ROSE COURT SENIOR LIVING

<p>Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident’s medical record, for three and three sampled residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's medical record contained a service plan dated July 17, 2025 . R1's service plan reported R1 would be provided assistance with <strong>dressing </strong>twice daily,<strong> transfer assistance i</strong>n and out of bed, <strong>toileting</strong> assistance every shift, personal hygiene of oral, skin and daily grooming twice daily, wellness and safety checks every shift.</p><p><br></p><p><br></p><p>2. A review of R1's medical record contained a document titled "Documentation Survey Report" dated August 2025 which reflected R1 was not provided assistance with following:</p><ul><li>Wellness checks on the day shift of August 1, 2025 and August 2, 2025 and night shift of August 15, 2025;</li><li>Dressing assistance <span style="background-color: rgb(255, 255, 255);">the day shift of August 1, 2025 and August 2, 2025;</span></li><li><span style="background-color: rgb(255, 255, 255);">Mobility and transfer </span>the day shift of August 1, 2025, August 2, 2025 and night shift of August 15, 2025;</li><li>Grooming personal hygiene/oral care <span style="background-color: rgb(255, 255, 255);">the day shift of August 1, 2025, August 2, 2025; and </span></li><li><span style="background-color: rgb(255, 255, 255);">Toileting not provided on the day shift of August 1, 2025, August 2, 2025 and night shift of August 15, 2025.</span></li></ul><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);">3. A review of R2's medical record contained a service plan dated July 25, 2025 . R2's service plan reported R2 would be provided reminders for dressing twice daily,</span><strong style="background-color: rgb(255, 255, 255);"> </strong><span style="background-color: rgb(255, 255, 255);">personal hygiene of oral, skin and daily grooming twice daily, wellness and safety checks every shift. </span></p><p><br></p><p><br></p><p>4. <span style="background-color: rgb(255, 255, 255);"> </span>A review of R2's medical record contained a document titled "Documentation Survey Report" dated August 2025 which reflected R2 was not provided assistance with following:</p><ul><li>Wellness checks on the day shift of August 1, 2025 and August 2, 2025 and night shift of August 15, 2025;</li><li>Dressing assistance <span style="background-color: rgb(255, 255, 255);">the day shift of August 1, 2025 and August 2, 2025; and</span></li><li>Grooming personal hygiene/oral care <span style="background-color: rgb(255, 255, 255);">the day shift of August 1, 2025, August 2, 2025.</span></li></ul><p><br></p><p><span style="background-color: rgb(255, 255, 255);">5. A review of R3's medical record contained a service plan dated July 18, 2025 . R3's service plan reported R3 would be provided assistance with </span><strong style="background-color: rgb(255, 255, 255);">dressing </strong><span style="background-color: rgb(255, 255, 255);">twice daily, personal hygiene of oral, skin and daily grooming twice daily, wellness and safety checks every shift. </span></p><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);">6. A review of R3's medical record contained a document titled "Documentation Survey Report" dated August 2025 which reflected R3 was not provided assistance with following:</span></p><ul><li>Wellness checks on the day shift of August 1, 2025 and August 2, 2025 and night shift of August 15, 2025;</li><li>Dressing assistance <span style="background-color: rgb(255, 255, 255);">the day shift of August 1, 2025 and August 2, 2025; and </span></li><li>Grooming personal hygiene/oral care <span style="background-color: rgb(255, 255, 255);">the day shift of August 1, 2025, August 2, 2025.</span></li></ul><p><br></p><p><br></p><p><span style="background-color: rgb(255, 255, 255);">7. In an interview, E1 acknowledged the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to R1, R2, and R3.</span></p>

<p>Based on documentation review and interview, the manager failed to ensure w<span style="background-color: rgb(255, 255, 255);">hen medication is stored by an assisted living facility, p</span>olicies and procedures were established and documented for inventorying and dispensing controlled substances.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of the facility's documentation of the policies and procedures showed that the medication policies and procedures did not cover inventorying and dispensing controlled substances.</p><p><br></p><p><br></p><p>2. In an interview, the E1 reported that the provided medication policies were the only available policies regarding inventorying and dispensing medications, and no other policies and procedures were available for review.</p>

<p><span style="font-family: sans-serif; font-size: 14px;">Based on record review and interview, the manager failed to ensure the facility</span><span style="font-family: sans-serif; font-size: 14px; color: black;"> maintained a standardized form for each resident that includes the information prescribed in subsection A of </span><span style="font-family: sans-serif; font-size: 14px;">A.R.S. § 36-420.04.A.1-9, </span><span style="font-family: sans-serif; font-size: 14px; color: black;"> for one of one sampled resident.</span></p><p><br></p><p><br></p><p><span style="font-family: sans-serif; font-size: 14px; color: black;"> </span></p><p><span style="font-family: sans-serif; font-size: 14px; color: black;">Findings include:</span></p><p><br></p><p><br></p><p><span style="font-family: sans-serif; font-size: 14px; color: black;"> </span></p><p><span style="font-family: sans-serif; font-size: 14px; color: black;">1. A review of R1’s medical record contained an incident report dated May 7, 2025 for an unwitnessed fall that required 911 services. R1's medical record revealed a packet of information to be given to an emergency responder on behalf of the resident, the packet of information and standardized form did not include the reason or reasons the emergency responder would be requested on behalf of the resident</span><span style="font-family: sans-serif; font-size: 14px;">s’, a list of the residents’ prescription and over-the-counter medications, their dosages and how frequently they would be administered, the name, address and telephone number of the residents’ current pharmacy, the contact information for the residents’ primary care physician, basic information about the residents’ physical conditions and a copy of the residents’ health insurance portability and accountability act release (HIPPA) authorizing the receiving hospital to communicate with the assisted living facility.</span></p><p><br></p><p><span style="font-family: sans-serif; font-size: 14px;"> </span></p><p><br></p><p><span style="font-family: sans-serif; font-size: 14px; color: black;">2. In an interview, E1 reviewed the information to be given to the emergency responder on behalf of R1 and acknowledged the above information was not included in the packet.</span></p><p><span style="font-size: 16pt;"> </span></p>

