Crystal Joy Care Home LLC

Based on documentation review and interview, the manager failed to ensure a quality management plan was documented for an ongoing quality management program, to include the required components. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Review of the facility documentation revealed no documentation of an ongoing quality management program. 2. In an interview, E1 reported the quality management documents were not present at the facility. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a bell or other mechanical means to alert employees to a resident’s needs was available in a bedroom for use by a resident receiving personal care services, for two of four residents. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed that there was no bell or other mechanical means of alerting employees to the needs of R1 and R2. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings Include: 1. During an environmental inspection of the facility with E1, the Compliance Officers observed insulin and eye drops unlocked in the door of the refrigerator. 2. During an environmental inspection of the facility with E1, the Compliance Officers observed Lorazepam sitting on the kitchen counter. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for three of three caregivers sampled. The deficient practice posed a risk if E1, E2 and E3 were unable to meet a resident's needs. Findings include: 1. A review of E1's personnel record revealed documentation of the verification of E1's skills and knowledge was not available for review. 2. A review of E2's personnel record revealed documentation of the verification of E2's skills and knowledge was not available for review. 3. A review of E3's personnel record revealed documentation of the verification of E3's skills and knowledge was not available for review. 4. In an interview, E2 acknowledged E1's, E2's and E3's verification of skills and knowledge had not been completed. E2 reported to be unaware of this requirement.

Based on observation, record review and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a potential for physical harm or psychological distress. Findings include: 1. The Compliance Officer observed R1's bed had two long side bedrails, one on each side (length) of the bed. 2. A review of R1's medical record revealed a service plan dated in September of 2023. The service plan revealed R1 received directed level of care. 3. In an interview, E1 reported the bedrails were in place so R1 would not roll out of bed. E1 reported R1 was unable to put the bedrails down or get out of bed with the bedrails in place. 4. In an interview, E2 acknowledged the bedrails could be considered a restraint. E2 reported to be under the impression if a medical practitioner ordered bedrails for the resident, the bedrails were acceptable. E2 acknowledged the bedrails were put into place to prevent R1 from rolling out of the bed.

Based on observation, record review and interview, the manager failed to ensure medication was stored by the facility, for one of three residents sampled who received medication administration. The deficient practice posed a risk as R1 received medication administration and the resident's service plan did not state medication could be stored by the resident. Findings include: 1. The Compliance Officer observed the following medications in R1's bedroom: -Olopatadine .2% prescription eye medication (on R1's bedside table) -Gas-x (in a closet drawer) -Clotrimazole and Betamethasone cream (in an unlocked medicine cabinet in the closet) -Medicated arthritis cream (on the bathroom counter) -Pain relief cream (in an unlocked medicine cabinet in R1's private bathroom) -Hydrocortisone lotion (in an unlocked medicine cabinet in R1's private bathroom) -Polysporin medicated cream (in an unlocked medicine cabinet in R1's private bathroom) 2. A review of R1's medical record revealed a service plan, dated in September 2023. The service plan indicated R1 was to receive medication administration and R1 was not able to store R1's own medication. 3. The Compliance Officer observed one ambulatory resident on premises. 4. In an interview, E2 acknowledged R1 received medication administration and should not have unlocked medications in R1's bedroom, bathroom or closet.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. Findings include: 1. The Compliance Officer observed unlocked cabinets beneath the kitchen sink. The cabinets contained the following poisonous or toxic materials: -Scrubbing Bubbles with Bleach cleanser -Calcium Lime Rust (CLR) bathroom cleanser -Pine Sol The containers included toxic warning labels. 2. The Compliance Officer observed an unlocked medicine cabinet in R1's bedroom closet. The cabinet contained the following poisonous or toxic materials: -Disinfectant spray The container included toxic warning labels. 3. The Compliance Officer observed an unlocked cabinet in the unlocked garage. The cabinet contained the following poisonous or toxic materials: -Glass cleaner -Spackling paste -Winshield washer fluid -Hardwood floor cleaner -Pine Sol -CLR cleanser -Simple Green -Paint -Orange Clean cleanser -Raid Ant Killer -Raid Roach Spray -Febreeze The containers included toxic warning labels. 4. The Compliance Officer observed one ambulatory resident on premises. 5. In an interview, E2 acknowledged the unlocked poisonous or toxic materials throughout the facility were accessible to residents.

Based on observation and interview, the manager failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents. Findings include: 1. The Compliance Officer observed an unlocked cabinet in the unlocked garage. The cabinet contained the following flammable or hazardous materials: -Lighter fluid The container had a flammable warning label. 2. The Compliance Officer observed one ambulatory resident on premises. 3. In an interview, E2 acknowledged the flammable material was not locked up and was accessible to residents.