Kellys Adult Care Home

Based on documentation review, record review, and interview, the manager accepted and retained an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: R9-10-101.5. states: "Activities of daily living" means ambulating, bathing, toileting, grooming, eating, and getting in or out of a bed or a chair. R9-10-101.32. states: "Behavioral health issue" means an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors. 1. A review of Department documentation revealed the facility was not authorized to provide behavioral health services, per R9-10-802(2)(b). 2. A review of R2's medical record revealed a current written service plan for supervisory care dated November 2023, which stated "Primary Medical Diagnosis: Alcoholism", no other diagnosis was listed. 3. In an interview, E1 reported that R2 needed assistance with cooking and cleaning. E1 reported that R2's only diagnosis was alcoholism. E1 acknowledged R2 was accepted and retained when the primary condition for which R2 needed assisted living services was a behavioral health issue.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, 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. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility with E1, the Compliance Officer observed a door leading to a backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door did not have a device that alerted employees of the egress of a resident from the facility and was unlocked. 3. In an interview, E1 reported that the alarms had been taken down for repainting a few weeks prior, and had not been reinstalled. E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed the following in a caregiver bathroom. The bathroom door was equipped with a privacy latch, however, this latch was able to be opened without a key or combination. -"Lysol All Purpose Cleaner" which stated "Warning: Keep out of reach of children"; -"Dawn Powerwash" which stated "Keep out of reach of children". 2. In the unlocked backyard, the Compliance Officer observed a container of "Oatey Clear Cleaner" which stated "Danger! May be fatal if swallowed and enters airways". 3. In an interview, E1 acknowledged toxic materials stored by the facility were not stored in a locked area and inaccessible to residents. This is a repeat deficiency from the on-site compliance inspection conducted on October 26, 2022 and August 30, 2021.