Az Happy Valley Royal Care Home LLC.

“Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, 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 and provided access to an outside area which allowed the resident to be 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 documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officers observed ambulatory residents within the facility. 3. The Compliance Officers observed an alert system was installed on the backyard door. However, the alert system was not functioning. 4. The Compliance Officers observed the aforementioned door allowed residents to be at least 30 feet away from the facility. 5. A review of the facility's policies and procedures revealed a policy titled, "Wandering" which stated, "5. If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security." 6. In an interview, E1 acknowledged the aforementioned door did not alert employees of the egress of a resident from the facility.”

“Based on observation, record review, documentation review, and interview, the manager failed to ensure medications were stored by the facility, for one of two residents sampled. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. The Compliance Officers observed the following medications in R1's room. - Albuterol Sulfate (8.5 Gm) - Two boxes of Mupirocin ointment 2% - Original Sarna itch relief (Camphor .5% and Menthol .5%) 2. A review of R1's medical record revealed a service plan dated July 18, 2024. The service plan indicated R1 required medication administration. 3. A review of the policy and procedures revealed a policy titled, "Medication Services" which stated, " 5. All residents medications brought to the facility will be received by the caregiver on duty. Medications will be locked in the medication storage area..." 4. In an interview, E1 acknowledged R1 required medication administration and the medications were not stored by the facility.”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a signed medication order dated April 30, 2024. The medication order stated the following: "Insulin Lispro 100 unit/mL injection. Inject 3-9 units under the skin prior to meals per sliding scale (”

“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. The Compliance Officers observed ambulatory residents within the facility. 2. The Compliance Officers observed a spray bottle of Clorox bleach and a spray bottle of Windex window cleaner in a cabinet in the employees' bathroom. The bathroom was accessible and was not locked. 3. In an interview, E1 acknowledged toxic materials were stored unlocked.”