All Stars Assisted Living

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required intermittent nursing services or restraints, for one of three residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. In record review, R2's medical record did not include documentation signed by a Physician, Registered Nurse practitioner, Registered nurse, or Physician assistant, which included whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2's acceptance date, this documentation was required to be in the record. 2. During an interview, E1 acknowledged the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours of acceptance, for one of three residents reviewed. The deficient practice posed a health and safety risk if the resident needed to exit the facility in an emergency. Findings include: 1. A review of R3's medical record revealed no documentation of orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours of acceptance. Based on R3's date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged documentation was not available that showed R3 was oriented to the facility's evacuation plan within 24 hours of acceptance.