GIFTS OF GRACE ASSISTED LIVING HOMES II

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of two residents reviewed.

Findings include:

1. Review of R2's record revealed a residency agreement. However, this residency agreement did not include the signature of the manager and date signed. Based on R2's acceptance date, this document was required to be signed.

2. During an interview, E1 acknowledged R2's residency agreement did not include the signature of the manager and date signed.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, 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 documentation revealed the facility was authorized to provide directed care services.

2. During the facility tour with E1, the Compliance Officer observed the door leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not work.

3. In an interview, E1 reported the alarm does work, but the device was switched off.

4. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on observation and interview, the manager failed to ensure a current drug reference guide was available for use by personnel members.

Findings include:

1. The Compliance Officer observed the facility's drug reference guide was the "2020 Lippincott Pocket Drug Guide for Nurses".

2. A review of the publisher's website revealed the "2024 Lippincott Pocket Drug Guide for Nurses" was the most recent edition.

3. In an interview, E1 acknowledged that a current drug reference guide was not available for use by personnel members.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication.

Findings include:

1. During the facility tour with E1, the Compliance Officer observed medication cups filled with multiple medications in a unlocked kitchen drawer.

2. In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on observation, documentation review, and interview, the manager failed to ensure toxic material stored by the facility was 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 the facility tour, the Compliance Officer observed a can of "Tuff Stuff multi-purpose foam cleaner" in an unlocked garage.

2. A review of facility documentation revealed a policy titled "Safety of the Facility and Grounds" which stated "Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas."

3. In an interview, E1 reported that the garage was normally locked. E1 acknowledged toxic material stored by the facility was not stored in a locked area and inaccessible to residents.

Based on observation, documentation review, and interview, the manager failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored 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. During the facility tour, the Compliance Officer observed 4 cans of "Red butane gas" in an unlocked garage attached to the facility building.

2. A review of facility documentation revealed a policy titled "Safety of the Facility and Grounds" which stated "Combustible, flammable and other hazardous materials will be stored in safety approved containers outside the facility in a locked secure area that is inaccessible to residents."

3. In an interview, E1 reported that the garage was normally locked. E1 acknowledged combustible or flammable liquids stored by the assisted living facility were not stored in a locked area inaccessible to residents.