Sunnyhill Adult Care Home INC, II

Based on observation and interview, the manager failed to ensure that toxic materials stored by the facility were stored 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. During the environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet under the sink in the kitchen, which contained the following toxic materials: 2- Box of “Cascade Platinum.” 1- Bottle of “Cascade Complete.” 1- Bottle of “Raid Ant and Roach Killer.” 1- Bottle of “Easy-Off Oven Cleaner.” 1- Bottle of “OdoBan Disinfectant Fabric and Air Freshener.” 1- Bottle of “Glass Cleaner.” 1- Bottle of “Lysol All Purpose Cleaner.” 1- Bottle of “Ajax with Bleach 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services created on December 16, 2021, and updated on June 1, 2022, December 1, 2022, and June 1, 2023. The service plan contained a section titled, "Elimination" which stated R1 was "Continent...Uses disposable undergarments...Change PRN, Peri Care PRN." 2. Further review of R1's medical record revealed a "House Call Visit Note," dated December 23, 2021 which stated, "ROS:...Exercise: incontinent of bowels at all times, incontinent of urine at all times, non-ambulatory, uses wheelchair, 1-person transfer, requires direct caregiver support with bathing..." The document was completed and electronically signed by a Nurse Practitioner. 3. In an interview, R1 reported R1 no longer receives caregiver assistance with toileting. R1 reported R1 is incontinent and receives assistance from carestaff with brief changes and peri care "a couple of times a day." 4. In an interview, E2 reported R1 has been incontinent for "almost two years." E2 reported caregivers assist R1 with incontinence care on an ongoing basis. E2 acknowledged R1's change in continence was not reflected in R1's service plan, and the manager failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change in the resident's physical condition.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of current cardiopulmonary resuscitation (CPR) training and first aid training, for one of five personnel members sampled. The deficient practice posed a risk if the personnel member was unable to assist a resident during an emergency. Findings include: 1. A review of facility policies and procedures revealed an undated policy titled "Staffing & Record Keeping" which stated, "...5. All staff must have current CPR and First Aid Course and Fingerprinting Clearance." 2. A review for facility documentation revealed an "Employee Monthly Work Schedule" dated August 2023. The schedule revealed E4 was scheduled to work the night shift (9:00 PM to 9:00 AM) alone on August 1-3, 5-10, 12-17, 19-24, and 26-31, 2023. 3. A review of E4's personnel record revealed E4 was hired as a caregiver. E4's personnel record contained documentation of CPR and first aid training certification. However, the certification card on record listed an expiration date of July 31, 2023. No documentation of current CPR and first aid training for E4 was available for review. 4. In an interview, E2 reported E2 thought E4 had recently renewed E4's CPR and first aid certification, however E2 was unable to locate any updated documentation. E2 acknowledged E4's personnel record did not contain documentation of current CPR and first aid training.

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 three residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services updated on June 1, 2023. The service plan listed the following services to be provided for R1: -"Bathing, CG Assist, Shower, Complete bath 2 X week/PRN, Wash hair, With shower, Peri care, After each disposable change"; -"Elimination, Continent, Uses disposable undergarments, Change every two hours/PRN, Peri Care PRN"; and -"Hygiene/Grooming, Foot Care Daily." 2. Further review of R1's medical record revealed activities of daily living logs (ADLs) for July and August 2023. R1's ADLs revealed documentation of the following services provided for R1: -"Full Bath" and "Shampoo" on July 4, 11, 19, and 25, 2023, and August 1 and 8, 2023. However, documentation indicating R1 received assistance with bathing, peri care, changing, and foot care at the frequency specified in R1's service plan was not available for review. 3. In an interview, E2 reported all services were provided to R1 according to the frequency specified in R1's service plan July and August 2023. E2 reported all residents receive assistance with bed baths on each day when a full bath is not completed. E2 acknowledged bathing (partial and complete), peri care, disposable brief changes, and foot care services provided to R1 in July and August 2023 were not documented in R1's medical record. 4. A review of R3's medical record revealed a service plan for personal care services updated on June 5, 2023. The service plan listed the following services to be provided for R3: -"Bathing, CG Assist, Shower, Complete bath 2 X week/PRN, Wash hair, With shower, Peri care, After each disposable change". 5. Further review of R3's medical record revealed an ADL log for August 2023. R3's August 2023 ADL revealed R3 received assistance with a "Full Bath" on August 1, 2023, and a "Partial Bath" on August 7, 2023. However, documentation to indicate R3 received bathing assistance at the type and frequency specified in R3's service plan was not available for review. 6. In an interview, E2 reported R3 was assisted with showers "at least twice a week", and partial baths on each day when R3 did not have a full bath in August 2023. E2 reported hospice certified nursing assistants (CNAs) assist R3 with showers, and facility staff assist R3 with partial baths. E2 acknowledged bathing (partial and complete) services provided to R3 in August 2023 were not documented in R3's medical record.

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 three residents sampled. Findings include: 1. A review of R2's medical record revealed a current service plan for directed care services. R2's medical record also contained a medication order for "AMLODIPINE BESYLATE, 2.5 MG (milligrams), PO, 1T QD noon." 2. Further review of R2's medical record revealed medication administration records (MARs) for July and August 2023. However, administration of the aforementioned medication was not documented on R2's July or August 2023 MARs. 3. The Compliance Officer observed a bottle of "Amlodipine Besylate 2.5 MG Tab" in a basket containing R2's medications. 4. In an interview, E2 reported R2 received medication administration of the aforementioned medication as ordered in July and August 2023. E2 reported R2 was a new resident and the facility must have forgotten to add the medication to R2's MAR. E2 acknowledged a medication administered to R2 was not documented in R2's medical record.