Az Happy Valley Royal Care Home LLC

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a 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 and provided access to an outside area which allowed the 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 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. The Compliance Officers observed ambulatory residents within the facility. 3. The Compliance Officers observed an alert system was installed on the backyard door. However, the alert system was not functioning. 4. The Compliance Officers observed the aforementioned door allowed residents to be at least 30 feet away from the facility. 5. A review of the facility's policies and procedures revealed a policy titled, "Wandering" which stated, "5. If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security." 6. In an interview, E1 acknowledged the aforementioned door did not alert employees of the egress of a resident from the facility.

Based on observation, record review, documentation review, and interview, the manager failed to ensure medications were stored by the facility, for one of two residents sampled. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. The Compliance Officers observed the following medications in R1's room. - Albuterol Sulfate (8.5 Gm) - Two boxes of Mupirocin ointment 2% - Original Sarna itch relief (Camphor .5% and Menthol .5%) 2. A review of R1's medical record revealed a service plan dated July 18, 2024. The service plan indicated R1 required medication administration. 3. A review of the policy and procedures revealed a policy titled, "Medication Services" which stated, " 5. All residents medications brought to the facility will be received by the caregiver on duty. Medications will be locked in the medication storage area..." 4. In an interview, E1 acknowledged R1 required medication administration and the medications were not stored by the facility.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a signed medication order dated April 30, 2024. The medication order stated the following: "Insulin Lispro 100 unit/mL injection. Inject 3-9 units under the skin prior to meals per sliding scale ( <95 - 0 units, 95-124- 3 units, 125-149- 4 units, 150-199-5 units, 200-249-6 units, 250-299-7 units, 300-349-8 units, 350+-9 units)." 2. A review of R1's medical record revealed a September 2024 medication administration record (MAR) that showed Insulin Lispro 100 units/mL was administered on the following days: - September 9th, - September 11, - September 15, - September 16, - September 17, - September 21, and - September 30, However, documentation was not available showing the blood sugar reading or how many units of insulin were administered on the days listed above. 3. The Compliance Officers observed insulin pens were available. 4. In an interview, E1 reported R1 received medication administration. E1 acknowledged documentation was not available that showed R1's medication was administered in compliance with the medication order. 5. A review of R2's medical record revealed a current signed medication order dated April 5, 2024. The medication order stated the following: "Sertraline 25mg, take 1 tab (25mg) PO QD in addition to 50 mg tab for a total 75 mg." 6. A review of R2's medical record revealed a September 2024 MAR which stated, "Sertraline 50 mg tab, take 1 tab PO QD AM." 7. The Compliance Officers observed a bottle of Sertraline 50 mg was available and one tab was prefilled in the medication organizer. 8. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R2's medication was not administered per the medication order.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officers observed ambulatory residents within the facility. 2. The Compliance Officers observed a spray bottle of Clorox bleach and a spray bottle of Windex window cleaner in a cabinet in the employees' bathroom. The bathroom was accessible and was not locked. 3. In an interview, E1 acknowledged toxic materials were stored unlocked.