LA BELLA VITA ASSISTED LIVING HOME

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and 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 records revealed the facility was licensed to provide directed care services.

2. While on-site, the Compliance Officers observed two ambulatory residents.

3. During the environmental inspection of the facility, the Compliance Officers observed a sliding glass door leading to the backyard. The door had a device that was intended to alert employees of the egress of a resident to the outside area; however, the door chime was turned off.

4. A review of facility documentation revealed a policy regarding wandering residents. The policy stated, "C. Environmental Strategies : The facility should make the following changes to the physical environment, to minimize inappropriate wandering behavior: ... 7. Place warning bells or alarms at the doors. The alarm will alert the caregivers when the resident attempts to exit the facility unsupervised."

5. In an interview, E1 reported E1 only turned the back door alert on at night. E1 demonstrated turning the device on to show it was in working order. E1 acknowledged at the time of the inspection the back door leading to an outside area did not alert employees of the egress of a resident from the facility.

Based on record review, documentation review, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk if medication administered to a resident was not accurately documented.

Findings include:

1. A review of R2's medical records revealed R2 received medication administration.

2. A review of R2's medication administration record (MAR) revealed documentation that medication had been administered prior to R2's date of admission.

3. A review of the facility's policies and procedures revealed a policy titled "Medication Policy and Procedure." Within the policy was a subsection titled "Documentation of Medication," which stated the following: "A separate medication record is maintained for each resident who's receiving assistance in self-administration of medication or medication administration that includes...d. Date and time of actual assistance in self-administration of medication or medication administration...[and]...f. Signature or initials of the employee/caregiver providing assistance in self-administration of medication or medication administration."

4. In an interview, E2 reported E2 made an error in the documentation on R2's MAR as R2 was not admitted until the day after the documentation of medication administration was initialed by E2 as being administered. E1 and E2 acknowledged the inaccurate documentation of medication administration prior to R2's date of admission.

Based on observation, documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident covering cardiopulmonary resuscitation (CPR) including the method and content of cardiopulmonary resuscitation training to include a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation. The deficient practice posed a risk if E1, E2 and E3 were unable to perform CPR and the facility's standards were not followed.

Findings include:

1. The Compliance Officer observed E1 and E2 working at the facility upon arrival at 8:30 AM.

2. A review of facility documentation revealed a policy and procedure titled "PERSONNEL POLICY" (dated in May 2022). The policy and procedure stated "...Each Manager and Caregiver: ...b. Obtains CPR training specific to adults which includes a demonstration of the individual's ability to perform CPR ..."

3. A review of facility documentation revealed staff schedules dated April 2023, May 2023, and June 2023. The staffing schedules revealed E1, E2, and E3 were the only caregivers scheduled to work throughout the months of April 2023, May 2023, and June 2023.

4. A review of E1's personnel record revealed a CPR training card from "National Health Care Provider Solutions" with an issue date of September 7, 2021 and renewal date of September 7, 2023. However, documentation of E1's demonstration of CPR was not available for review.

5. A review of E2's personnel record revealed a CPR training card from "National Health Care Provider Solutions" with an issue date of September 7, 2021 and renewal date of September 7, 2023. However, documentation of E2's demonstration of CPR was not available for review.

6. A review of E3's personnel record revealed a CPR training card from "Lifeline Training Resources" with an issue date of September 7, 2021 and renewal date of September 7, 2023. However, documentation of E3's demonstration of CPR was not available for review.

7. In an interview, E1 reported E1, E2, and E3 completed their CPR training online.

8. In an interview, E1 acknowledged E1's, E2's, and E3's CPR training's were not in compliance with the facility's policy and procedure.

Based on record review and interview, the manager failed to ensure a service plan included strategies to ensure a resident's personal safety, and encouragement to eat meals and snacks, for five of five residents who received directed care services.

Findings include:

1. A review of R1's medical record revealed a written service plan dated in May 2023. However, the service plan did not include strategies to ensure a resident's personal safety and encouragement to eat meals and snacks.

2. Review of R2's medical record revealed a written service plan dated in June 2023. However, the service plan did not include strategies to ensure a resident's personal safety and encouragement to eat meals and snacks.

3. Review of R3's medical record revealed a written service plan dated in June 2023. However, the service plan did not include strategies to ensure a resident's personal safety and encouragement to eat meals and snacks.

4. Review of R4's medical record revealed a written service plan dated in May 2023. However, the service plan did not include strategies to ensure a resident's personal safety and encouragement to eat meals and snacks.

5. Review of R5's medical record revealed a written service plan dated in April 2023. However, the service plan did not include strategies to ensure a resident's personal safety and encouragement to eat meals and snacks.

6. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, and R5's service plans did not include strategies to ensure a resident's personal safety and encouragement to eat meals and snacks.

Based on observation, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of five residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration.

Findings include:

1. The Compliance Officer observed a medication bottle for Acetaminophen (Tylenol) 500mg (take two tablets by mouth three times a day) belonging to R2.

2. A review of R2's medical record revealed a medication order dated June 8, 2023 for "Tylenol Extra Strength 500mg tablet, 1000 mg 3 times a day."

3. A review of R2's medication administration records (MAR) dated June 2023 and July 2023 revealed the above mentioned medication was listed on the MARs as "PRN" and was not documented as administered to R2 on the following dates:
-June 8, 2023-June 30, 2023; and
-July 1, 2023-July 2, 2023.

4. In an interview, E1 reported the above mentioned medication had always been scheduled and not as needed. E1 reported the medication was transcribed on R2's MAR as "PRN" in error. E1 acknowledged R2 had not received medication administration in compliance with a medication order.