Mayfair Eden Homes INC

Based on documentation review and interview, the manager failed to ensure that a documented report was submitted to the governing authority that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer requested the facility's quality management documentation. However, no documentation was provided for Compliance Officer review. 2. In an interview, E1 and E2 acknowledged the facility's quality management report was not provided for Compliance Officer review.

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 which included the requirements in R9-10-807(D)(1-10) for one of two residents sampled. 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 no documented residency agreement dated before or at the time of R1's acceptance into the facility. 2. In an interview, E1 and E2 acknowledged there was no documented residency agreement dated before or at the time of R1's acceptance into the facility at the time of the inspection.

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 the disaster plan. Findings include: 1. In an interview, E1 reported the facility had two shifts: 7am-7pm and 7pm-7am. 2. Review of the facility's documentation drills revealed documentation of a disaster drill conducted on April 3, 2024 during the 7pm-7am shift. However, no additional documentation of completed disaster drills was available for review. 3. In an interview, E1 and E2 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 documentation of evacuation drills conducted within the last 12 months. 3. In an interview, E1 and E2 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 two resident records reviewed. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. A review of R1's medical record revealed there was no documentation indicating R1 received orientation to exits from the facility and the route to be used when evacuating the facility within 24 hours after the resident was accepted by the facility. 2. In an interview, E1 and E2 acknowledged R1's medical record did not contain documentation to indicate R1 had received evacuation orientation to the exits from the facility.

Based on observation, interview, and record review, the manager failed to ensure the premises were 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 the resident. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed R1's bed with a full bedrail on one side of the bed. The other side of the bed was pushed up against the wall. 2. In an interview, E2 reported the bedrails were placed in the upright position to prevent R1 from falling out of the bed. 3. A review of R1's medical record revealed a service plan for directed care services dated March 1, 2025. This service plan stated R1 was "Bed Bound" and unable to ambulate even with assistance. 4. In an interview, E1 and E2 reported R1 did not get out of bed at all, could not move the rails up or down, and could not move around them and acknowledged the situation may cause the resident to suffer physical injury.