Villas at Green Valley, Villa B

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or documentation from a medical practitioner which stated weighing the resident was contraindicated. The deficient practice posed a risk as the facility would not be aware if there was a significant change in R1's weight. Findings include: 1. A review of R1's medical record revealed a service plans dated August 6, 2024, which indicated R1 was receiving directed care services. The service plan did not include documentation of R1's weight. 2. Further review of R1's medical record revealed documentation from a medical practitioner which stated weighing R1 was contraindicated was unavailable for review. 3. In an interview, E1 reported R1's service plan was the most recent service plan available. E1 acknowledged R1's service plan did not contain the residents' weight, and R1's medical record did not contain documentation from a medical practitioner indicating weighing R1 was contraindicated.

Based on record review, documentation review, and interview, the manager failed to ensure a manager, a caregiver, and an assistant caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two caregivers sampled. Findings include: 1. A review of E3's personnel record revealed E3 was hired on May 26, 2023 as a caregiver. Further review revealed a document titled, "TB Screening Result." The document indicated R3 had a history of a positive TB test, had "no signs of active disease," was "Negative screen for active TB disease and NOT CONTAGIOUS." The document was signed by a medical doctor on "April 1, 2022. No additional evidence of documentation of freedom from infectious TB was available for review, and E3's personnel record did not contain current documentation of baseline screening. 2. In an interview, E1 acknowledged evidence of current documentation of freedom from infectious TB and baseline screening was not available for E3.

Based on record 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 one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan dated June 19, 2023, for directed care services, and indicated R2 would be provided the following services: "Showering: Complete Assist, 2x per week;" "Oral Care: "Morning and Night, Complete Assist;" and "Dressing: Monitor, Set up, Standby, Daily." 2. A review of R2's medical record revealed a document titled "Caregiver ADL Checklist," for the month of June 2023, to document services provided and activities of daily living, during each of three shifts, 1, 2 and 3. The tracking sheet included a legend with codes used in the document, to include "SU=Set Up," "SB=Standby," "CU=Cue," M=Monitor," "NA=No Assist," and "N/A=Not Applicable." The tracking sheet also contained sections for documenting services "Bathing," and "Oral Care" which were documented as noted below on the shifts and dates indicated: Bathing: "N" or "NA" for shift 1, 2 and 3 on June 1-6 and June 8-18, 2023; "Y" for shift 2, and "NA" for shift 1 and 3 on June 7, 2023; and "I" for shift 1 and 2, and "NA" for shift 3 on June 19, 2023 Oral Care: "I" for each shift on June 1-19, 2023 Dressing: "I" for each shift on June 1-19, 2023. 3. A review of R3's medical record revealed a service plan dated May 5, 2023, for directed care services, and indicated R3 would be provided the following services: "Showering: Set up, Standby, 2x per week;" and "Oral Care: "Morning and Night, Monitor, Set up." 4. A review of R3's medical record revealed a document titled "Caregiver ADL Checklist," for the month of June 2023, to document services provided and activities of daily living, during each of three shifts, 1, 2 and 3. The tracking sheet included a legend with codes used in the document, to include "SU=Set Up," "SB=Standby," "CU=Cue," M=Monitor," "NA=No Assist," and "N/A=Not Applicable." The tracking sheet also contained sections for documenting services "Bathing," and "Oral Care" which were documented as noted below on the shifts and dates indicated: Bathing: "N" or "NA" for shift 1, 2 and 3 on June 1, 3-10, 11-19, 2023 "Y" for shift 1, and "N" for shift 2 and 3 on June 2, 2023 "NA" for shift 1 and 2, and "NO" for shift 3 on June 11, 2023 Oral Care: "I" for each shift on June 1-19, 2023 5. In an interview, E1 advised not knowing what the acronyms "N," "Y" or "I" in the ADL checklists meant, but presumed they represented "No," "Yes" or "Independent." E1 acknowledged the caregivers were not correctly documenting services provided for R2 or R3, and there was not way to determine if the services had been provided according to R2's or R3's service plan.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During a tour of the facility the Compliance Officer observed a night stand next to a bed in a resident's bed in Unit 2. On top of the night stand was a partially used tube of "Clobetasol propionate Cream USP 0.05%," and the tube was marked "Keep out of reach of children." The Compliance Officer also observed a bathroom in Unit 8 which contained cabinets equipped with magnetic locking devices for securing the doors, however the magnetic lock was not engaged and the Compliance Officer was able to open the cabinet with little effort. Inside the cabinet were two partially used tubes of prescribed "CalProtect" ointment. Each tube was marked "For External Use Only. Keep Out Of The Eyes, Inside Of Nose, Or Mouth," and "Keep out of reach of children." 2. In an interview, E2 verified the residents in Unit 2 and Unit 8 were receiving directed care. E2 acknowledged that the medications had not been stored in a separate locked cabinet the facility uses for medication storage.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, separate from medications and inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than three ambulatory residents in the common area near the kitchen of the residence. Two caregivers, E3 and E4, were on duty and were observed to leave the kitchen area and go into the back of the residence for several minutes, leaving the kitchen unattended. The Compliance Officer also observed a cabinet under the kitchen sink which was equipped with magnetic locks to secure the doors, however the locks were not engaged. The Compliance Officer was able to open the cabinet with little effort and observed a can of "Easy-Off" oven cleaner and a one gallon bottle of Clorox bleach. 2. In an interview, E3 advised the magnetic locks had been "working sometimes, and sometimes not." E3 reported they had not submitted a work order to have the magnetic locks repaired or replaced. 3. In an interview E2 acknowledged the poisonous and toxic materials were not kept in a locked area, inaccessible to residents. E2 immediately contacted facility maintenance and replaced the magnetic locks.