MAYFAIR EDEN HOMES INC

INSP-0134004

Complete

Date: 6/18/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-06-20

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on June 18, 2025:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

R9-10-113.A.1-2. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for one of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1) Review of E4's personnel record revealed E4 worked as a caregiver and had a hire date of May 11, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 2) Review of E5's personnel record revealed E5 worked as a caregiver and had a hire date of May 11, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3) Review of E6's personnel record revealed E6 worked as a caregiver and had a hire date of March 25, 2024. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 4) In an interview, E1 and E3 acknowledged documentation was not available that showed E4, E5, and E6 had completed training and education related to recognizing the signs and symptoms of TB.

Temporary Solution:

Upload the TB training certificates

Permanent Solution:

Make sure the certificates for TB training is available and uploaded to the electronic system.

Person Responsible:

Wanessi Haley - Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-804.1.a-e. Quality Management A manager shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents; b. A method to collect data to evaluate services provided to residents; c. A method to evaluate the data collected to identify a concern about the delivery of services related to resident care; d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and e. The frequency of submitting a documented report required in subsection (2) to the governing authority;

Evidence/Findings:

Based on documentation review and interview, the manager failed to implement the facility's quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1) Review of the facility's policies and procedures revealed a policy titled "Quality Management". The policy stated "...A manager shall ensure that personnel shall make appropriate and complete documentation in a timely manner for all resident services and accidents...on the Quality Management Summary Report Form...A documented report is submitted annually by the manager to the governing authority...". 2) Review of facility documentation revealed no documentation of a quality management report. 3) During an interview, E1 and E3 acknowledged a quality management report was not available for review.

Temporary Solution:

Create a report immediately by reviewing the incident reports, and progress notes.

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:

Wanessi Haley - Manager

Deficiency #3

Rule/Regulation Violated:

R9-10-808.A.1-5. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 1. Is completed no later than 14 calendar days after the resident's date of acceptance; 2. Is developed with assistance and review from: a. The resident or resident's representative, b. The manager, and c. Any individual requested by the resident or the resident's representative; 3. Includes the following: a. A description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; b. The level of service the resident is expected to receive; c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication; d. For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner; e. For a resident who requires behavioral care: i. Any of the following that is necessary to provide assistance with the resident's psychosocial interactions to manage the resident's behavior: (1) The psychosocial interactions or behaviors for which the resident requires assistance, (2) Psychotropic medications ordered for the resident, (3) Planned strategies and actions for changing the resident's psychosocial interactions or behaviors, and (4) Goals for changes in the resident's psychosocial interactions or behaviors; and ii. Review by a medical practitioner or behavioral health professional; and f. For a resident who will be storing medication in the resident's bedroom or residential unit, how the medication will be stored and controlled; 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): a. No later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition; and b. As follows: i. At least once every 12 months for a resident receiving supervisory care services, ii. At least once every six months for a resident receiving personal care services, and iii. At least once every three months for a resident receiving directed care services; and 5. When initially developed and when updated, is signed and dated by: a. The resident or resident's representative; b. The manager; c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan was available, for one of three residents sampled. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive. Findings include: 1) Review of R2's medical record revealed no documentation of a written service plan. Based on R2's date of acceptance, a service plan was required. 2) In an interview, E1 and E3 acknowledged R2's medical record did not contain a service plan.

Temporary Solution:

Acquire the service plan for this resident as it was pending representative signature. Reach out to the rep again for signatures and a meeting immediately.

Permanent Solution:

Make sure to meet with the representative of resident within 14 days of admission. Continue to reach out for signatures and to go over the service plans. Make sure caregivers are able to access the service plans.

Person Responsible:

Wanessi Haley - Manager

Deficiency #4

Rule/Regulation Violated:

R9-10-808.A.4.b.ii. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): b. As follows: ii. At least once every six months for a resident receiving personal care services, and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated at least once every six months for a resident receiving personal care services, for one of three residents sampled. The deficient practice posed a risk if a resident's service plan was not updated as required to reinforce and clarify services, and a caregiver was not aware of the services to be provided for a resident. Findings include: 1) Review of R3's medical record revealed a service plan for personal care services dated November 30, 2024. However, an updated service plan after November 30, 2024 was not available for review. 2) In an interview, E1 and E3 acknowledged R3's medical record did not include a service plan updated at least once every six months.

Temporary Solution:

Complete the service plan of the resident reviewed that did not have an updated service plan of 6 months for personal level of care. Meet with the Resident's Rep to go over any updates on the service plan and get appropriate signatures.

Permanent Solution:

Make sure service plans are updated according to the level of care. Document all changes, declines, and improvements of care. Annually for supervisory, 6 months for personal and every 3 months for directed.

Person Responsible:

Wanessi Haley - Manager

Deficiency #5

Rule/Regulation Violated:

R9-10-816.F.1. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;

Evidence/Findings:

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. Findings Include: 1) During the environmental tour of the facility, the Compliance Officer observed a medication cabinet. The cabinet was equipped with a locking mechanism, however, the cabinet was not locked at the time of inspection. 2) In observation, the caregivers were not accessing the medications at the time of arrival. 3) In an interview, E1 and E3 acknowledged the medications were stored in an unlocked manager and accessible to residents.

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:

Wanessi Haley - Manager

Deficiency #6

Rule/Regulation Violated:

R9-10-818.A.4. Emergency and Safety Standards A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

Evidence/Findings:

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) The Compliance Officer requested the disaster drills conducted for the last 12 months. 2) Review of facility documentation revealed no disaster drills conducted within the last 12 months. 3) In an interview, E1 and E3 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Temporary Solution:

Find the binder where the employee disaster drills was documented as the owner had it but she was on vacation.

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:

Wanessi Haley - Manager

Deficiency #7

Rule/Regulation Violated:

R9-10-818.A.5.a-b. Emergency and Safety Standards A. A manager shall ensure that 5. An evacuation drill for employees and residents: a. Is conducted at least once every six months; and b. Includes all individuals on the premises except for: i. A resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident, and ii. Sufficient caregivers to ensure the health and safety of residents not evacuated according to subsection (A)(5)(b)(i);

Evidence/Findings:

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. Findings include: 1) The Compliance Officer requested the evacuation drills conducted for the last 12 months. 2) Review of facility documentation revealed no evacuation drills conducted within the last 12 months. 3) In an interview, E1 and E3 acknowledged an evacuation drill for employees and residents was not conducted at least once every six months and documented as required.

Temporary Solution:

Find the binder where the resident/employee evacuation drills was documented as the owner had it but she was on vacation.

Permanent Solution:

Make sure the documentation of the resident/employee evacuation 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:

Wanessi Haley - Manager

Deficiency #8

Rule/Regulation Violated:

R9-10-818.B.1-2. Emergency and Safety Standards B. A manager shall ensure that: 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, 2. The resident's orientation is documented.

Evidence/Findings:

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 three residents sampled. The deficient practice posed a health and safety risk if the resident needed to exit the facility in an emergency. Findings include: 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. Based on R2's date of acceptance, this documentation was required. 2) In an interview, E1 and E3 acknowledged R2's medical record did not contain documentation to indicate R2 had received evacuation orientation to the exits from the facility.

Temporary Solution:

Meet with resident representative 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:

Wanessi Haley - Manager

Facility Information

Inspection History

INSP-0134004

Summary:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0103839

Summary: