Jane's Place

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedure manual revealed documentation indicating the policies and procedures were reviewed by the manager on January 29, 2021. However, there was no signature or date to verify that the manager had reviewed and updated the policies and procedures within the required three-year timeframe. 2. During an interview, E2 and O1 acknowledged E1 failed to ensure policies and procedures were reviewed and updated at least once every three years.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility, for two of three sampled residents. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1's medical record revealed a residency agreement. However, the residency agreement stated it was between R1 and a different assisted living facility, not " AL10372H_JANE'S PLACE." 2. A review of R3's medical record revealed a residency agreement. However, the residency agreement stated it was between R3 and a different assisted living facility, not " AL10372H_JANE'S PLACE." 3. In an interview, E2 and O1 acknowledged R1 and R3 did not have a residency agreement with this facility.

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 controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if facility staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed the door leading out to the backyard from bedroom 2. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. However, the door was not secured and the door chime was not functioning. 3. During the environmental tour, the Compliance Officer observed a door located in the kitchen leading to the back yard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. However, the door was not secured and the door chime was not functioning. 4. In an interview, E2 and O1 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.