Mount Zion Assisted Living Home LLC

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility with E3, the Compliance Officers observed a medication closet that contained one resident's medications, which was unlocked. The medication closet doors were equipped with locking devices, however, were not locked. 2. In an interview, E2 acknowledged a medication closet where medication is stored was unlocked and accessible to residents.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed the following materials stored in an unlocked laundry room; - Kirkland Laundry Detergent - Glidden Gallon of paint - Autozone Brake Fluid 2. In an interview, E2 acknowledged the aforementioned poisonous or toxic materials were not maintained in a locked area and were 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. Findings include: 1. Review of the facility's work schedule revealed the facility has two shifts per day, the day shift was 6 am to 6 pm and the night shift was 6 pm to 6 am. 2. Review of facility disaster drills provided to the surveyor revealed drills for the previous twelve months were conducted on: January 12, 2022 June 22, 2022 January 29, 2023 at 3:30 pm 3. In an interview, E1 acknowledged the disaster drills provided were all of the drills for the facility. E1 reported E1 confused disaster drills and evacuation drills. E1 acknowledged the facilities drills documentation provided to the Department did not reveal disaster drills were documented for each shift at least once every three months. This is a repeat deficiency from the compliance inspection conducted on January 25, 2022.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in the areas of a facility used by residents. Findings include: 1. During the facility tour with E1, the surveyor observed the water temperature at 77 \'b0 F in a resident shared bathroom. 2. In an interview, E1 reported the hot water needed repair. E1 acknowledged the resident shared bathroom temperature was not maintained between 95\'b0 F and 120\'b0 F in the area of a facility used by residents.

Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. Findings include: 1. The surveyor observed a hallway bathroom accessible from a common area the bathroom hot water pipe was not functional. The compliance officer observed the hot water valve did not produce any water when turned on. 2. In an interview, E1 reported the hot water pipe was in need of repair and was not working. E1 acknowledged the manager failed to ensure equipment used at the assisted living facility was maintained in working order.