Desert Pond Assisted Living

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officer observed three ambulatory residents on the premises. 2. The Compliance Officer observed an unlocked storage box in the unlocked kitchen refrigerator. The storage box contained multiple pre-filled syringes of Morphine 20 mg prescribed to R3. 3. In an interview, E3 reported administered the medication to R3 in the morning. E1 and E3 acknowledged the medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on observation and interview, the manager failed to ensure frozen foods were stored at a temperature of 0\'b0 F or below. The deficient practice posed a food borne illness risk. 1. The Compliance Officer observed a large freezer in the garage. The freezer contained fish, chicken, beef, pork, frozen vegetables, and hotdogs. The freezer thermometer temperature registered +25\'b0 F. The freezer was not in use during the observation. E1, E3, and the Compliance Officer observed all of the foods were soft to the touch. 2. In an interview, E1 and E3 acknowledged the freezer was not maintained at a temperature of 0\'b0 F or below.

Based on observation and interview, the manager failed to ensure the hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of an assisted living facility used by residents. The deficient practice posed a burn risk to residents. Findings Include: 1. The Compliance Officer observed the water temperature reach 137\'b0F in the common bathroom used by residents at the facility. 2. In an interview E1 acknowledged the hot water temperatures were not maintained between 95\'ba F and 120\'ba F in areas of an assisted living facility used by residents.

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. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of facility documentation revealed an untitled and undated training program to cover fall prevention and fall recovery. The program stated "1. All employees will have an initial training on fall prevention and recovery. Training shall be included in the orientation for new hires... 3. After initial training, all employees will be required to attend continuing competency training on fall prevention and recovery at least every 12 months. Completion of the training shall be documented and included in the employee files." 2. A review of E4's (hired November 2022) personnel record revealed documented orientation dated November 2022. However, the orientation did not include training on fall prevention and fall recovery. 3. A review of E4's personnel record revealed a form titled, "Fall Prevention and Fall Recovery Techniques." The form included E4's name, however, the document was not dated to indicate when the training was completed. 4. In an interview, E1 acknowledged the facility's fall prevention and fall recovery program had conflicting information and was not developed and administered per the program. This is a repeat deficiency from the on-site compliance inspection completed on May 20, 2022.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for one of three caregivers sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of E4's (hired in 2022) personnel record revealed documentation of evidence of freedom from infectious TB was not available for review. 2. In an interview, E1 reported E4 had evidence of freedom from TB. However, E1 was unable to locate the documentation.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of three residents sampled. The deficient practice posed a risk as the residents did not receive the expected service. Findings include: 1. A review of R1's medical record revealed a current service plan for directed care services dated in May 2023. The service plan revealed R1 was to receive the following service: -"Shower: 1-2x/week." 2. A review of R1's medical record revealed an activities of daily living (ADL) log for June 2023 and July 2023. The ADL revealed R1 received the following services on the following dates: - Shower on June 5, 6, 21, 24, and 28, 2023; and - Partial bath on June 10, 2023, and July 1, 4, and 7, 2023. However, documentation to indicate R1 received a shower one to two times weekly in June 2023 and July 2023 was not available for review. 3. A review of R3's medical record revealed a current service plan for personal care services dated in June 2023. The service plan revealed R3 was to receive the following service: - Shower/bed bath, two to three times per week; - Partial Bath, on days when complete bath is not given." 4. A review of R3's medical record revealed an activities of daily living (ADL) log for June 2023 and July 2023. The ADL revealed R2 received the following services on the following dates: - Shower on June 18, 19, 21, 23, 27, and 30, 2023; and - Shower on July 3, 5, 7, and 12, 2023. However, documentation to indicate R2 received a partial bath on days when complete bath was not given in June 2023 and July 2023 was not available for review. 5. In an interview, E1 reported R1 significantly declined at the beginning of July, and an updated service plan for R1 needed to be completed. 6. In an interview, E1 reported R3 refused bathing. 7. In an interview, E1 acknowledged R1 and R3 had not received showering or bathing services per R1's and R3's service plans.