Cactus Star 1 Assisted Living Home, LLC

Based on record review, and interview, for one of three residents reviewed, who received medication administration, the manager failed to ensure a resident's medical record included the dosage of medication administered to a resident. The deficient practice posed a risk if documentation of a medication administered to a resident did not include the dosage administered to the resident, ensuring the resident was administered the correct dosage per the resident's medication orders. Findings include: 1. In record review, R2's medication administration records (MAR), dated September and October, 2024, included documentation R2 received Insulin medication on a sliding scale. The resident's record included documentation of the following: - August 29, 2024; Medication order for "HumalOG Solution 100 UNIT/ML. Directions: inject as per sliding scale if: 71-149 = 0 150-199 = 3 200 - 249 = 5 250-299 = 7 300 - 349 = 10 350 - 399 = 12 400 - 500 = 14 Call Provider, Subcutaneously before meals and at bedtime for DMII" - September 6, 2024: Medication order for "Humalog SOL 100 unit/ml inject as per sliding scale if: 71-149 = 0 150-199 = 3 200 - 249 = 5 250-299 = 7 300 - 349 = 10 350 - 399 = 12 400 - 500 = 14 every meals and at bedtime" - October 8, 2024: Insulin order changed to: "Lispro Insulin 100 UNIT/ML INJECT SUBCUTANEOUSY (sic) BEFORE MEALS PER SLIDING SCALE IF; 71-149 = 0 150-199 = 3U 200 - 249 = 5U 250-299 = 7U 300 - 349 = 10U 350 - 399 = 12U 400 - 500 = 14U" "BLOOD SUGAR CHECK... THREE TIMES DAILY AND AS NEEDED" 2. In record review, R2's MARs for September and October, 2024, indicated R2 received Humalog Insulin Solution September 6 - October 8, 2024, and Lispro Insulin October 8 - 12, 2024 and the Lispro Insulin from October 8 - 19, 2024. (Note: overlap of Insulin administration October 8 - 12, 2024). The documentation of Insulin administration for R2 did not include the dosage (Units) of Insulin administered to R2 on any dates of Insulin administration. 3. During an interview, E3 reported being unaware of the need to document the dosage of Insulin which was administered to R2, and acknowledged the Insulin dosage was not documented. E3 acknowledged the medication order changed on October 8; however, the MAR indicated R2 was administered both Insulin medications from October 8 - 12, 2024. E1 and E2 acknowledged the Insulin dosage administered to R2 was not documented by the caregiver, as required.

Based on observation, documentation review, and interview, for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which 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 the license issued by the Department revealed the facility was licensed at the directed care level. 2. The Compliance Officer observed a patio door to the backyard did not control or alert employees of the egress of a resident. The door had a non working alarm. R2 was observed to exit the patio door, to the backyard, and the alarm did not sound. 3. During an interview, E2 reported the door alarm battery was not working, and was observed to add a working alarm to the door during the inspection.

Based on record review, and interview, for one of three residents reviewed, the manager failed to ensure medication was administered to a resident in compliance with a medication order. The deficient practice posed a health and safety risk to residents, if the facility did not administer medication in compliance with a medication order, and a resident did not receive medication as ordered. Findings include: 1. In record review, R2's medical record (received personal care and medication administration services), included the following medication orders dated August 29, 2024: - "HumalOG Solution 100 UNIT/ML. Directions: inject as per sliding scale if: 71-149 = 0 150-199 = 3 200 - 249 = 5 250-299 = 7 300 - 349 = 10 350 - 399 = 12 400 - 500 = 14 ... Subcutaneously before meals and at bedtime for DMII" - "Insulin Glargine Subcutaneous Solution 100 UNIT/ML... Inject 12 unit subcutaneously one time a day for diabetes 8pm. - "Humalog Solution 100 UNIT/ML... Inject 7 unit subcutaneously before meals for diabetes 6a, 11a, 4p." 2. In record review, R2's medication administration record (MAR) dated September, 2024, revealed R2 did not receive the Insulin medications as ordered: - did not receive the Humalog Insulin medication on September 1 - 5, 2024 and the morning dose on September 6, 2024. - did not receive the Insulin Glargine September 1 - 4, 2024. - did not receive the Humalog insulin solution 7 units before meals September 1 - 7, 2024. 3. In record review, R2's MAR dated October, 2024, did not include documentation R2 received the Humalog insulin solution 7 units before meals. 4. In record review, R2's record included an Insulin medication order, dated October 8, 2024, for "Lispro Insulin 100 UNIT/ML INJECT SUBCUTANEOUSY (sic) BEFORE MEALS PER SLIDING SCALE IF; 71-149 = 0 150-199 = 3U 200 - 249 = 5U 250-299 = 7U 300 - 349 = 10U 350 - 399 = 12U 400 - 500 = 14U" "BLOOD SUGAR CHECK... THREE TIMES DAILY AND AS NEEDED" 5. In record review, R2's MAR, dated October 2024, documented R2 received the Lispro insulin medication at 8am, 12pm and 8pm. There was no documentation R2 received the medication prior to the dinner meal, as ordered. 6. During an interview, the findings were reviewed with E1, E2 and E3, who acknowledged R2 received no insulin for several days, and reported the facility did not have the medication to administer to R2. E2 reported the dinner meal was served between 4:30pm and 5:00pm, and acknowledged the documentation indicated R2 did not receive the insulin medication prior to the dinner meal, as ordered.

Based on documentation review, record review, and interview, for five of five employees reviewed, the health care institution failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. In documentation review, a review of facility's documents revealed the facility had established and documented TB infection control activities. 2. In record review, the personnel records for E1 (hired on February 15, 2021), E2 (hired on December 15, 2021), E3 (hired on March 22, 2024), E4 (hired on December 15, 2022), and E5 (hired on September 6, 2024), did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. During an interview, E1 acknowledged the facility did not provide training for employees on recognizing the signs and symptoms of TB.