Wyns Garden Assisted Living LLC

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed a review date of November 11, 2020. No documentation of further review was available for Compliance Officer review. 2. In an interview, E1 acknowledged that the polices and procedures were not reviewed at least once every three years and updated as needed.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2) for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R1's service plan (dated March 9, 2024) revealed R1 received personal care services, and was confined to a bed or chair. 3. A review of R1's medical record revealed a determination for continued residency dated October 30, 2022. No further documentation was available for Compliance Officer review. 4. In an interview, E1 acknowledged R1's medical record did not include the required determination per R9-10-814(B)(2) updated at least once every six months.

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures (dated November 11, 2020) revealed documentation of the facility's disaster plan. However, no documentation of disaster plan reviews were available for Compliance Officer review. 2. In an interview, E1 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.

Based on documentation review and interview, the manager failed to ensure that 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 a disaster plan. Findings include: 1. A review of the facility's documents revealed no documentation of disaster drills conduced on each shift at least once every three months. 2. In an interview, E1 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on observation and interview, the manager failed to ensure that poisonous materials stored by the assisted living facility were maintained in labeled containers in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed bottles of the following toxic materials in an unlocked cabinet below the sink in the kitchen of the home, accessible to residents: - OdoBan Disinfectant spray; - Two bottles of Febreze Fabric Spray; and - Finish Jet-Dry Rinse Aide. The cabinet had a locking mechanism attached, but the lock was not secured while personnel were out of the kitchen. 2. In an interview, E1 acknowledged toxic materials stored by the facility were not maintained in labeled containers in a locked area inaccessible to residents.