Mayfair Eden Homes INC

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for one of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1) Review of E4's personnel record revealed E4 worked as a caregiver and had a hire date of May 11, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 2) Review of E5's personnel record revealed E5 worked as a caregiver and had a hire date of May 11, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3) Review of E6's personnel record revealed E6 worked as a caregiver and had a hire date of March 25, 2024. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 4) In an interview, E1 and E3 acknowledged documentation was not available that showed E4, E5, and E6 had completed training and education related to recognizing the signs and symptoms of TB.

Based on documentation review and interview, the manager failed to implement the facility's quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1) Review of the facility's policies and procedures revealed a policy titled "Quality Management". The policy stated "...A manager shall ensure that personnel shall make appropriate and complete documentation in a timely manner for all resident services and accidents...on the Quality Management Summary Report Form...A documented report is submitted annually by the manager to the governing authority...". 2) Review of facility documentation revealed no documentation of a quality management report. 3) During an interview, E1 and E3 acknowledged a quality management report was not available for review.

Based on record review and interview, the manager failed to ensure a written service plan was available, for one of three residents sampled. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive. Findings include: 1) Review of R2's medical record revealed no documentation of a written service plan. Based on R2's date of acceptance, a service plan was required. 2) In an interview, E1 and E3 acknowledged R2's medical record did not contain a service plan.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services, for one of three residents sampled. The deficient practice posed a risk if a resident's service plan was not updated as required to reinforce and clarify services, and a caregiver was not aware of the services to be provided for a resident. Findings include: 1) Review of R3's medical record revealed a service plan for personal care services dated November 30, 2024. However, an updated service plan after November 30, 2024 was not available for review. 2) In an interview, E1 and E3 acknowledged R3's medical record did not include a service plan updated at least once every six months.

Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication. Findings Include: 1) During the environmental tour of the facility, the Compliance Officer observed a medication cabinet. The cabinet was equipped with a locking mechanism, however, the cabinet was not locked at the time of inspection. 2) In observation, the caregivers were not accessing the medications at the time of arrival. 3) In an interview, E1 and E3 acknowledged the medications were stored in an unlocked manager and accessible to residents.

Based on documentation review and interview, the manager failed to ensure that 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) The Compliance Officer requested the disaster drills conducted for the last 12 months. 2) Review of facility documentation revealed no disaster drills conducted within the last 12 months. 3) In an interview, E1 and E3 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if personnel members were unable to safely evacuate residents in an emergency situation. Findings include: 1) The Compliance Officer requested the evacuation drills conducted for the last 12 months. 2) Review of facility documentation revealed no evacuation drills conducted within the last 12 months. 3) In an interview, E1 and E3 acknowledged an evacuation drill for employees and residents was not conducted at least once every six months and documented as required.

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, for one of three residents sampled. 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 R2's medical record revealed no documentation indicating R2 received orientation to exits from the facility and the route to be used when evacuating the facility. Based on R2's date of acceptance, this documentation was required. 2) In an interview, E1 and E3 acknowledged R2's medical record did not contain documentation to indicate R2 had received evacuation orientation to the exits from the facility.