West Valley Care Home

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort which provides access to an outside area which controls or alerts employees of the egress of a resident from a facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1 . A review of Department documentation revealed the facility was licensed for directed care services. 2 . During an environmental inspection of the facility, the Compliance Officer observed the front and back door of the facility leading to outside areas had alerts and no control. However, both alerts were turned off. 3 . In an interview, E1 reported the residents would turn off the alerts because they found them annoying. E1 acknowledged the alerts were turned off.

Based on observation and documentation review, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a cabinet under the kitchen sink locked with magnetic locks. However, the key for the magnetic locks was sitting on the handle of an adjacent cabinet. The Compliance Officer was able to use the magnetic key to unlock the cabinet and access the following chemicals: -A bottle of "Windex" glass cleaner; -A can of "Sprayway" glass cleaner; -A Jug of "Fabuloso" multi-purpose cleaner; -A bottle of "Clorox" bleach; and -A container of "Member's Mark" dishwasher packs. 2 . In an interview, E1 acknowledged the toxins were accessible.

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of facility documents revealed a policy and procedure titled "Fall Prevention" that did not include the timeframe for employee training. 2. Review of E2's personnel record revealed E2 worked as an assistant to the manager and had a hire date of August 1, 2022. The personnel record did not include documentation showing E2 completed fall prevention and fall recovery training. 3. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of April 25, 2022. The personnel record revealed documentation of fall prevention training dated April 26-27, 2022. However, current documentation was not available indicating E3 completed fall prevention and fall recovery training. 4. Review of E4's personnel record revealed E4 worked as a caregiver and had a hire date of February 4, 2023. The personnel record did not include documentation showing E4 completed fall prevention and fall recovery training. 5. In an interview, E1 and E2 acknowledged documentation was not available showing E2, E3, and E4 had completed initial training and continued competency training for fall prevention and fall recovery.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for one of four caregivers. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Review of E4's personnel record revealed E4 worked as a caregiver and had a hire date of February 4, 2023. The personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on August 10, 2022, and valid for two years. There was no other current documentation of CPR training available for review that documented E4 had attended an approved CPR training course that included a demonstration of the individual's ability to perform CPR. 2. Review of the August 2023 personnel schedule revealed E4 worked every day in August. 3. Review of the facility's policy and procedure revealed a policy titled "First Aid/CPR Training Requirements" reviewed and signed by E1 July 12, 2020. This policy stated "1. The manager requires that a caregiver obtains and providers documentation of cardiopulmonary resuscitation training specific to adults, which includes a demonstration of the caregiver's ability to perform cardiopulmonary resuscitation..." 4. In an email exchange, a representative from NationalCPRFoundation, stated "Our courses are online only." 5. In an interview, E1 and E2 acknowledged E4 did not have current documentation of CPR training, including a demonstration of the individual's ability to perform CPR.

