Asov Borrower, LLC

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During a tour of the facility, the Compliance Officer observed in the facility's medication closet a tall oxygen container was standing upright and unsecured. 2. In an interview, E1 acknowledged the oxygen container was not secured in an upright position.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's staffing schedule revealed three shifts: - 6:00 am - 2:00 pm (First Shift), - 2:00 pm to 10:00 pm (Second Shift), and - 10:00 pm - 6:00 am (Third Shift). 2. A review of documentation titled, "Disaster Drill" revealed the following information: - January 28, 2023, time: 10:00 am (first shift), - February 16, 2023, time: 2:00 pm (second shift), - March 7, 2023, time 5:00 am (third Shift), - April 13, 2023, 10:00 am (first shift), and - August 16, 2023, time 3:00 pm (second shift). There was no additional documentation or evidence to indicate a disaster drill was conducted on each shift at least once every three months and documented. 3. In an interview, E1, acknowledged the documentation was unavailable for review. Technical assistance was given on the last compliance survey completed on November 14, 2023.

Based on record review, documentation review, and interview, the manager failed to ensure an individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility including whether the individual requires restraints for eight of eight residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1, R2, R3, R4, R5, R6, R7, and R8's medical records revealed a document titled "Determination for Admission". This document did not include the following: - if an individual is requesting or is expected to need restraints. 2. In an interview, E1 reported being unaware the verbiage for restraints was not on the admission paperwork. E1 acknowledged the document was missing this information.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of five caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E3's personnel record revealed E3 was hired as a caregiver in April 2023. 2. A review of E3's personnel record revealed a National CPR Foundation CPR/Automated External Defibrillator (AED)/First Aid training certification. The course was taken on August 4, 2022. 3. An online search of the National CPR Foundation revealed this is an online course. 4. A review of documentation titled, "Staffing Training" revealed .... 1. Training on the following topics is included during caregiver orientation training and ongoing in-services. ... 3. Training for CPR and First aid will be done by a certified trainer to give CPR instruction. (American Red Cross, American Heart Assoc, The National Safety Council, etc..). Staff will be required to submit a copy of their CPR and First aid card upon employment. Staff will be required to update the CPR and First aid card every 2 years or by the expiration date on the care". 5. In an interview, E8 reported not realizing E3's CPR certification was an online course, and a hands-on demonstration was not performed. E8 and E1 reported E3 will be taken off caregiver duties until current proof of CPR training is provided.

Based on observation, documentation review, and interview, the manager failed to ensure medication stored by the facility was in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During a tour of the facility the Compliance Officer observed in the medication closet stored with medications the following: - seven document boxes titled "Assisted Living Thinned Charts"; and - an unsecured oxygen tank in its upright position. 2. In an interview, E1 reported being unaware these documents were being stored in the medication closet and acknowledged that they were in the medication closet.