Rancho Santa Fe Assisted Living LLC

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical record, for two of two current residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1’s medical record revealed a service plan dated July 4, 2025. This service plan revealed R1 received the following services; -Night checks every four hours, -Encourage to drink fluids to maintain hydration, and -Encourage to eat meals and snacks. 2. Review of R1’s medical record revealed an activity of daily living (ADL) log for the month of July 2025. On the ADL log, the services mentioned above were not documented as completed on July 22, 2025. 3. Review of R2’s medical record revealed a service plan dated April 4, 2025. This service plan revealed R2 received the following services; -Dressing AM and PM, -Encourage to drink fluids, and -Incontinence checks every two hours during the day and twice at night. 4. Review of R2’s medical record revealed an ADL log for the month of July 2025. On the ADL log, dressing was not documented as completed in the PM on July 22, 2025. Encouragement to drink fluids and incontinence checks were not documented as completed on July 22, 2025. 5. Review of the facility policies and procedures revealed a policy titled, “Resident Medical Records (including electronic records) and Documentation," which stated, “4. Care or services provided to the residents are to be documented as they are provided as much as possible.” 6. In an interview, E2 reported the services were provided to the R1 and R2, however, were not documented as completed on the ADL logs. 7. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area that allowed residents to exit to a location at least 30 feet away from the facility that was secure, and monitored 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 at the directed level of care. 2. The Compliance Officer observed the alerts on the front door and the door leading to the backyard were off. The Compliance Officer opened the doors and the alerts did not sound. 3. The Compliance Officer observed the backyard did not allow residents to be a least 30 feet away from the facility. A lock was observed lying on top of the fence next to the gate. The gate was not secured or alerted. 4. Review of the facility's policies and procedures revealed a policy titled, “Environmental and Physical Plant Safety, includes Pest Control Program” which stated, “4. Exit doors and windows to the outside that a wandering resident may exit through, will be alarmed to alert employees in the event a resident is wandering. 7. Gates or door ways for exiting the facility by a wandering resident will be equipped with devices to alert employees of the exiting of a resident from the facility.” 5. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record, for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1’s medical record revealed signed medication orders dated October 29, 2024. The orders stated the following: - "Carvedilol 6.25 MG 1 tab BID" - "Memantine HCI 10 MG 1 tab BID" - "Atorvastatin 20 MG 1 tab QHS" 2. Review of R1’s medical record revealed a Medication Administration Record (MAR) for the month of July 2025. This MAR did not include documentation showing the following medications were administered in the evening on July 22, 2025: - Carvedilol 6.25 MG - Memantine HCI 10 MG - Atorvastatin 20 MG 3. Review of R2’s medical record revealed signed medication orders dated July 2, 2025. The orders stated the following: - "Tylenol 500 MG 2 tabs QHS" - "Trazadone 100MG 1 tab QHS" - "Tramadol 50 MG 1 tab QHS" - "Quetiapine 100 MG 1 tab BID" 4. Review of R2’s medical record revealed a MAR for the month of July 2025. This MAR did not include documentation showing the following medications were administered in the evening on July 22, 2025: - Tylenol 500 MG - Trazadone 100MG - Tramadol 50 MG - Quetiapine 100 MG 5. In an interview, E2 reported the medications were administered, however, were not documented on R1’s and R2’s MAR. 6. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. The Compliance Officer observed two oxygen containers stored upright in R1's bedroom closet. One oxygen container was on a two-wheel vertical medical cylinder cart, however, one oxygen container was not secured. 2. In an interview, E1 acknowledged there was an unsecured oxygen container in R1's bedroom closet. E1 reported to be unaware the oxygen containers were required to be stored secured and in an upright position.