Deficiency #1
Rule/Regulation Violated:
R9-10-804.2.a-b. Quality Management<br> A manager shall ensure that:<br> 2. A documented report is submitted to the governing authority that includes: <br> a. An identification of each concern about the delivery of services related to resident care, and <br> b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care;
Evidence/Findings:
<p>Based on documentation review and interview, the manager failed to ensure that a documented report was submitted to the governing authority that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. </p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. While on-site for the compliance inspection, the Compliance Officer requested the facility's quality management documentation. However, no documentation was provided for Compliance Officer review.</p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 and E2 acknowledged the facility's quality management report was not provided for Compliance Officer review. </p>
Permanent Solution:
Every quarter (3 months) a report will be submitted to the manager identifying how many incidents, falls, 911 called, wounds, infections, med-errors, refusal of care, etc. happened during the quarter. Also what action plan will be developed to improve the quality of care in the home.
Person Responsible:
Madelyn Macasinag - Manager
Deficiency #2
Rule/Regulation Violated:
R9-10-816.F.1. Medication Services<br> F. When medication is stored by an assisted living facility, a manager shall ensure that: <br> 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;
Evidence/Findings:
<p>Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication.</p><p><br></p><p><br></p><p>Findings Include:</p><p><br></p><p><br></p><p>1. During the environmental tour of the facility, the Compliance Officer observed a medication cabinet located near the kitchen. The cabinet was equipped with a locking mechanism, however, the cabinet was not locked at the time of inspection.</p><p><br></p><p><br></p><p>2. In observation, the caregivers were not accessing the medications at the time of arrival.</p><p><br></p><p><br></p><p>3. In an interview, E1 and E2 acknowledged the medications were stored in an unlocked manager and accessible to residents.</p>
Temporary Solution:
Immediately lock the medication cabinet and remind caregivers that they need to make sure the med cart is locked at all times.
Permanent Solution:
Remind caregivers the seriousness of leaving the med cart unlocked and the risk to the safety of the residents. Make sure the key is on their wrist or around their neck. Also create a sign that reminds caregivers to lock after use and keep it lock after opening.
Person Responsible:
Madelyn Macasinag - Manager
Deficiency #3
Rule/Regulation Violated:
R9-10-818.A.4. Emergency and Safety Standards<br> A. A manager shall ensure that: <br> 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;
Evidence/Findings:
<p>Based on documentation review and interview, the manager failed to ensure 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 the disaster plan.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. In an interview, E1 reported the facility had two shifts: 7 am-7 pm and 7 pm-7 am. </p><p><br></p><p><br></p><p>2. Review of the facility's documentation drills revealed documentation of a disaster drill conducted on April 8, 2024 during the 7 am-7 pm shift. However, no additional documentation of completed disaster drills was available for review. </p><p><br></p><p><br></p><p>3. In an interview, E1 and E2 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented. </p>
Temporary Solution:
Found the binder where the employee disaster drills was documented.
Permanent Solution:
Continue to do the employee disaster drills every 3 months and document in the binder. Another solution can be to scan the paperwork right away in order to have access from anywhere from the software instead of a binder being misplaced.
Person Responsible:
Madelyn Macasinag - Manager
Deficiency #4
Rule/Regulation Violated:
R9-10-818.A.5.a-b. Emergency and Safety Standards<br> A. A manager shall ensure that<br> 5. An evacuation drill for employees and residents: <br> a. Is conducted at least once every six months; and <br> b. Includes all individuals on the premises except for: <br> i. A resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident, and <br> ii. Sufficient caregivers to ensure the health and safety of residents not evacuated according to subsection (A)(5)(b)(i);
Evidence/Findings:
<p>Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if personnel members were unable to safely evacuate residents in an emergency situation.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. The Compliance Officer requested the evacuation drills conducted for the last 12 months.</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed no documentation of evacuation drills conducted within the last 12 months.</p><p><br></p><p><br></p><p>3. In an interview, E1 and E2 acknowledged an evacuation drill for employees and residents was not conducted at least once every six months and documented as required. </p>
Temporary Solution:
Found the binder with documentation of the disasters and the evacuation drills.
Permanent Solution:
Make sure the documentation of the disasters drills are accessible and done every 6 months. Scan the paperwork in order to have access to it when asked instead of looking for a binder. It is best to have access in person and remotely.
Person Responsible:
Madelyn Macasinag - Manager
Deficiency #5
Rule/Regulation Violated:
R9-10-818.B.1-2. Emergency and Safety Standards<br> B. A manager shall ensure that: <br> 1. A resident receives orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident's acceptance by the assisted living facility,<br> 2. The resident's orientation is documented.
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility, for one of two resident records reviewed. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R2's medical record revealed no documentation indicating R2 received orientation to exits from the facility and the route to be used when evacuating the facility within 24 hours after the resident was accepted by the facility.</p><p><br></p><p><br></p><p>2. In an interview, E1 and E2 acknowledged R2's medical record did not contain documentation to indicate R2 had received evacuation orientation to the exits from the facility.</p>
Temporary Solution:
Meet with resident representative of R2 to have a re-orientation to the exits of the facility and the route to be used when evacuating. Representative signed documentation.
Permanent Solution:
Add orientation to exits and evacuation documentation into the move in packet to make sure family received orientation within 24 hours of admission.
Person Responsible:
Madelyn Macasinag - Manager
Deficiency #6
Rule/Regulation Violated:
R9-10-819.A.11. Environmental Standards<br> A. A manager shall ensure that: <br> 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;
Evidence/Findings:
<p>Based on observation and interview, the manager failed to ensure poisonous or 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 residents with access to the materials. </p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. During the environmental inspection of the facility, the Compliance Officer observed a spray bottle of "Lysol All-Purpose Cleaner" and a container of "Clorox Disinfecting Wipes" in an unlocked cabinet in the bathroom used by residents. The Compliance Officer also observed a spray bottle of "Great Value Multi-Purpose Cleaner", a spray can of "Great Value Disinfectant Spray", and "Fabuloso Original Multi-Purpose Cleaner" in an unlocked cabinet under the kitchen sink.</p><p><br></p><p><br></p><p>2. In an interview, E1 and E2 acknowledged the aforementioned positionous or toxic materials were not stored in a locked location and inaccessible to residents.</p>
Temporary Solution:
We immediately remove the spray bottle of cleaner and of disinfectant spray that was in an unlocked cabinet under the kitchen sink and in the bathroom and placed it in the locked laundry room which is inaccessible to residents.
Permanent Solution:
Remind caregivers that all poisonous or toxic materials need to be stored in a locked area and inaccessible to residents no matter what. Buy new locks to put in cabinets under the kitchen and bathroom sink in order to make it inaccessible to any resident.
Person Responsible:
Madelyn Macasinag - Manager
Summary:
The following deficiencies were found during the on-site compliance inspection conducted on May 21, 2025: