Casa De Sonshine Assisted Living, LLC

Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed no documentation of a disaster plan review was available for the Compliance Officer to review. 2. In an exit interview, the findings were reviewed with E1. E1 acknowledged E1 was unaware that the facility had to review the disaster plan at least once every 12 months. 3. This is a repeat deficiency from the compliance inspection conducted December 21, 2022.

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. Findings Include: 1. During an environmental tour of the facility, the Compliance Officer checked the water temperature of the bathroom by bedroom #8 and it read 130.1º F. The Compliance Officer checked the water temperature of the bathroom by bedroom #1 and it read 129.6º. 2. In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on documentation review, record, review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. Findings include: 1. On February 3, 2023, the Compliance Officer requested the following documents during the on-site inspection: - Medical record for R3; and - Documentation of an incident when R3 was sent to the hospital. 2. In an interview, E1 acknowledged this information was not provided to the Compliance Officer within the two hours requested. E1 reported the previous owner was in possession of the files and passed away unexpectedly.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's service plan and updates, for one of three resident records reviewed. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not in the medical record during the inspection. Findings include: 1. A review of R3's medical record revealed no service plan was available for review. However, based on R3's date of acceptance, a completed service plan was required. 2. In an interview, E1 acknowledged a complete medical record for R3 was not provided for review, because E1 could not locate a file for R3.

Based on documentation review, observation, and interview, the manager failed to ensure a facility authorized to provide directed care services had 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 alerted employees of the egress of a resident from the facility. The deficient practice posed potential egress dangers to residents. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed when exiting from back door leading to the backyard, no alarm sounded to alert employees of the egress of a resident from the facility. Further inspection revealed the door alert was set to the "OFF" position. 3. The Compliance Officer observed E1 switch the alert to the "CHIME" position and heard the alert sound. 4. In an interview, E1 acknowledged the back door alert was not active and would not alert employees of the egress of a resident from the facility.

Based on record review, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of three resident records reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services and medication administration. 2. A review of R1's medical record revealed a signed list of medication orders dated October 27, 2023. The list included the following: - "Levetiracetam (Keppra) 250MG/PO/Q12/half a tablet/7:30am@7:30pm"; - "Donepezil Hydrochloride 5MG PO QD HS"; and - "Furosemide 20MG PO QD AM". 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated December 2023. The MAR was not documented to indicate the administration of Levetiracetam at 7:30pm or Donepezil Hydrochloride on December 30 and 31, 2023. 4. A review of R1's medical record revealed a MAR dated January 2024. The MAR was not documented to indicate the administration of Furosemide on January 23, 24, and 25, 2024. 5. In an interview, E1 acknowledged medication administered to a resident was not correctly documented in the resident's medical record.