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 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 located near the kitchen. 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 E2 acknowledged the medications were stored in an unlocked manager and accessible to residents.

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: 7 am-7 pm and 7 pm-7 am. 2. Review of the facility's documentation drills revealed documentation of a disaster drill conducted on April 8, 2024 during the 7 am-7 pm 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. A 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 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 within 24 hours after the resident was accepted by the facility. 2. In an interview, E1 and E2 acknowledged R2's medical record did not contain documentation to indicate R2 had received evacuation orientation to the exits from the facility.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a spray bottle of "Lysol All-Purpose Cleaner" and a container of "Clorox Disinfecting Wipes" in an unlocked cabinet in the bathroom used by residents. The Compliance Officer also observed a spray bottle of "Great Value Multi-Purpose Cleaner", a spray can of "Great Value Disinfectant Spray", and "Fabuloso Original Multi-Purpose Cleaner" in an unlocked cabinet under the kitchen sink. 2. In an interview, E1 and E2 acknowledged the aforementioned positionous or toxic materials were not stored in a locked location and inaccessible to residents.