Legacy Assisted Living LLC

Based on observation, record review, and interview, the manager failed to ensure a resident was not subjected to seclusion. The deficient practice posed a risk if a resident or other individual could be locked in a bedroom. Findings include: R9-10-101(205) "Seclusion" means the involuntary solitary confinement of a patient in a room or an area where the patient is prevented from leaving. 1. The Compliance Officers observed the lock on R1's bedroom door handle was facing into the common area and not facing into R1's bedroom. 2. The Compliance Officers observed the lock on the caregiver bedroom door handle was facing into the common area and not facing into the caregiver bedroom. 3. The Compliance Officers observed all remaining bedroom door handle locks were facing into resident bedrooms. 4. A review of R1's (accepted in 2024) medical record revealed a service plan for personal care services (dated in March 2024). 5. In an interview, E3 reported R1's door was always open. 6. In an interview, R1 reported R1 has been locked in R1's bedroom approximately one to two times. R1 reported R1 knocks on R1's bedroom door and a caregiver will open the door. R1 reported R1 did not know who locked R1's bedroom door. 7. In a telephonic interview, conducted on March 21, 2024, E1 reported the lock on R1's bedroom door handle was always facing into the common area and not facing into R1's bedroom when R1 purchased the assisted living facility. E1 reported R1's door was always open. 8. In a telephonic interview, conducted on March 21, 2024, E1 acknowledged the lock on R1's bedroom door handle was facing into the common area and not facing into R1's bedroom.

Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents if the caregiver was locked inside the bedroom. Findings include: 1. The Compliance Officers observed the lock on the caregiver bedroom door handle was facing into the common area and not facing into the caregiver bedroom. 2. The Compliance Officers observed the keys to the caregiver bedroom were not located inside the caregiver bedroom. The Compliance Officers observed E2 retrieve the keys and attempted to open the door from the inside. The Compliance Officers observed it took approximately thirty (30) seconds for E2 the unlock the caregiver bedroom door. 3. In an interview, E3 reported the caregiver bedroom door was always open. 4. In a telephonic interview, conducted on March 21, 2024, E1 reported the lock on the caregiver bedroom door handle was always facing into the common area and not facing into the caregiver bedroom when E1 purchased the assisted living facility. E1 reported the caregiver bedroom door was always open. 5. In a telephonic interview, conducted on March 21, 2024, E1 reported a caregiver was always awake during the night. 6. In a telephonic interview, conducted on March 21, 2024, E1 acknowledged the premises was not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount of assisted living services being provided to the resident, for two of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services (dated in March 2024). The service plan stated the following: -"Hair Care Requires assistance Daily and as needed;" -"Dressing Requires assistance Daily and as needed;" and -"Bathing Requires assistance Twice weekly and as needed." However, the service plan did not include the amount of this assisted living service being provided to R1. 2. A review of R2's medical record revealed a service plan for personal care services (dated in November 2023). The service plan stated the following: -"Oral Care Requires total care Daily and as needed;" -"Hair Care Requires total care Daily and as needed;" and -"Dressing Requires total care Daily and as needed." However, the service plan did not include the amount of this assisted living service being provided to R2. 3. In a telephonic interview, conducted on March 21, 2024, E1 acknowledged the amount of assisted living services being provided to R1 and R2 was not included on R1's and R2's service plans.

Based on observation, record review, and interview, the manager failed to ensure a resident was not subjected to restraints. The deficient practice posed a potential for psychological distress and physical injury. Findings include: R9-10-101(201) "Restraint" means any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body. R9-10-807(C)(5) A manager shall not accept or retain an individual if the individual requires restraints, including the use of bedrails. 1. The Compliance Officers observed R2's bed was against a wall and had bedrails on both sides of the bed. The Compliance Officers observed R2 was laying in bed. 2. A review of R2's (accepted in 2022) medical record revealed a service plan for personal care services dated November 2023. The service plan stated " ... Bed Ridden, Wheel Chair, Chair Ridden, Hoyer Lift, Needs Supervision" and " ... Assistive Devices ... Fall Pad ... bed cane." 3. A review of R2's medical record revealed documentation in compliance with the requirements in R9-10-814(B) (dated January 12, 2024). 4. A review of R2's medical record revealed a document titled "Initial Physician Recommendation Form" (dated July 7, 2022) and signed by a physician. The document stated " ... Please check ones that apply: ... does not require restraints" with an "x" marking "does not require restraints." 5. A review of R2's medical record revealed a document titled "Initial Physician Recommendation Form" (dated July 29, 2022) and signed by a registered nurse practitioner. The document stated " ... Please check ones that apply: ... does not require restraints" with an "x" marking "does not require restraints." The "not" was crossed out. 6. In an interview, E2 reported the bedrail was to prevent R2 from falling out of bed. 7. In an interview, E3 reported the bedrail was to prevent R2 from falling out of bed. 8. In a telephonic interview, conducted on March 21, 2024, E1 reported the bedrail was a bed cane. E1 reported hospice may have changed the bed cane to a bedrail. 9. In a telephonic interview, conducted on March 21, 2024, E1 acknowledged R2's bed contained a bedrail and the bedrail was used as a restraint.