The Groves Assisted Living Place Llc-Peach

Based on observation and interview, the manager failed to ensure frozen foods were stored at 0° F or below. Findings include: 1. During a facility tour, the Compliance Officer observed a chest style deep freezer in a hallway connected to the kitchen. The Compliance Officer observed the freezer was full of raw meat. The Compliance Officer observed two beef roasts were not frozen. The Compliance Officer observed two thermometers in the freezer, however, on thermometer read 30° F and a second thermometer read 24° F. 2. In an interview, E3 reported the two roasts were put in the freezer the previous day and might not be fully frozen yet. E3 placed a third thermometer in the freezer. 3. Approximately 2 hours later, the Compliance Officer observed the freezer thermometer read 20° F. 4. During a facility tour, the Compliance Officer observed a storage room connected to the hallway containing the deep freezer. The storage room contained two freezers and shelving for food storage. The Compliance Officer observed five frozen turkeys and one ham, stored at room temperature in the storage room. 5. The Compliance Officer observed staff filling large containers with cold water to place the frozen meat into during the on-site inspection. 6. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for one of one resident reviewed who had an incident resulting in the resident needing medical services. Findings include: 1. A review of R2's medical record revealed a progress note, dated, May 1, 2022, which stated, "[R2] was sent to the hospital because [R2] was shaking a lot. [R2] looked very strange, [R2] was reported to [E1], came back by 4:30-5 PM. 2. A review of R2's medical record revealed documentation of the immediate notification of R2's emergency contact and primary care provider on May 1, 2022 was not available for review. 3. A review of R2's medical record revealed an incident report, dated April 24, 2023 at 9 PM. The incident report documented stated 911 was called after R2 fell. The incident report documented the immediate notification of R2's emergency contact. However, documentation of the immediate notification of R2's primary care provider was not available for review. 4. In an interview, E1 acknowledged documentation of the immediate notification of R2's emergency contact and primary care provider on May 1, 2022 and April 24, 2023, were not available for review.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a 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 risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officer observed a door located in the dining room leading to the back yard of the facility. The door was equipped with a door alarm; however, the alarm did not sound when the door was opened. The Compliance Officer observed door alarm had been turned off. 3. During an environmental inspection of the facility, the Compliance Officer observed a door located in the kitchen leading to a storage room. The door was equipped with a door alarm; however, the alarm did not sound when the door was opened. The Compliance Officer observed door alarm had been turned off. The storage room had a sliding glass door leading outside the facility, however the sliding glass door did not have an alarm. 4. During an environmental inspection of the facility, the Compliance Officer observed a door located in the north hallway between a resident room and the laundry room, leading to the back yard of the facility. The door was equipped with a door alarm; however, the alarm did not sound when the door was opened. The Compliance Officer observed door alarm had been turned off. 5. In an interview, E1 acknowledged a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility did not control or alert employees of the egress of a resident from the facility. E1 immediately asked the staff to turn on the door alarms and ensured they were functioning.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers in a locked area and inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed an unsecured and unlocked bottle of a purple liquid on a cabinet in a resident's bedroom. The bottle did not have a label. 2. During an environmental inspection of the facility, the Compliance Officer observed a shed in the backyard of the facility, in an area accessible to residents. The shed did not have a door. Inside the shed, the Compliance officer observed four, five-gallon buckets of, "Kilz 2, All purpose interior / exterior primer." 3. In an interview, E1 acknowledged poisonous or toxic materials had not been maintained in labeled containers in a locked area and inaccessible to residents.