Gardens at San Carlos, the

Based on observation and interview, the manager failed to ensure a swimming pool enclosure's gate was locked when the swimming pool was not in use. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed no residents or staff were in the backyard at the time of the inspection, and observed the swimming pool was not in use. However, the Compliance Officer observed the swimming pool gate had been left open and unlocked. 2. In an interview, E1 acknowledged the swimming pool was not locked when the swimming pool was not in use.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officer observed a door located in the kitchen room leading to a side yard of the facility. The door was equipped with a door alarm; however, the alarm did not sound when the door was opened. 3. In an interview, E1 acknowledged a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility did not control or alert employees of the egress of a resident from the facility. E1 immediately replaced the battery in the door alarm and verified it was working correctly.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated March 5, 2024, for personal care services including medication administration. 2. A review of R1's medical record revealed a list of medication orders, dated September 5, 2024, which included the following: - "Insulin Aspart Protamine Novolog 70-30 100 Unit/ML, Inject 15 units subcutaneously every morning at 8 AM"; and - "Myrbetriq 50 MG, Take 1 tablet by mouth at bedtime." 3. A review of R1's medical record revealed an electronic Medication Administration Record (eMAR) dated October 1 through October 14, 2024. The eMAR documented the following: - The eMAR documented an exception on October 2 and October 4 for "Novolog." - The eMAR did not document the administration of Myrbetriq to R1. 4. A review of R1's medical record revealed the comments on the October 2 and October 4 Novolog exceptions stated, "Passed 10 units." However, this was not the ordered dosage of the medication. 5. A review of R1's medical record revealed an order to reduce the dosage of Novolog on October 2 and October 4 were not available for review. 6. A review of R1's medical record revealed incident reports for the medication errors on October 2 and October 4 were not available for review. 7. A review of R1's medical record revealed the comments on the October 1 through October 14 Myrbetriq exceptions stated the medication was not available. 8. A review of R1's medical record revealed an order to hold or discontinue administration of Myrbetriq from R1's medical practioner was not available for review. 9. A review of R1's medical record revealed incident reports for the medication errors on October 1 through October 14 were not available for review. 10. In an interview, E1 acknowledged the eMAR indicated R1 had not been administered the ordered dosage of Novolog on October 2 or October 4 and R1 had not been administered Myrbetriq according to a medication order on October 1 through October 14, 2024..

Based on record review, and interview, for one of two residents sampled, who received personal care services, the manager failed to ensure a written service plan was reviewed and updated at least once every six months. Findings include: 1. A review of R1's medical record revealed a service plan, dated March 5, 2024, for personal care services. However, an updated service plan, dated on or before September 5, 2024, was not available for review. 2. In an interview, E1 acknowledged a current service plan had not been provided for R1.

Based on documentation review, record review, and interview, the manager failed to ensure an individual authorized to administer an opioid in treating a patient documented in the resident's medical record the effect of the opioid administered, for one of one sampled resident who received medication administration of an opioid. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Opioid Prescribing and Treatment." The policy stated "The caregiver will ask the resident to rate the pain level before administering the medication. After the medication has taken effect, the caregiver will ask again. Both responses shall be documented in the resident's medical record." 2. A review of R1's medical record revealed a service plan dated March 5, 2024, for personal care services including medication administration. 3. A review of R1's medical record revealed a list of medication orders dated September 5, 2024, which included an order for, "Morphine sulfate 15 MG, take 1 tablet by mouth every 8 hours." 4. A review of R1's medical record revealed an electronic medication administration record (eMAR) dated October 2024. The eMAR documented "Morphine Sulfate 15 MG " had been administered at 8 am, 2 pm, and 10 PM on each day between October 1, 2023, and the day of the survey. 5. A review of R1's medical record revealed a chart of R1's pain levels between October 22, 2024 and October 27, 2024. However, the chart included only three entries per day and included the following: - "10/22/2024, 6:58 AM, 8"; - "10/22/2024, 1:28 PM, 6"; - "10/22/2024, 10:21 PM, 8"; - "10/23/2024, 6:08 AM, 8"; - "10/23/2024, 8:28 PM, 4"; - "10/23/2024, 10:24 PM, 6"; - "10/24/2024, 7:26 AM, 8"; - "10/24/2024, 5:14 PM, 8"; - "10/24/2024, 9:52 PM, 9"; - "10/25/2024, 5:48 AM, 9"; - "10/25/2024, 1:35 PM, 7"; - "10/25/2024, 10:02 PM, 9"; - "10/26/2024, 5:43 AM, 9"; - "10/26/2024, 5:16 PM, 3"; - "10/26/2024, 9:48 PM, 9"; - "10/27/2024 5:41 AM, 9"; - "10/27/2024, 2:53 PM, 7"; - "10/27/2024, 5:10 PM, 4." 5. In an interview, E1 acknowledged the effect of the Morphine administered to R1 during October 2024, had not been documented in R1's medical record.