PENZI CARE HOME LLC

Based on documentation review, record review, and interview, the manager of an assisted living facility authorized to provide directed care services shall ensure that policies and procedures are established, documented, and implemented that ensure the safety of a resident who may wander. The deficient practice posed a risk to the health and safety of residents if residents whom were high risk for wandering were left alone and/or unattended.

Findings include:

1. A review of the facility's policies and procedures dated in 2022, stated "All facility personnel will keep an eye on wandering residents to reduce the risk of eloping/wandering away from the Assisted Living Facility premises to avert endangering themselves and jeopardizing facility operations. Maintain security of locks on the front door, yard, and hazardous areas at all times."

2. A review of R1's medical record, revealed R1 has been diagnosed with dementia and was at high risk for wandering. Further review revealed special instructions indicating "all around standby assist by caregivers" was required.

3. A review of R1's medical record, revealed a service plan, dated in September 2023, indicating "resident is not physically or mentally capable of getting out of the house without assistance from another individual or mobility aids".

4. In an interview, E2 was asked where E2 was at the approximate time R1 left the home unnoticed. E2 reported to have been taking a nap, believing all residents were napping as well.

5. In an interview, E1 was asked if a door alarm sounded off when R1 left the residence unnoticed. E1 reported E1 believed R1 turned off the door alarm, and then exited the facility. E1 was asked how E1 believed R1 exited the facility's back yard area. E1's response was E1 believed R1 climbed the wall, which is about 6 ft tall, and exited the facility property.

6. In an interview, E1 was asked where E1 was located at the approximate time R1 left the home unnoticed. E1 reported to have been working on the computer in the living room at the time and added E1 did not notice when R1 left the home as the door alarm did not sound off. E1 acknowledged R1's physical limitations, according to R1's service plan.

Based on observation, interview, and record review, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility, and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk to the health and safety of residents if there was no control to alert employees of resident egress from the facility.

Findings include:

1. Upon arrival to the facility, the Compliance Officer noticed the front door alarm, alerting a resident's egress from the the facility, did not sound off.

2. In an interview, E1 acknowledged the door alarm was set to the off position, but reported the alarm is in working condition.

3. E1 acknowledged the door alarm should be on at all times to alert employees of the egress of a resident from the facility.

Based on observation, and interview, the manager failed to ensure a resident was not subjected to a restraint for two of three residents sampled. The deficient practice posed a risk to a resident if the resident was unable to move freely without restriction.

Findings include:

1. R9-10-101.199 defines "Restraint" as any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body.

2. During the facility tour, the Compliance Officer observed R2's and R3's beds had a set of bed rails. The bed rails were observed in the up position with R2 and R3 in the bed.

3. In an interview, E1 reported the bedrails were used to prevent R2 and R3 from falling off the bed.

4. In an interview, E1 reported R2 and R3 were unable to unlatch the bedrails to put it in the down position.

5. In an interview, E1 acknowledged the bed rails was restricting residents' movement, and posed a safety risk for the residents.

6. In an interview, E1 acknowledged if bedrails were needed in the facility for residents, a higher level of care to meet residents' needs would need to be sought.

Based on observation and interview, the manager failed to ensure the premises were cleaned and, if applicable, disinfected, according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a risk to the health and safety of the residents.

Findings include:

1. During the facility tour, the Compliance Officer observed soiled, disposable incontinence chux pads still on residents' beds in the facility, while the residents were awake and off the bed. As a result, the soiled pads produced a strong urine smell throughout the health care institution.

2. In an interview, E1 acknowledged the strong urine smell in residents' bedrooms, and throughout the health care institution.

3. In an interview, E1 acknowledged E1 had not had time to remove the chux pads from the residents' rooms.

Based on observation and interview, the manager failed to ensure hazardous materials were stored in a locked area inaccessible to residents. The deficient practice posed a risk to the health and safety of residents if residents gained access to hazardous materials.

Findings include:

1. During the facility tour, the Compliance Officer, observed an open and unlocked shed outside of the facility, in the back yard, which contained:

-3 cans of spray paint
-1 bottle of brake fluid,
-1 five gallon bucket of paint
-1 quart of engine oil
-1 can of hydraulic fluid

2. In an interview, E1 acknowledged the shed was open and unlocked in the back yard of the facility, which contained accessible chemicals, hazardous to residents.

Based on observation and interview, the manager failed to ensure a resident's sleeping area was not used as a passageway to another sleeping area.

Findings include:

1. During the facility tour, the Compliance Officer observed a resident bedroom in the facility, where two residents resided. In the bedroom's bathroom was a walk-in closet which contained a fully made bed and personal belongings.

2. In an interview, E1 confirmed two of the facility's residents reside in the resident bedroom, and reported the closet served as a caregiver's resting area.

3. In an interview, E1 acknowledged the residents' sleeping area was being used as a passage way to another sleeping area.