Mary & Pete's Assisted Living

Based on record review and interview, the manager accepted and retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2). The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R2’s medical record revealed a current service plan for directed care services, which indicated R2 was bedbound. Further review of R2’s medical record revealed evidence of documentation indicating R2 was examined by a medical provider per R9-10-814(B)(2), was unavailable for review. 3. In an interview, E1 acknowledged R2 was non-ambulatory and was accepted into the facility in the same condition. E1 acknowledged R2’s medical record did not include the required determination per R9-10-814(B)(2). 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident that cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. The deficient practice posed a risk as the standards expected of employees in the policies and procedures were not followed. Findings include: 1. A review of the facility's policy and procedure manual revealed the manual was last reviewed on April 3, 2023. 2. A review of this manual revealed no documentation was available for review on covering methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. 3. In an interview, E1 and E2 acknowledged documentation was not available for review on covering methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide.

Based on record review, documentation review, observation, and interview, the manager of a facility providing directed care services failed to ensure a means of exiting the facility providing access to an outside area controls or alerts 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 the license issued by the Department revealed the facility was licensed to provide directed care services. 2. During the environmental inspection the Compliance Officer observed the patio door led into a courtyard. The patio door did not have any means to alert employees of a resident's egress. The Compliance Officer check a door located in a hallway on the left side of the facility. This door had an alarm at the top, however, the alarm was not in working order. The Compliance officer checked a door off the kitchen which entered onto the patio. This door did not alert employees of a resident's egress. 3. During an interview, E1, and E2 acknowledged the patio doors did not have any means to alert employees of a resident's egress.

Based on documentation review, observation, and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future. The deficient practice posed a direct health and safety risk to residents. Findings include: 1. A review of documentation provided by E1 revealed R1 had an incident on July 10, 2023, and July 11, 2023. The Compliance Officer observed the following was missing from the incident reports: - any action taken to prevent the incident from occurring in the future. 2. During an interview, E1, and E2 acknowledged R1's incident reports did not include documentation showing any action taken to prevent the incident from occurring in the future.