27, 2024 that R1 received "night checks turn in bed."

3. In record review, at approximately 12:00 pm on August, 27, 2024, R2's ADL form, dated August 2024, included documentation on August 27, 2024 that R2 received "night checks turn in bed."

4. In an interview, E1 acknowledged the ADL sheet was not filled out accurately for both R1 and R2 for the date of August 27, 2024 as the night checks had not been completed at the time it was marked as completed.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and 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 authorized to provide directed care services.

2. During the environmental inspection of the facility, the Compliance Officer observed the front door of the facility had a control and alert. However, both the control and the alert were deactivated at the time of observation.

3. During the environmental inspection of the facility, the Compliance Officer observed an unlocked door leading to the laundry room. Inside the laundry room, there was a door leading to the back yard that had a control and alert. However, both the control and alert were deactivated at the time of observation.

4. In an interview, E1 acknowledged both the control and alert were deactivated on the front door and the door in the laundry room that lead into the backyard. E1 acknowledged there were means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.