FIREBIRD ASSISTED LIVING #2

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of two residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R1's (accepted April 2023) medical record revealed documentation to include R1 did not require continuous medical services, continuous or intermittent nursing services, or restraints dated January 24, 2024. However, the documentation was not dated within 90 calendar days before the individual was accepted by the facility.

2. A review of R2's (accepted April 2022) medical record revealed documentation to include R2 did not require continuous medical services, continuous or intermittent nursing services, or restraints dated January 05, 2024. However, the documentation was not dated within 90 calendar days before the individual was accepted by the facility.

3. In an interview, E1 and E2 acknowledged R1's and R2's documentation was not submitted within 90 calendar days on or before the residents were accepted.

Based on documentation review, observation and interview, the manager failed to ensure 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 that provided access to an outside area from which a resident may exit to a location 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 the license issued by the Department revealed the facility was authorized to provide directed care services.

2. During the environmental tour, the Compliance Officer observed two ambulatory residents.

3. During the environmental tour, the Compliance Officer observed an open door leading to the back yard. The back yard did not allow residents to be at least 30 feet away from the facility. The door leading out to the back yard was not controlled or did not alert employees to the egress of a resident from the facility.

4. During the environmental tour, the Compliance Officer observed a gate in the back yard leading to the front yard. The gate was unlocked and was not equipped with a device that alerted caregivers of the egress of a resident.

5. In an interview, E1 and E2 acknowledged the facility did not have a means of exiting to an outside area that allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees to the egress of a resident from the facility.

Based on observation and interview, the manager failed to ensure a fire extinguisher was mounted in the assisted living home.

Findings include:

1. During the environmental tour, the Compliance Officer observed a fire extinguisher on a counter top near the front hallway. However, the fire extinguisher was not mounted.

2. In an interview, E1 and E2 acknowledged one of the fire extinguisher was not mounted.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. The deficient practice posed a health and safety risk to the residents if a fire extinguisher was needed and did not work properly.

Findings include:

1. During the environmental tour, the Compliance Officer observed the facility's rechargeable fire extinguisher on a counter top near the front hallway. A receipt was taped to the fire extinguisher indicating the fire extinguisher was purchased on April 25, 2023.

2. In an interview, E1 and E2 acknowledged the rechargeable fire extinguisher was not serviced at least once every 12 months.

Based on observation and interview, the manager failed to ensure the swimming pool on the premises of the assisted living facility was enclosed by a wall or fence with a self-closing, self-latching gate that was locked when the swimming pool was not in use. The deficient practice posed a risk to the physical health and safety of residents with access to the swimming pool.

Findings include:

1. A review of the license issued by the Department revealed the facility was authorized to provide directed care services.

2. During the environmental tour, the Compliance Officer observed two ambulatory residents.

3. During the environmental tour, the Compliance Officer observed a door leading to the back yard. The door leading out to the back yard was not controlled or alert employees to the egress of a resident from the facility.

4. During the environmental inspection, Compliance Officer observed that the pool gate was unsecured. The latch was unlocked, and the key remained in the keyhole.

5. In an interview, E1 and E2 acknowledged the swimming pool gate was unlocked.