Based on record review, observation, and interview, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a health and safety risk to the resident. Findings include: 1. R9-10-101.199 defines "Restraint" as any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body. 2. Review of R1's medical record revealed a service plan for directed care services dated June 1, 2023. This service plan stated R1 had a diagnosis of "Lewy Body Dementia" and was "confused, forgetful and hallucinates". 3. When the Compliance Officer arrived, R1 was observed sitting in a wheelchair with a lap belt attached to the wheelchair securing R1 to the wheelchair. 4. In an interview, E4 reported R1 could not remove the seat belt and the seat belt was used to keep R1 in the wheelchair. 5. During an environmental inspection of the facility with E1, the Compliance Officer observed R1's bed with a half bedrail positioned in the middle of the bed. The other side of the bed was pushed up against the wall. 6. In an interview, E1 reported the bedrail was put up when R1 was in the bed and a reclining chair was moved up against the bed near the head of the bed. E1 reported R1 could not move the bedrail up or down. 7. In an interview, E3 reported R1 tried to get out of bed when R1 could not sleep.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. 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 R2's medical record revealed a current written service plan dated March 10, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed signed medication orders dated February 27, 2023 and August 25, 2023. These medication orders stated the following: "Triamcinolone Acetonide 0.1% 1 application to L leg ulcer externally once a day" "Miconazole Nitrate 2% 1 application topically q 8 hrs" "Nystatin 100000 unit/gm 1 application topically 2-3 times daily" "Loratadine 10mg 1 tablet orally once a day" "Colace 100mg 2 caps orally 2 times a day" 3. Review of R2's medical record revealed an August 2023 medication administration record (MAR). This MAR stated the following: Triamcinolone Acetonide 0.1% was not listed on the MAR. Miconazole Nitrate 2% was not listed on the MAR. Nystatin 100000 unit/gm was not listed on the MAR. Loratadine 10mg was not listed on the MAR. "Colace 100mg 2 caps PO once a day" and indicated two caps were administered at 8:30am August 8th - present. 4. During an observation of R2's medications, the following was observed: Triamcinolone Acetonide 0.1% was not available in R2's medication box. Miconazole Nitrate 2% was available. Nystatin 100000 unit/gm was not available in R2's medication box. Loratadine 10mg was available. Colace 100mg was observed and one cap was observed prefilled in the "Morn" slot of R2's medication organizer. 5. In an interview, E1 reported Triamcinolone Acetonide, Miconazole Nitrate, Nystatin, and Loratadine were discontinued and only one cap of Colace was administered every day. E1 and E2 acknowledged R2's medications were not administered in compliance with the available medication orders.

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 two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R2's medical record revealed a current written service plan dated March 10, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated August 25, 2023. This medication order stated "Hydrocodone-Acetaminophen 5-325mg tablet 1 tablet as needed orally every 6 hrs". 3. Review of R2's medical record revealed an August 2023 medication administration record (MAR). This MAR did not include documentation the medication was administered August 1st - present. 4. During an observation of R2's medications, Hydrocodone-Acetaminophen 5-325mg was observed. 5. In an interview, E1 reported R2 was administered the medication approximately two to three times a week. E1 and E2 acknowledged R2's medical record did not include documentation the medication was administered.

Based on observation and interview, the manager failed to ensure 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 an environmental inspection of the facility with E1, the Compliance Officer observed Lysol toilet bowl cleaner and Scubbing Bubbles unlocked in the cabinet under the hall bathroom sink. This cabinet did not have a locking device. In addition, the Compliance Officer observed Clorox, Member's Mark fabric softener, and All laundry detergent unlocked in the laundry room. The laundry room door had a keyed locking device, however the key was stored in the door. 2. During an observation, O1 was observed cleaning the facility, however was not in the hall bathroom or in the laundry room during the environmental inspection. 3. In an interview, E1 and E2 acknowledged toxic materials were stored unlocked.

Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. Review of facility's documents revealed a policy titled "TB - Tuberculosis Screening and Risk Assessment Form (Infection Control Policy and Procedure)" that stated "...All individuals employed by the facility or providing volunteer services for the facility will be required to complete Tuberculosis (TB) Training and Education upon hire and annually thereafter..." 2. Review of E2's personnel record revealed E2 worked as an assistant to the manager and had a hire date of August 1, 2022. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of April 25, 2022. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 4. Review of E4's personnel record revealed E4 worked as a caregiver and had a hire date of February 4, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 5. In an interview, E1 and E2 acknowledged E2, E3, and E4 had not completed training and education related to recognizing the signs and symptoms of TB. 6. Technical assistance was provided on this Rule during the compliance inspection conducted September 30, 2022.

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility's documents revealed a policy titled "TB - Tuberculosis Screening and Risk Assessment Form (Infection Control Policy and Procedure)" that stated "...The facility will be assessed on an annual basis to determine TB risk. . This assessment will be completed on the facility form called "Facility Tuberculosis Risk Assessment" at least once every 12 months..." 2. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB. 3. In an interview, E1 and E2 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 4. Technical assistance was provided on this Rule during the compliance inspection conducted September 30, 2022.