Palos Verdes Senior Living

Based on observation and interview, the manager failed to ensure if an assisted living maintained residents' record electronically, safeguards existed to prevent unauthorized access. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed an unattended med cart on the second floor of the facility with an unlocked laptop. The laptop contained a minimized Google Chrome screen, which, when clicked, allowed the Compliance Officer to access a resident's medical record. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a cleaning cart unattended in the hallway of the memory care unit. The bottom compartment of the door was unlocked, and the following items were accessible: -A bottle of "Betco" multi-purpose cleaner; -A bottle of "Betco" glass cleaner; -A bottle of "Betco" versiFect cleaner; -A bottle of "Betco" toilet and urinal cleaner; and -A bottle of "Ecolab" stainless steel polish. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided. This citation is a repeat deficiency from an inspection conducted on October 2, 2024.

Based on documentation review and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was unable to meet a resident's needs during an emergency. Findings include: 1. A review of facility documentation revealed a training program for all staff regarding fall prevention and fall recovery was not available for review at the time of inspection. 2. In an interview, E1 acknowledged documentation of a training program for all staff regarding fall prevention and fall recovery was not available for review at the time of inspection.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for two of five residents sampled. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R2's and R4's medical record revealed documentation of the resident's orientation to exits from the assisted living facility was not available for review at time of inspection. 2. In an interview, E1 acknowledged R2's and R4's medical record did not contain documentation of R2's and R4's orientation to exits from the assisted living facility at the time of the inspection.

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. Findings include: 1. During an environmental inspection of the facility the Compliance Officer observed a bag of "Cascade Platinum" dishwasher detergent pods in an unlocked cabinet below the sink in a all purpose room on the second floor of the facility. 2. In an interview, E1 acknowledged the dishwasher detergent pods were not stored in a locked area and inaccessible to residents.

Based on documentation review and interview, the manager failed to establish and document policies and procedures for administering an opioid to protect the health and safety of a patient in compliance with Arizona Administrative Code (A.A.C.) R9-10-120(F). The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Medication assistance/Administration: Controlled Substance" reviewed September 1, 2023. However, this policy did not cover which personnel members may administer an opioid in treating a patient and the required knowledge and qualifications of these personnel members; how, when, and by whom a patient's need for opioid administration are assessed; how, when, and by whom a patient receiving an opioid is monitored; and when and by whom the aforementioned actions taken are documented. 2. In an interview, E1 acknowledged the policies and procedures did not cover which personnel members may administer an opioid in treating a patient and the required knowledge and qualifications of these personnel members; how, when, and by whom a patient's need for opioid administration are assessed; how, when, and by whom a patient receiving an opioid is monitored; and when and by whom the aforementioned actions taken are documented.

Based on documentation review, record review and interview, the health care institution failed to provide appropriate first aid to a noninjured resident who had fallen, appeared to be uninjured and was unable to reasonably recover independently. The deficient practice posed a risk as the facility called 911 instead of providing first aid to a non-injured resident by assisting them off the floor after a fall. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Fall- lift assist" (per A.R.S. \'a7 36-420.01). The policy and procedure stated "Whenever a resident has fallen (witnessed or un-witnessed), team members will determine if there is a need to call 911...Team member must provide lift assistance when deemed appropriate instead of relying on emergency medical responders." 2. A review of facility documentation revealed documentation titled "Spectrum scope of care." The documentation stated "Services beyond SRC's level of care... Hoyer lifts or sit to stands." 3. In an interview, E1 reported the facility would not accept residents who required Hoyer lifts. 4. A review of R1's medical record revealed a "Care plan detail." (dated February 2023). The plan stated "Mobility/Ambulation... Resident is independent with mobility/ambulation." 5. A review of R1's medical record revealed an incident form dated June 1, 2023. The incident form stated "Resident called at 12:45 and she was on the floor next to her bed. We called the fire department and they came and picked her up ... she has no bruises or injuries." However, the situation was not an emergency and personnel members did not utilize first aid by assisting R1 off the floor. 6. In an interview, E1 reported E1 told caregivers to call the fire department when R1 had fallen. E1 stated E1 had caregivers "call the fire department to minimize workplace injuries." 7. In an interview, E1 acknowledged the health care institution failed to provide appropriate first aid to a noninjured resident who had fallen, appeared to be uninjured and was unable to reasonably recover independently.

Based on documentation review, record review and interview, the health care institution implememented policies that prevented employees from providing appropriate first aid. The deficient practice posed a risk as the facility called 911 instead of providing first aid to a non-injured resident by assisting them off the floor after a fall. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Fall- lift assist" (per A.R.S. \'a7 36-420.01). The policy and procedure stated "Whenever a resident has fallen (witnessed or un-witnessed), team members will determine if there is a need to call 911...Team member must provide lift assistance when deemed appropriate instead of relying on emergency medical responders." 2. A review of R1's medical record revealed an incident form dated June 1, 2023. The incident form stated "Resident called at 12:45 and she was on the floor next to her bed. We called the fire department and they came and picked her up ... she has no bruises or injuries." However, the situation was not an emergency and personnel members did not utilize first aid by assisting R1 off the floor. 3. In an interview, E1 reported E1 told caregivers to call the fire department when R1 had fallen. E1 stated E1 had caregivers "call the fire department to minimize workplace injuries." 4. In an interview, E1 acknowledged the health care institution implemented policies preventing employees from providing appropriate first aid.

Based on record review and interview, the manager failed to ensure a resident's orientation to the assisted living facility's evacuation plan and the route to be used was documented, for four of four current residents sampled. Findings include: 1. A review of R1's, R2's, R3's and R4's medical record revealed documentation of the resident's orientation to the assisted living facility's evacuation plan and the route to be used was not available for review. 2. In an interview, E1 stated "When taking over as assisted living manager as of May 1st, 2023, I had noticed there was no orientation documented. I am currently working with the facility manager to complete documentation." 3. In an interview, E1 acknowledged E1 failed to ensure a resident's orientation to the assisted living facility's evacuation plan and the route to be used was documented.