Portobello Assisted Living Home LLC

Based on documentation review and interview, the manager failed to ensure that policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. A review of the facility's policies and procedures revealed policies on medication administration. However, documentation of a review by a medical practitioner, registered nurse, or pharmacist was not available. 2. In an interview, E2 reported the signature of approval was misplaced when updating the facility's policies. E2 acknowledged that policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse or pharmacist.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed debris and a trailer that blocked the evacuation pathway. 2 . During an environmental inspection of the facility, the Compliance Officers observed ambulatory residents in the facility. 3 . In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a health and safety risk if the facility was not aware of the general or specific whereabouts of a resident. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. During a tour of the facility, the Compliance Officer observed when exiting through the patio door to the back yard, no alarm sounded to alert employees of the egress of a resident from the facility. The patio door provided access to an area which allowed the residents to be at least 30 feet away from the facility. 3. In an interview, E2 acknowledged a resident could exit the facility without a key, special knowledge for egress, or the ability to expend increased physical effort through the patio door to the backyard. E2 reported there was an alarm on the patio door but it was only used during nighttime hours as a staff member was always present and aware of the residents' whereabouts. E2 reported staff were the means to control the egress of a resident from the facility when the alarm was turned off.