Citrus Villa Mesa Assisted Living, LLC

Based on observation, documentation review, and interview, the manager failed to ensure a resident’s cat was vaccinated against rabies. The deficient practice posed a health and safety risk to residents if an animal was not vaccinated against rabies. Findings include: 1. During an environmental inspection, the Compliance Officer observed O1 and O2 on the premises. 2. A review of the facility's documentation revealed a document titled "Rabies Vaccination Certificate" for O2. However, the certificate had an expiration date of August 24, 2024. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy regarding fall prevention and fall recovery. However, a review of E1's, E3's, and E4's personnel records revealed no documentation of fall prevention and fall recovery training. 2. In an interview, E1 acknowledged E1, E3, and E4 did not have documentation of fall prevention and fall recovery training.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 days before the individual was accepted by an assisted living facility, and, if the individual was requesting or was expecting to receive supervisory care services, personal care services, or directed care services, included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician's assistant, for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed there was no documentation indicating whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview, E1 reviewed R1's medical record and acknowledged R1's medical record did not contain documentation that was dated within 90 days before the individual was accepted by the assisted living facility and was signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant. E1 reported the documentation was usually included in the admission packet.

Based on record review and interview, the manager failed to ensure a resident had a written service plan to include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for two of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan dated May 1, 2023 for personal care services. However, the service plan did not include a description of R1's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. A review of R2's medical record revealed a service plan dated May 17, 2023 for personal care services. However, the service plan did not include a description of R2's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 3. In an interview, E1 acknowledged R1's and R2's service plans did not include a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for five of five residents sampled. The deficient practice posed a risk as the Department was provided false and misleading documentation as the facility pre-filled activities of daily living documentation. Findings include: 1. A review of R1's, R2's, R3's, R4's, and R5's medical records each revealed a document titled "Vitals and Activities of Daily Livings [sic]," which documented the services that were provided to each resident in May 2023. Further review of the documentation revealed all services on May 31, 2023 (the day of the inspection) had been prefilled with numbers and/or letters to indicate all services had been provided for the day. 2. In an interview, E1 acknowledged all of the services provided had been prefilled for May 31, 2023 for R1, R2, R3, R4, and R5.

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the name and signature of the individual administering the medication, for one of three residents sampled. The deficient practice posed a risk to the health and safety of residents if unable to identify the individual who administered medication for follow up after a medication error or adverse reaction. Findings include: 1. A review of R3's medical record revealed R3 received medication administration. 2. A review of R3's medical record revealed a signed medication order dated March 28, 2022 for Humalog KwikPen (U-100) Insulin 100 unit/milliliters (mL) to be administered three times a day with meals, according to the following sliding scale: -131-180 = 2 units; -181-240 = 4 units; -241-300 = 6 units; -301-350 = 8 units; -351-400 = 10 units; -Call if over 450. 3. A review of R3's medical record revealed a medication administration record (MAR) for March 2022, April 2022, and May 2022. The MAR documented the date, time, R3's blood sugar reading, and the number of units of Humalog R3 received. However, the name and signature of the individual administering the Humalog was not indicated on the MAR. 4. In an interview, E1 acknowledged the name and signature of the individual administering the Humalog was not indicated on the MAR.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R3's medical record revealed R3 received medication administration. 2. A review of R3's medical record revealed a signed medication order dated March 28, 2022 for Humalog KwikPen (U-100) Insulin 100 unit/milliliters (mL) to be administered three times a day with meals, according to the following sliding scale: -131-180 = 2 units; -181-240 = 4 units; -241-300 = 6 units; -301-350 = 8 units; -351-400 = 10 units; and -Call if over 450. 3. A review of R3's medical record revealed the units received was incorrectly documented on the following days and times: -March 17, 2022 at 11:00 AM: blood sugar recorded as 204, received 0 units (should have received 4 units); -March 18, 2022 at 7:00 AM: blood sugar recorded as 110, received 2 units (should have received 0 units); -March 18, 2022 at 11:00 AM: blood sugar recorded as 169, received 0 units (should have received 2 units); -March 19, 2022 at 11:00 AM: blood sugar recorded as 203, received 0 units (should have received 4 units); -March 20, 2022 at 7:00 AM: blood sugar recorded as 108, received 2 units (should have received 0 units); -March 21, 2022 at 11:00 AM: blood sugar recorded as 188, received 0 units (should have received 4 units); -March 22, 2022 at 7:00 AM: blood sugar recorded as 198, received 2 units (should have received 4 units); -March 22, 2022 at 11:00 AM: blood sugar recorded as 169, received 4 units (should have received 2 units); -April 1, 2022 at 11:00 AM: blood sugar recorded as 145, received 0 units (should have received 2 units); -April 1, 2022 at 4:00 PM: blood sugar recorded as 106, received 2 units (should have received 0 units); -April 3, 2022 at 11:00 AM: blood sugar recorded as 187, received 2 units (should have received 4 units); -April 11, 2022 at 11:00 AM: blood sugar recorded as 155, received 0 units (should have received 2 units); -April 12, 2022 at 11:00 AM: blood sugar recorded as 132, received 0 units (should have received 2 units); -April 12, 2022 at 4:00 PM: blood sugar recorded as 101, received 2 units (should have received 0 units); -May 28, 2022 at 8:00 AM: blood sugar recorded as 94, received 2 units (should have received 0 units); and -May 28, 2022 at 11:00 AM: blood sugar recorded as 138, received 0 units (should have received 2 units). 4. In an interview, E1 acknowledged the administration of Humalog had not been correctly documented in R3's medical record. E1 reported E1 believed R3 received the correct units of Humalog according to the sliding scale. However, E1 acknowledged mistakes occurred in the documentation of medication administration.

Based on documentation review, record review, and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider for one of one resident sampled. The deficient practice posed a risk to the health and safety of R3 if R3's emergency contact was required to make medical decisions and/ or if the primary care provider needed to coordinate care. Findings include: 1. A review of R3's medical record revealed an incident report dated September 20, 2020. The document reported R3 had an unwitnessed fall in [R3's] bedroom at approximately 4:00 AM. The report revealed the fire department was called "for assistance to bring [R3] back to bed." 2. A review of R3's medical record revealed E1 was notified of the incident via telephone. There was no indication at what time E1 was called. R3's emergency contact and physician were not documented on the incident report as being notified of the incident. 3. Further review of R3's medical record revealed progress notes which included observations, notes, and comments from R3's caregivers. The progress notes indicated R3 was taken to the hospital on May 30, 2022 and July 26, 2022. 4. A review of the facility's quality management summary revealed 911 was called during the month of May 2022 as R3 requested to go the hospital. 5. The compliance officer requested the incident reports that documented R3's aforementioned hospital visits. 6. In an interview, E1 acknowledged there were no incident reports that documented R3's emergency contact and R3's physician were immediately notified of the aforementioned incidents.