Cc's Adult Care INC

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included cardiopulmonary resuscitation (CPR) training, if required for the individual in this Article or policies and procedures, for one of three personnel sampled. Findings include: 1 . A review of facility documentation revealed a policy titled "First Aid and CPR Training." The policy stated: The hiring person will require that each new employee or volunteer have CPR training specific for adults from a CPR training organization...Each employee or volunteer will demonstrate and perform CPR by going through the motion of performing cardio pulmonary resuscitation, if training through a different training organization other than the National Safety Council, American Heart Association, or American Red Cross..." 2 . A review of R3's personnel record revealed documentation of CPR training from NationalCPRFoundation.com. 3 . A review of NationalCPRFoundation.com's Frequently Asked Questions (FAQ) section revealed the question, "Do you offer hands-on training?" The answer stated, "No, we do not offer hands-on training." 4 . In an interview, E4 acknowledged E3's CPR training did not include a demonstration of CPR.

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. During an environmental inspection of the facility with E1, the Compliance Officer observed LA Totally Awesome window cleaner, Mohawk hardwood and laminate floor cleaner, and Bar Keepers Friend cleanser unlocked in the cabinet under the kitchen sink. This cabinet had a locking device, however the device was not locked. 2. During an observation, E2 was the only employee at the facility when the Compliance Officer arrived and was not accessing the toxic materials at the time of arrival. 3. In an interview, E1 acknowledged toxic materials were stored unlocked.

Based on record review and interview, the manager failed to ensure a service plan included incontinence care that ensured a resident maintained the highest practicable level of independence when toileting for one of two residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's medical record revealed a current written service plan for directed care services dated August 16, 2023. This service plan revealed no documentation of incontinence care that ensured a resident maintained the highest practicable level of independence when toileting. 2. In an interview, E1 reported R2 wore briefs and would alert the caregiver during waking hours of the need to toilet, however was incontinent during the night. E1 acknowledged R1's service plan did not include documentation of the incontinence care provided to R2. 3. This is a repeat deficiency form the compliance inspection conducted November 8, 2022.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed Toujeo unlocked in the kitchen refrigerator. 2. During an observation, E2 was the only employee at the facility when the Compliance Officer arrived and was not accessing the medication at the time of arrival. 3. In an interview, E1 acknowledged medication was stored unlocked.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated August 16, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated August 2, 2023. This medication order stated "Losartan 50mg 0.5 tab(s) oral once every day". 3. Review of R2's medical record revealed a September 2023 medication administration record (MAR). This MAR stated "Losartan Potassium 25mg 1 T PO QOD" and indicated one tab was administered at 11am September 2nd, 4th, 6th, 8th, 10th, 12th, 14th, 16th, 18th, and 20th. 4. During an observation of R2's medications, Losartan 25mg was observed and one tab was observed prefilled in the "Noon" slot of R2's medication organizer every other day. 5. In an interview, E1 reported the medication was administered per the MAR and acknowledged R2's medication was not administered in compliance with the available medication order. 6. This is a repeat deficiency form the compliance inspection conducted November 8, 2022.