Pleasant Sunset Assisted Living LLC

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. Review of Department documentation revealed the facility is licensed to provide directed care services. 2. The Compliance Officer observed ambulatory residents. 3. The Compliance Officer observed a door leading to the garage. On the door was a key pad lock. However, when the Compliance Officer pulled on the door handle the door opened. 4. The Compliance Officer observed an unlocked refrigerator door in the garage which contained a sample of the following medications that were found: - One bag of Morphine 20 mg - Two bottles of Haloperidol .5 ml that was prescribed to two different residents. 5. In an interview, E3 acknowledged the medications were not locked in the refrigerator.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained 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. The Compliance Officer observed a door leading to the garage. On the door was a key pad lock. However, when the Compliance Officer pulled on the door handle the door opened. 2. The Compliance Officer observed the following toxic materials in the garage: - Two bottles of Clorox Bleach -Two bottles of Fabuloso 3. In an interview, E2 reported the padlock was broken. E3 was not aware of the broken lock. E3 acknowledged the padlock was broken and the door was unlocked.

Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R1's medical record revealed no documentation of a baseline symptom screening signed by a registered nurse, medical practitioner or local health department. Based on R1's date of acceptance, this documentation was required. 3. A review of R2's medical record revealed no documentation of a baseline symptom screening signed by a registered nurse, medical practitioner or local health department. Based on R2's date of acceptance, this documentation was required. 4. In an interview, E2 acknowledged R1's and R2's medical records did not include a baseline symptom screening signed by a registered nurse, medical practitioner or local health department as required. Technical assistance was provided on this Rule during the compliance inspection conducted on June 8, 2023.

Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the manager, for one of two residents reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. Review of R2's medical record revealed a current written service plan for personal care services dated August 19, 2024. However, this service plan did not include a signature and date from the manager. 2. During an interview, E3 reported R2 received personal care services. E3 acknowledged R2's service plan did not include a signature and date from the manager.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of three residents sampled. 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 April 27, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated April 21, 2023. This medication order stated "Metoprolol 25 mg take one tablet twice a day. Hold for SBP less than 110." 3. Review of R1's medical record revealed a form titled "Vital Signs Chart" dated June 2023. The chart, on June 5, 2023, indicated the systolic blood pressure was recorded as 93. However, a review of the Medication Administration Record for June 2023, revealed Metoprolol 25 mg was documented as given by E2. This medication was required to be held according to the medication order. 4. During an interview, E1 acknowledged the medication was not administered in compliance with the medication order.

Based on record review and interview, the manager failed to ensure when a resident had an emergency resulting in the resident needing medical services, a caregiver documented the date and time of the incident, a description of the accident, emergency, or injury, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R3's medical record revealed hospital discharge paperwork for the following dates: -June 5, 2022 June 16, 2022 -September 1, 20222 2. The Compliance Officer requested to review the documentation of the incidents involving R3. . However, documentation was not provided for review. 3. In an interview, E1 acknowledged the required information was not documented for R3's incidents.