Mayfair Eden Homes INC

Based on documentation review and interview, the manager failed to submit a documented report 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. A review of the facility's policies and procedures revealed a policy titled "Quality Management" reviewed in May 2023. The policy stated "...A documented report is submitted that includes an identification of each concern about the delivery of services related to resident care, any change made or action taken as a result...of the concern...the report...are maintained for 12 months after the date the report is submitted..." 2. A 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 resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of three residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2’s acceptance date, this documentation was required. 2. In an interview, E1 acknowledged R2's medical record did not contain documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on observation, documentation review, and interview, the manager failed to ensure the assisted living facility's license was conspicuously posted. Findings include: 1. In an on-site complaint investigation, the Compliance Officer observed the only license posted in the facility was the license of the previous facility, AL10787 Eden Adult Care Facility, Inc. 2. A review of Department documentation revealed AL10787 closed on May 11, 2023. 3. In an interview, E1 acknowledged the facility's current license was not posted. 4. In an on-site follow up visit conducted August 3, 2023, the compliance officer observed the current license was not posted.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included the the requirements in subsection C for one of three employees sampled. The deficient practice posed a risk as required information could not be verified for O1. Findings include: 1. Upon arrival to the facility, the compliance officer was greeted and invited into the facility by O1. 2. A review of facility documentation revealed a policy and procedure titled, "Personnel Records." Under the title, "Policy Statement," the document stated, "The manager shall ensure that a personnel record for each personnel or volunteer is initiated upon hire and maintained throughout the personnel or volunteer's period of providing services in or for Mayfair Eden and for at least 24 months after the last date the personnel or volunteer provided services in or for the Assisted Living Facility." 3. Further review of facility documentation revealed under the title, "Procedure" the procedure stated, "A personnel record for each personnel or volunteer includes: -The individual's name, date of birth, contact telephone number. -The starting date of service and, if applicable, the ending date. -Documentation of the individual's experience and qualifications, including skills, and knowledge applicable to the individual's job duties. -Documentation of the individual's education that may include a copy of their license or certification, if required according to R9-10-806 Personnel or this Policy and Procedure. -Documentation of the individual's completed orientation and as needed in-service education required by Policies and Procedures. -Documentation of evidence of freedom from infectious tuberculosis, if required for the position. -Documentation of cardiopulmonary resuscitation training, if required for the position. -Documentation of first aid training, if required for the position. -Documentation of fingerprint compliance, if required for the position." 4. The Compliance Officer requested all personnel records. However, O1's personnel record was not made available for review. 5. In an interview, E2 reported O1 was on a "trial period" and did not have a personnel record to review. 6. In an interview, E2 acknowledged O1 did not have a personnel record available for review.

Based on observation, interview, and record review, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a risk to the health and safety of R3. Findings include: 1. During a tour of the facility, the Compliance Officer observed both sides of R3's bed had full bed rails. 2. In an interview, E2 reported R3 was non-ambulatory and the bed rails were in place to prevent R3 from falling out of bed. E2 stated R3 had an order from a medical practitioner for the bed rails. 3. A review of R3's medical record revealed an order dated June 15, 2023. The order stated, "[R3] will require the use of a bed rail at all times in bed." 4. In an interview, E2 reported thinking the bed rails were acceptable if they were ordered by a medical practitioner. 5. In an on-site follow up visit conducted August 3, 2023, E2 revealed the bed rails had not been removed. E2 reported the facility manager and R3's family had been informed that the bed rails needed to be removed. However, they had not been removed yet.

Based on documentation review and interview, the manager failed to ensure the facility's policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 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 policies and procedures for medication administration revealed no indication the policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 2. In an interview, E2 acknowledged the facility's policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed an incident report dated July 4, 2023. The report indicated that on July 4, 2023, "[R1] was mistakenly given medication for nausea (Meclizine/Bonine) that was thought to be in [R1's] medication list." 3. A review of R1's medical record revealed a signed medication list, dated January 17, 2023, which included the following medications: -Levothyroxine 100 micrograms (mcg); -Isosorbide Mononit ER 30 milligrams (mg); -Clopidogrel 75 mg; -Losartan Potassium 25 mg; and -Ezetimibe 10 mg. However, R1's medical record revealed there was no medication order for Meclizine/Bonine. 4. In an interview, E2 acknowledged that E2 administered a medication to R1 without a medication order.