Sage House - Calavar

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a personal care service plan dated February 7, 2023. The service plan listed the following services to be provided for R1: -"Nail Care, Requires total care, Nails checked daily and trimmed as needed." 2. A review of R1's medical record revealed an activities of daily living (ADL) log for May 2023. However, R1's May ADL revealed no documentation indicating the aforementioned services were provided to R1. 3. In an interview, E1 reported the aforementioned services were provided to R1 according to the frequency specified in R1's service plan every day in May 2023. E1 acknowledged the services provided to R1 were not documented in R1's medical record. 4. A review of R2's medical record revealed a personal care service plan dated March 2, 2023. The service plan listed the following services to be provided for R2: -"Nail Care, Requires total care, Nails checked daily and trimmed as needed." 5. A review of R2's medical record revealed an activities of daily living (ADL) log for May 2023. R2's May ADL log revealed "Nail Care" was documented as completed on May 1, 3, and 23, 2023. However, no documentation indicating the aforementioned services were provided according to the frequency specified in R2's service plan was available for review. 6. In an interview, E1 reported the aforementioned services were provided to R2 according to the frequency specified in R2's service plan every day in May 2023. E1 acknowledged the services provided to R2 were not documented in R2's medical record.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. The Compliance Officer observed three ambulatory residents on the premises. 2. During the environmental inspection of the facility, the Compliance Officer observed an unlocked medication cart containing the residents' medications near the table in the facility's dining room. The Compliance Officer observed the top drawer of the medication cart contained fourteen labeled cups filled with assorted medications. The Compliance Officer also observed three pre-filled medication sets, and a basket of assorted pill bottles. 3. In an interview, E2 acknowledged the medication cart was unlocked, and the medications were not stored in a locked room, closet, cabinet, or self-contained unit.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95 \'b0F and 120 \'b0F in the areas of a facility used by residents. Findings include: 1. Using a Department-issued thermometer, the Compliance Officer observed the hot water temperature meausred 123.7 \'b0F at the sink of a common bathroom used by residents. 2. In an interview, E2 acknowledged the hot water temperature was not maintained between 95 \'b0F and 120 \'b0F. 3. In a separate interview, E1 acknowledged the hot water temperature was not maintained between 95 \'b0F and 120 \'b0F. E1 reported E1 adjusted the hot water heater temperature while the Compliance Officer was on site.