MAJESTIC ROSE LLC-PR

Based on documentation review and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents.

Findings include:

1. Review of the posted personnel schedule dated June 2024 revealed no documentation of the hours worked by each caregiver.

2. During an interview, E1 and E3 acknowledged documentation was not maintained of the caregivers working each day, including the hours worked.

3. This is a repeat deficiency from the compliance inspection conducted September 7, 2022.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan.

Findings include:

1. Review of R1's medical record revealed a service plan for personal care dated March 14, 2024, which reported that R1 required the following assisted living services:
-"Cleans nails PRN";
-"Comb hair daily";
-"Foot care"; and
-"Skin care PRN".
However, review of R1's "ADL [Activities of Daily Living] Documentation Sheet" revealed that these services were not documented.

2. Review of R's medical record revealed a service plan for directed care dated May 19, 2024, which reported that R2 required the following assisted living services:
-"Cleans nails PRN";
-"Comb hair daily";
-"Foot care"; and
-"Skin care PRN".
However, review of R2's "ADL Documentation Sheet" revealed that these services were not documented.

3. In an interview, E1 reported that the services were provided to R1 and R2, but did not realize they needed to be documented. E1 and E3 acknowledged that R1's and R2's medical records did not contain documentation of assisted living services provided to the residents.

Based on observation and interview, the manager failed to ensure a resident received privacy in care for personal needs. The deficient practice posed a risk of a privacy rights violation to the residents.

Findings include:

1. During the facility tour, the Compliance Officer observed a television screen in the common area which showed a live view from cameras in each occupied resident bedroom simultaneously. The cameras provided a view of the residents beds.

2. The Compliance Officer observed that the view of one resident receiving care for personal needs from a caregiver was visible on the screen in the common area.

3. In an interview, E2 reported that only caregivers look at the screen, however the screen was in view of residents sitting in the common area.

4. In an interview, E3 reported that residents signed documentation of consent to be videotaped. E1 and E3 acknowledged the resident's right to receive privacy in care for personal needs was not ensured at the time of the inspection.

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. Review of Department documentation revealed the facility was authorized to provide directed care services.

2. Review of facility policies and procedures revealed a document titled "Wandering Residents", which stated: "If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security."

3. During the facility tour with E2, the Compliance Officer observed two doors leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The doors leading out to the backyard each had a device that was intended to alert employees to the egress of a resident to the outside area. However, the devices were not functioning.

4. During the facility tour with E2, the Compliance Officer observed a door in an unlocked garage that led to the back yard. This door was not equipped with a device to alert caregivers to the egress of a resident.

5. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

6. This is a repeat deficiency from the compliance inspection conducted on September 7, 2022.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered.

Findings include:

1. Review of R2's June 2024 medication administration record (MAR) revealed the following medications were not documented as administered to R2 on June 2, 2024:
-Raloxifene 60mg;
-Sertraline 25mg;

2. Review of R2's medical record revealed a medication order that stated the following:
-"raloxifene 60 mg tablet GIVE [R2] 1 TABLET BY MOUTH EVERY MORNING";
-"sertraline 25mg tablet TAKE 1 TABLET BY MOUTH EVERY MORNING".

3. In an interview, E1 reported that E2 had administered the medication, but forgot to document them. E1 and E3 acknowledged R2's medication administration was not documented in R2's medical record.

4. This is a repeat deficiency from the compliance inspection conducted on September 7, 2022.

Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication.

Findings include:

1. During the facility tour with E2, the Compliance Officer observed the following:
In a refrigerator in an unlocked laundry room:
-Lorazepam prefilled syringes;
-Calcitonin salmon nasal spray; and
-Morphine Sulfate prefilled syringes.
In a drawer in the kitchen:
-Docusate softgel
In an unlocked caregiver room:
-Motrin IB; and
-a bottle of 70% Isopropyl alcohol.

2. During an observation, the caregivers were not accessing the medications at the time of arrival.

3. In an interview, E1 and E3 acknowledged the medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

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

Findings include:

1. During the facility tour with E2, the Compliance Officer observed an unsecured oxygen container in the garage.

2. In an interview, E1 and E3 acknowledged that an oxygen container was not secured in an upright position.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. During the facility tour with E2, the Compliance Officer observed the following:
In an unlocked laundry room:
-"Chase home value spray" which stated "Caution keep out of reach of children";
-"Spic and span everyday cleaner" which stated "Caution keep out of reach of children";
- "Kroger pro strength drain cleaner gel" which stated "Danger: keep out of reach of children causes burns to eyes, skin, and mucus membranes. Harmful if swallowed"; and
-"Pledge wood oil" which stated "Caution may be harmful if swallowed".
In a cabinet in an unlocked garage, stored next to beverages:
-six bottles of "Pine-sol multi-surface cleaner" which stated "Caution: keep out of reach of children"; and
-two bottles of "Lysol advanced power cleaning gel" which stated "Danger: keep out of reach of children".
In an unlocked cabinet under the kitchen sink:
-"Easy off oven and grill cleaner" which stated "Keep out of reach of children. danger: corrosive. contains sodium hydroxide (lye). will burn eyes and skin. harmful if swallowed."

2. Review of facility documentation revealed a policy titled "Environmental safety". The policy stated "All poisonous and toxic materials will be in labeled containers, locked area separate from food preparation and storage areas, dining areas, and medications such that they are inaccessible to residents."

3. In an interview, E1 and E3 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents.