Desert Cove Assisted Living

Based on the record review and interview, the manager failed to ensure that a caregiver or assistant caregiver provided assistance with activities of daily living according to the resident's service plan for two of the two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated March 11, 2025. R1's service plan indicated R1 required assistance with foot care. 2. A review of R1’s activities of daily living (ADL) document revealed that foot care was not listed in R1's ADL as specified in R1’s service plan. 3. A review of R2's medical record revealed a service plan dated May 8, 2025. R2's service plan indicated R2 required assistance with foot care. 4. A review of R2’s activities of daily living (ADL) document revealed that foot care was not listed in R2's ADL as specified in R2’s service plan. 5. In an interview, E2 acknowledged that R1's and R2’s documentation of services provided did not reflect what was on the service plan.

Based on observation and interview, the manager failed to ensure there was a current toxicology reference guide that was available for use by personnel members. This posed a health and safety risk to the resident if the caregiver was unable to reference a toxic material. Findings include: 1. The Compliance Officer requested the current toxicology reference guide. However, the toxicology reference guide was not provided to the department for review. 2. In an interview, E2 acknowledged that the facility did not have a toxicology reference guide available for use by personnel members.

Based on observation, documentation review, and interview, for the facility which 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 health and safety risk to residents as an unlocked door provided access to the outside, without alerting employees. Findings include: 1. In documentation review, the facility was licensed at the directed level of care. 2. During an environmental inspection, the Compliance Officer observed the facility had several doors in the facility, with alerts attached, that exited to either the back yard, or side yards. The doors were located in the laundry room, in a hallway with resident rooms, and in R1's and R4's bedroom. The alarms were either turned off, or were not in working order. 3. During an interview, E1, E2, and E3 acknowledged the facility was licensed at the directed level of care, and the facility did not provide access to an outside area which controlled or alerted employees of the egress of a resident from the facility.

Based on observation, documentation review, record review, and interview, for one resident reviewed, who received a controlled substance, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility. Findings include: 1. In observation, R2 had Tramadol 50mg medication, (a schedule IV controlled substance), take one tablet three times daily. The package indicated 90 tablets were dispensed on May 29, 2024, with 32 tablets remaining. 2. In record review, R2's medical record (received directed care and medication administration services) included documentation R2 received the opioid medication, as ordered. The documentation provided indicated there were 26 tablets remaining, which was not consistent with what was observed. 3. In documentation review, a facility policy, titled, "... Controlled Substance Narcotic Drug Count," on page 99, documented; "... The purpose of the policy is to have in place an accountability process for handling of all controlled drugs... All medications received by the pharmacy that are identified as a controlled substance, regardless of class/schedule of the drug will be counted at each shift change... The pharmacy provides narcotic usage sheets; the staff will be trained by the pharmacy or designee on how to use these sheers (see for - individual resident's controlled substance record)... The narcotic count sheet will be signed off by those doing the counts at the end of every shift (Inventorying each shift)... Signatures on the narcotic count sheet indicate the count was done and was correct at the change of each shift..." 4. During an interview, E1 and E2 reported the resident received a controlled medication, and the computer system automatically initiated a count of the medication each time the medication was dispensed. They acknowledged, however, the count in the computer indicated there were 26 pills remaining, while the medication container showed 32 pills remained.

Based on observation, record review, documentation review, and interview, for one resident reviewed, and receiving opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual, authorized to administer opioids, documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident if a resident's pain was not identified, monitored and documented, as required. Findings include: 1. In observation, R2 had Tramadol 50mg medication, (a schedule IV controlled substance), take one tablet three times daily. The package indicated 90 tablets were dispensed on May 29, 2024, with 32 tablets remaining. 2. In record review, R2's medical record (received directed care and medication administration services) included documentation R1 received the opioid medication, as ordered; however, the record did not include documentation of an identification of the resident's need for the opioid, and the monitoring of the effect of the opioid administered. 3. In documentation review, a facility policy, titled "... Assessing, Monitoring Need for Opioid Administration, and Documentation," on page 104, documented, "... Before administering an opioid... a trained certified caregiver identifies the resident's need for the opioid... is assessed by the trained caregiver using the "pain scale" assessment tool. Resident's pain is identified and documented on the medication administration records... Caregivers will monitor the resident's response to any opioid administered... will document in the resident's medical record on the "Opioid Administration & Assessment Flow Sheet" ... each time the medication is given... 4. During an interview, E1 and E2 reported R2 received an opioid medication, and acknowledged the facility did not identify and document the residents' need for the opioid before the opioid was administered, and monitor and document the effect of the opioid administered, according to the facility's policies and procedures.