Xanadu Assisted Living Residence

12.2.2 Infection Control Officer (B) Each facility shall assign at least one (1) staff member responsible for the site ma.. A relicensure survey was completed on 1/22/25. Deficiencies were cited. ased on record review and interview, the residence failed to have an involuntary discharge grievance policy that com.. Based on observation and interview, the residence failed to ensure designated outdoor smoking areas had fire-resistant waste disposal containers, affecting eight current residents. Findings include:On 1/21/25 at 7:19 a.m., .. Based on observation and interview, the residence failed to have a locked refrigerator to store medications unattend.. Based on observation and interview, the residence failed to maintain a physically safe and sanitary environment to reduce the risk of potential hazards affecting eight current residents.Findings include:On 1/21 and 1/22/25 during th.. Based on observation, record review, and interview, the residence failed to have a readily available roster of current.. Based on observation, record review, and interview, the residence failed to have documentation indicating evidence that staff (#1 and owner) successfully completed an accredited food safety course, affecting eight current residents. .. Based on record review and interview, the residence failed to complete a risk assessment of all hazards and prepare.. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associate.. Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting eight current residents.Findings include:The .. Based on record review and interview, the residence failed to ensure personnel files included a description of the em.. Based on record review and interview, the residence failed to have one staff member onsite at all times who has current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally reco.. Based on record review and interview, the residence failed to have policies and procedures to ensure the continuatio.. Based on record review and interview, the residence failed to implement a policy and procedure for an effective information management system that allowed effective continuity of care which included a method of integration for.. Based on record review and interview, the residence failed to meet the required elements and have written policies .. Based on record review and interview, the residence failed to, on a quarterly basis, audit the accuracy and completeness of the medication administration records list, controlled substance list, medication error reports and .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The re..

A recertification survey was completed on 1/22/25. Deficiencies were cited. Based on observation, record review and interview, the facility (residence) failed to develop written policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency including, but not limited to, a long-term power failure; and failed to provide reading material in the common areas at all times, reflecting the interests, hobbies, and requests of the members, affecting eight current members (residents).Findings include:1. 72 Hour PolicyOn 1/21/25 at 9:00 a.m., a 72-hour continuation of care policy and procedure was requested; however, it was not provided.On 1/22/25 at 11:57 a.m., the administrator stated he was unaware of the requirement for the residence to have a policy to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency and needed to create one.On 1/22/25 at 11:57 a.m., the owner stated that she was unaware of the requirement to have a policy to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency.2. Reading materials in the common area that reflect the interests and hobbies.During an onsite visit from 1/21 to 1/22/25, the residence had no reading material reflecting the interests and hobbies of the members in the common areas at all times.On 1/22/25 a.. Based on record review and interview, the facility (residence) failed to review medications quarterly to determine medications are taken correctly for members (residents) who are independent in the administration of medications and who do not require monitoring each time medication is taken affecting three of three sample members (residents) (#1-#3).Findings include:1. Record ReviewOn 1/21/25, documentation of the residence' s last two quarterly medication audits was requested but not provided.2. InterviewsOn 1/21/25 at 4:42 p.m., the administrator reported an external service provider completed the residence' s medication audits.On 1/22/25 at 12:26 p.m., the administrator reported he reviewed medication orders and the medication administration record (MAR) for each resident, however, he did not document this.On 1/22/25 at 12:27 p.m., the owner reported they did not document medication audits due to lack of oversight and expected this to be completed.