Vitality Assisted Living, LLC

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to include whether the individual required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. Findings include: 1. A review of R1's (admitted in 2023) medical record revealed a document titled "Determination form to identify if resident is appropriate for assisted living services based on upon the facility's scope of services." However, the document was dated seven calendar days after R1's admission. 2. In an interview, E1 acknowledged the above mentioned document was not completed within 90 calendar days before R1 was accepted.

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated no later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition, for one of two residents sampled. Findings include: 1. The compliance officer observed a gentleman walking R2 around the facility. When asked who the staff person was, E2 reported it was a person from a home health agency who comes twice a week for physical therapy. 2. A review of R2's medical record revealed a service plan for personal care services (dated in May 2023). However, the service plan did not include the physical therapy twice a week from home health. 3. In an interview, E1 reported R2 started PT on August 29, 2023. E1 acknowledged R2's service plan was not updated within 14 calendar days after a significant change.

Based on observation and interview, the manager failed to ensure 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 a resident. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed Clorox, fabric softener, bleach and All laundry detergent unlocked in the laundry room. The laundry room door had a door handle with a broken keyed locking device as the metal locking mechanism was gone. 2. In an interview, E2 reported the lock had been broken for about a week. E1 and E2 acknowledged toxic materials were stored unlocked.