West Wing Loving Care LLC

Based on record review, documentation review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident. The deficient practice posed a risk as policies and procedures reinforce and clarify the health care institution's standards. Findings include: 1. A review of R5's medical record revealed a service plan for directed care services. 2. A review of R5's medical record revealed an incident report dated July 08, 2024. The incident reported stated "R5 managed to open the front door of the facility when no staff was around and snuck out of the house and took one of the staff member's car and drove off." 3. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are trigged will be investigated immediately by the caregiver on duty." 4. In an interview, E2 acknowledged that the facility had a system to control or alert staff about residents' egress to outside areas. However, despite this system, the caregiver had been unaware of the general or specific whereabouts of R5.

Based on documentation review, record review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to ensure the safety of a resident who may wander. The deficient practice posed a risk if facility staff were unaware of the whereabouts of a resident. Findings Include; 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance officer observed three ambulatory residents. 3. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are trigged will be investigated immediately by the caregiver on duty." 4. A review of R5's medical record revealed an incident report dated July 08, 2024. The incident reported stated "R5 managed to open the front door of the facility when no staff was around and snuck out of the house and took one of the staff member's car and drove off." 5. During the environmental tour, the Compliance Officer observed that the facility had means of controlling and alerting employees to residents' egress to outside areas. However, during the incident involving R5 on July 08, 2024, the caregiver failed to investigate immediately when an alarm was triggered upon the resident's departure from the facility. 6. In an interview, E2 reported that R5 had wandered from the facility. In addition, R5 had managed to obtain E2's car keys and had driven away in E2's vehicle and was subsequently involved in an accident. E2 acknowledged policies and procedures were not implemented that ensure the safety of a resident who may wander.

Based on documentation review, record review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled 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. A review of Department records revealed the facility was licensed to provide directed care services. 2. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are trigged will be investigated immediately by the caregiver on duty." 3. A review of R5's medical record revealed an incident report dated July 08, 2024. The incident reported stated "R5 managed to open the front door of the facility when no staff was around and snuck out of the house and took one of the staff member's car and drove off." 4. During the environmental tour, the Compliance Officer observed that the facility had means of controlling and alerting employees to residents' egress to outside areas. However, during the incident involving R5 in July 08, 2024, the caregiver failed to investigate immediately when an alarm was triggered upon the resident's departure from the facility. 5. In an interview, E2 reported that R5 had wandered from the facility. In addition, R5 had managed to obtain E2's car keys and had driven away in E2's vehicle and was subsequently involved in an accident. E2 acknowledged that the facility had a system to control or alert staff about residents' egress to outside areas. However, despite this system, the caregiver had been unaware of the general or specific whereabouts of R5. This is a repeat deficiency from the compliance inspection conducted June 23, 2023.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a document titled "Disaster Plan". However, the disaster plan was reviewed last on November 01, 2022. 2. A review of facility policies and procedures revealed a policy "Disaster plan, Relocation, Records, Medication, Food and Water," the policy stated "8. The disaster plan is reviewed and the review is documentation at least once every 12 months ..." 3. In an interview, E2 acknowledged there was no documentation available for review at the time of the inspection to indicate the disaster plan was reviewed at least once every 12 months.

Based on 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. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of E1's personnel record revealed Fall Prevention Training. E1's personnel record revealed no documentation indicating E1 completed fall recovery training. 2. During an interview, E1 reviewed E1's personnel record. E1 acknowledged documentation of fall recovery training was not available for review.

Based on observation, record review, and interview, the manager failed to ensure an individual residing in the assisted living home, who was not a resident, a manager, a caregiver, or an assistant caregiver and who was over 12 years of age or older, provided evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113. Findings include: 1. During a tour of the facility, the compliance officer observed O1 and O2 in the assisted living home when the compliance officer arrived at the facility. 2. The surveyor requested documentation of O1 and O2's freedom from infectious TB. No documentation was available for review. 3. In an interview with E1, E1 reported O1 and O2 resided at the assisted living home. E1 reported O1 and O2 were over the age of 12 years old. E1 reported O1 and O2 did not have documentation of freedom from TB.

