Lidia's Care Home LLC

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training, for one of four caregivers reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "First Aid and CPR Training" reviewed and signed by E2 January 2, 2022. This policy stated "...5. In the Application for Employment form, the hiring person will note expiration date of the CPR card and set up a reminder for expiration date of the card to ensure a timely retraining in CPR. 6. In the Application for Employment form, the hiring person will note expiration date of the First Aid card and set up a reminder for expiration date of the card to ensure a timely retraining in First Aid..." 2. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of June 15, 2021. The personnel record revealed a first aid and CPR card with an expiration date of June 2, 2023. There was no other documentation of first aid and CPR training in E3's record. 3. Review of the October 2023 personnel schedule revealed E3 worked 24 hours a day every day except Thursdays. 4. In an interview, E1 acknowledged documentation was not available that showed E3 had current training in first aid and CPR.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R2's medical record revealed a current written service plan for directed care services dated September 29, 2023. This service plan stated the following services were needed: "Requires positioning Q 2-3 hrs" "Shower 1x/wk, Sponge bath QD, Complete bath 2 X week/PRN" "Wash hair, Peri care daily & PRN, After each disposable change" "Brush Dentures daily &/or PRN" "Cleans nails PRN" "Assist Dressing" "Comb hair daily" "Check pressure areas PRN" "Encourage meals/snacks" "Fluids encourage 6 to 8 glasses per day" "Incontinent both, Change every two hours/PRN" However, documentation was not available indicating these services were provided October 1st - 3rd, and 6th - present. 2. In an interview, E1 acknowledged R2's medical record did not include documentation of the above listed services and reported the services were provided as indicated in the service plan.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated June 6, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated October 20, 2023. This medication order stated "Donopezil 10mg 1 tab QHS". 3. Review of R1's medical record revealed an October 2023 medication administration record (MAR). This MAR stated "Donopezil 10mg take 1 tab daily PO" and indicated one tab was administered at 8pm October 1st - present. 4. During an observation of R1's medications, Donopezil 5mg was observed and one tab was observed prefilled in the "Bed" slot of R1's medication organizer. 5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R1's medication was not administered in compliance with the available medication order.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R2's medical record revealed a current written service plan dated September 29, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated October 18, 2023. This medication order stated "Tylenol 500mg 1 tab BID". 3. Review of R2's medical record revealed an October 2023 medication administration record (MAR). This MAR did not include documentation Tylenol 500mg was administered. 4. During an observation of R2's medications, Tylenol 500mg was observed and one tab was observed prefilled in the "orange" and "blue" slot of R2's medication organizer. 5. In an interview, E1 reported the medication was administered per the medication order and acknowledged R2's medical record did not include documentation the medication was administered.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area separate from food storage 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: -The laundry room was unattended and Fabuloso, bleach, and laundry detergent were observed unlocked. -Simple Grout was observed unlocked in the hall bathroom. -Filter Charge was observed unlocked in a closet in the hall. -Snake-A-Way was observed unlocked in the backyard. -Weiman Stainless Steel wipes were observed unlocked in the kitchen pantry. 2. During an observation, the caregivers were not accessing the toxic materials at the time of arrival. 3. In an interview, E1 acknowledged toxic materials were stored unlocked.