La Bella Vita Assisted Living Home.

“Based on documentation 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 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. While on-site, the Compliance Officers observed two ambulatory residents. 3. During the environmental inspection of the facility, the Compliance Officers observed a sliding glass door leading to the backyard. The door had a device that was intended to alert employees of the egress of a resident to the outside area; however, the door chime was turned off. 4. A review of facility documentation revealed a policy regarding wandering residents. The policy stated, "C. Environmental Strategies : The facility should make the following changes to the physical environment, to minimize inappropriate wandering behavior: ... 7. Place warning bells or alarms at the doors. The alarm will alert the caregivers when the resident attempts to exit the facility unsupervised." 5. In an interview, E1 reported E1 only turned the back door alert on at night. E1 demonstrated turning the device on to show it was in working order. E1 acknowledged at the time of the inspection the back door leading to an outside area did not alert employees of the egress of a resident from the facility.”

“Based on record review, documentation review, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk if medication administered to a resident was not accurately documented. Findings include: 1. A review of R2's medical records revealed R2 received medication administration. 2. A review of R2's medication administration record (MAR) revealed documentation that medication had been administered prior to R2's date of admission. 3. A review of the facility's policies and procedures revealed a policy titled "Medication Policy and Procedure." Within the policy was a subsection titled "Documentation of Medication," which stated the following: "A separate medication record is maintained for each resident who's receiving assistance in self-administration of medication or medication administration that includes...d. Date and time of actual assistance in self-administration of medication or medication administration...[and]...f. Signature or initials of the employee/caregiver providing assistance in self-administration of medication or medication administration." 4. In an interview, E2 reported E2 made an error in the documentation on R2's MAR as R2 was not admitted until the day after the documentation of medication administration was initialed by E2 as being administered. E1 and E2 acknowledged the inaccurate documentation of medication administration prior to R2's date of admission.”