Based on record review, documentation review, and interview, the manager failed to ensure a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G). Findings include: 1. A review of the facilities policies and procedures revealed a policy titled "Resident Termination." The policy stated; "The facility manager may terminate residency of a resident as follows: without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility." 2. A review of R1 and R2's medical records revealed a residency agreement section titled "Terminations." The agreements stated; "The management will terminate the residency agreement without notice if: a The resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individual in the assisted living facility; b. the resident's medical or health needs require immediate transfer to another health care institution; c. the resident's care and service needs exceed the services the facility is licensed to provide." 3. In an interview, E1 reviewed R1 and R2's medical records. E1 reported E1 believes an old residency agreement was used for R1 and R2's medical records. E1 acknowledged the termination identified in the residency agreements were not in compliance with the facilities policies and procedures. E1 acknowledged the manager failed to implement policies and procedures to protect the health and safety of a resident to cover termination initiated by the manager of an assisted living facility in compliance with R9-10-807.G.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver correctly documented the services provided in the resident's medical record, for four of four residents sampled. The deficient practice posed a risk as the facility provided false and misleading information to the Department. Findings include: 1. A review of R1's medical record revealed an "Activities of Daily Living Chart." The chart identified the date of June 23, 2023, and documented that R1 received the following services "Dinner, and Night Checks Q 2-3 hrs." for the evening of June 23, 2023. 2. A review of R2's medical record revealed an "Activities of Daily Living Chart." The chart identified the date of June 23, 2023, and documented that R1 received the following services "Dinner, and Night Checks Q 2-3 hrs." for the evening of June 23, 2023. 3. A review of R3's medical record revealed an "Activities of Daily Living Chart." The chart identified the date of June 23, 2023, and documented that R1 received the following services "Dinner, and Night Checks Q 2-3 hrs." for the evening of June 23, 2023. 4. A review of R4's medical record revealed an "Activities of Daily Living Chart." The chart identified the date of June 23, 2023, and documented that R1 received the following services "Dinner, and Night Checks Q 2-3 hrs." for the evening of June 23, 2023. 5. In an interview, E2 acknowledged E2 did not complete dinner or bed checks as identified on R1, R2, R3 and R4's medical record. E2 reported E2 filled out the Activities of Daily Living "ahead of time." E2 acknowledged E2 provided the Department with false and misleading information. 6. In an interview, E1 reviewed R1, R2, R3, and R4's medical records. E1 acknowledged the identified services were documented in the identified medical records prior to the services being provided to the residents.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area that allowed residents to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the facility tour with E1, the compliance officer observed the back patio door contained an alarm to alert employees of the egress of a resident however the alert was not functioning. The door also contained a keypad lock that was not functioning and required a battery change. The compliance officer observed the back door, allowed residents to be a least 30 feet away from the facility and led to a gate that was unlocked and accessed the city street. The gate had a padlock that was located next to the gate not in use. 3. During an interview, E1 acknowledged the alarm and lock on the patio door was not working and required a battery change. E1 acknowledged the lock on the gate allowing access to the city street was unlocked. E1 reported E2 recently took the garbage out and forgot to lock the gate. E1 acknowledged the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area that allowed residents to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility.

Based on documentation review, record review, observation, and interview, the manager failed to ensure medication administered to a resident was correctly documented in the resident's medical record for four of four residents sampled. The deficient practice posed a risk as the facility provided false and misleading information to the Department. Findings include: 1. A review of the facilities policies and procedures dated October 30, 2021, revealed a policy titled "Medications." The policy states; "Medication Administration provided to a resident is in compliance with an order, and is documented in the resident's medical record. Medication administration is not documented until the resident is seen taking them." 2. A review of R1, R2, R3, and R4's medical record revealed all residents received medication administration. 3. A review of R1's medical record revealed signed medication orders for the following medications; Melatonin 3 mg 2 tab QHS PO, Mirtazapine 45 mg 1 tab QHS PO, and Trazadone 100 mg 1 tab QHS PO. A review of R1's medical record revealed the identified medications were documented as administered to R1 at "9 pm June 23, 2023." 4. A review of R2's medical record revealed signed medication orders for the following medications; Docusate Sodium 100 mg 1 cab BID PO, Divalproex Dr 125 mg 1 cap BID PO, Seroquel 50 mg 1 tab BID PO, and Trazodone 50 mg 2 tab QHS PO. A review of R2's medical record revealed the identified medications were documented as administered to R2 at "5 pm and 9 pm on June 23, 2023." 5. A review of R3's medical record revealed signed medication orders for the following medications; Carbidopa-Levodupa 25-100 mg 2 tab TID PO, Eloquis 2.5 mg 1 tab BID PO, Gabapentin 100 mg 1 tab TID PO, and Trazodone 50 mg 1 tab QHS PO. A review of R3's medical record revealed the identified medications were documented as administered to R3 at 5 pm and 9 pm on June 23, 2023. 6. A review of R4's medical record revealed signed medication orders for the following medications; Buspirone HCL 10 mg 1 tab BID PO, Senna 8.6 mg 2 tab QD PO, Amitriptyline 25 mg 1 tab QHS, and Gabapentin 300 mg 1 cap TID PO. A review of R4's medical record revealed the identified medications were documented as administered to R4 at 5 pm and 9 pm on June 23, 2023. 7. The compliance officer observed R1, R2, R3, and R4's medications were available at the facility. 8. In an interview, E2 reported E2 filled out the medication administration records "ahead of time" for R1, R2, R3, and R4. E2 reported R1, R2, R3 and R4 did not receive their medications for June 23, 2023, evening dosages as documented in their medical records. E2 acknowledged E2 provided the Department false and misleading information. 9. In an interview, E1 acknowledged the facility was not in compliance with their medication policy and procedure. E1 acknowledged R1, R2, R3, and R4's medical record revealed false and misleading information identifying R1, R2, R3, and R4's medication administration record r

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident, a description of the accident, emergency, or injury, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. Findings include: 1. Review of R1's medical record revealed a hospital discharge summary dated June 21, 2023, reporting R1 was admitted to hospital for "failure to thrive." A request to review the incident report revealed no documentation of an incident report for R1 was available for review. 2. In an interview, E1 reported medical services was called to the facility on June 19, 2023 for R1. E1 reported R1 was admitted to the hospital and returned to the facility on June 21, 2023. E1 reported E1 was unaware of the identified rule requirements and an incident report was not completed. E1 acknowledged the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident, a description of the accident, emergency, or injury, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future.

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. Findings include: 1. During the facility tour with E1 and E2, the compliance officer observed an unlocked kitchen cabinet with Lysol Disinfectant Spray and AJAX cleaner. The cabinet had the means of locking however was not locked. The compliance officer observed an unlocked garage containing Arm & Hammer Oxi Clean, interior car cleaner, Home Defense insect spray, scrubbing bubbles bathroom cleaner and paint. The garage contained a lock that could be opened without a key. 2. In an interview, E1 and E2 acknowledged the toxic materials were stored by the facility unlocked and accessible to residents. E1 acknowledged the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents.