Arrowhead Valley Assisted Living INC

Based on record review and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of one resident reviewed who experienced a change of condition. Findings include: 1. Review of R2's medical record revealed a current written service plan dated May 19, 2023. This service plan indicated R2 did not have any open wounds. A review of R2's medical record revealed a progress note from Bliss Hospice dated June 15, 2023, revealing R1 has an open area to the coccyx . R2's medical record revealed R2 was referred by Hospice for wound care. R2's medical record revealed on June 26, 2023, R2 was seen by Infinity Medical Providers to establish care for wound care. A review of R2's medical record revealed no service plan dated no later than fourteen days after the identified significant change in R2's physical condition was available for review. 2. In an interview, O1 acknowledged R2's medical record revealed R2 had a change in physical condition in June 2023. O1 acknowledged R2's service plan was not updated after the identified significant change of condition. O1 acknowledged the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of one resident reviewed who experienced a change of condition.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of the two residents sampled. Findings; 1. Review of R1's personal care service plan dated June 30, 2023, identified the following service: "complete bath 2 x a week." However, R1's medical record revealed no documentation of the identified service provided for the month of July 2023. 2. Review of R2's directed care service plan dated May 19, 2023, identified the following service: "complete bath 2 x a week." However, R1's medical record revealed no documentation of the identified service provided for the month of July 2023. 3. During an interview with E1, E1 reviewed R1 and R2's medical records. E1 acknowledged E1 did not document the identified service in R1 and R2's medical records. E1 reported that E1 provided R1 and R2 a bath twice a week. E1 acknowledged the manager failed to ensure a caregiver documented the services provided in the resident's medical record. This is a repeat deficiency from the compliance inspection conducted on August 31, 2022.

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 compliance officers 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 controlling or alerting employees of the egress of residents to the outside area. 3. During an interview, E1 reported E 1 was unaware the identified rule. E1 acknowledged the patio door exiting to the outside area did not have a means of controlling or 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. Technical assistance was provided to the facility during the compliance inspection conducted September 20, 2021.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. Findings include: 1. During the facility tour with E1, the compliance officers observed the facilities refrigerator door contained a box with multiple Lorazepam medications inside. The box had the means of locking, however was unlocked. The compliance officers observed additional Lorazepam located on the refrigerator shelf. The medications were unlocked and accessible to residents. 2. During an interview, E1 acknowledged the medication was stored unlocked. E1 acknowledged the manager failed to ensure medications stored by the facility were stored in a locked area. This is a repeat deficiency from the compliance inspection conducted August 31, 2022.