Based on record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for one of three sampled residents. The deficient practice posed a risk if the resident did not receive adequate follow-up care.

Findings include:

1. A review of R3's medical record reviewed a document titled "Medication Administration Record" dated November 2024 reflected R3 was not administered R3's 12pm and 6pm Oxycodone 15mg dose on November 29, 2024. R3's record revealed a document titled "Administration History" which reflected R3 was not administered Oxycodone due to R3 being absent from the facility.

2. In an interview, E1 reported R3's Oxycodone was not administered on November 29, 2024 at 12pm and 6pm due to R3 being at the hospital.

3. A review of facility documentation revealed a document titled "intake Information" dated November 29, 2024 which reflected R3 was transported to the emergency room via emergency medical transport from the facility.

4. A review of R3's medical record revealed R3's primary care provider and emergency contact were not notified.

5. In an interview, E1 acknowledged there was no documentation available for review to reflect R3's primary care provider and emergency contact were notified.

Based on record review and interview, the manager failed to ensure when a resident had an emergency resulting in the resident needing medical services, a caregiver documented the date and time of the incident, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future, for one of one resident sampled who had an incident resulting in the resident needing medical services.

Findings include:

1. A review of R3's medical record reviewed a document titled "Medication Administration Record" dated November 2024 reflected R3 was not administered R3's 12pm and 6pm Oxycodone 15mg dose on November 29, 2024. R3's record revealed a document titled "Administration History" which reflected R3 was not administered Oxycodone due to R3 being absent from the facility.

2. In an interview, E1 reported R3's Oxycodone was not administered on November 29, 2024 at 12pm and 6pm due to R3 being at the hospital.

3. A review of facility documentation revealed a document titled "intake Information" dated November 29, 2024 which reflected R3 was transported to the emergency room via emergency medical transport from the facility.

4. A review of R3's medical record revealed no documentation regarding R3's emergency requiring medical services.

5. In an interview, E1 reported there was no documentation to reflect the required components.

Based on documentation review and interview, the manager failed to ensure a pest control program compliant with Arizona Administrative Code (A.A.C.) R3-8-201(C)(4) was implemented.

Findings include:

1. A.A.C. R3-8-201(C)(4) states: "4. An individual may not provide pest management services at a...health care institution...unless the individual is a certified applicator in the certification category for which services are being provided."

2. A review of facility documentation revealed a Pest Control Log, which reflected pest control was completed on February 29, 2024, February 26, 2024, and October 23, 2024 by the facility's maintenance staff. There was no documentation of the individual conducting the pest control service being a certified applicator.

3. In an interview, E3 reported the maintenance staff provided pest control to the various locations in the facility, and there was no documentation available for review to reflect the individuals providing pest control services were certified applicators.

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently.


Findings include:

1. A review of E1's personnel record revealed there was no documentation of fall prevention and fall recovery training.

2. In an interview, E1 reviewed and acknowledged E1's personnel record did not include documentation of fall prevention and fall recovery training.

This is a repeat deficiency from the compliance inspection and complaint investigation conducted on August 29, 2023.

Based on observation, record review, documentation review and interview, the manager failed to ensure a caregiver provided valid documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of three caregivers sampled.

Findings include:

1. A review of E2's personnel record revealed E2 was hired as a caregiver. E2's record revealed a caregiver certification issued by "Platinum Training Services" with an ALTP number of 152.

2. A review of the NCIA board website revealed ALTP 152 belonged to "Comprehensive Training Program".

3. A review of R2's medical record revealed a document titled "Documentation Survey Report" dated October 2024 which reflected E2 assisted R2 with toileting, incontinence care and wellness checks.

4. A review of R4's medical record revealed a document titled "Documentation Survey Report" dated October 2024 which reflected E2 assisted R4 with oxygen management.

5. A review of R5's medical record revealed a document titled "Documentation Survey Report" dated October 2024 which reflected E2 assisted R5 with toileting, incontinence care and wellness checks.

6. A review of R7's medical record revealed a document titled "Documentation Survey Report" dated October 2024 which reflected E2 assisted R7 with dressing and wellness checks.

7. In an interview, E1 acknowledged there was no other certification available for review to reflect E2 had a valid caregiver certification.

Based on record review, documentation review, and interview, for two of seven employees reviewed, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, which posed a safety risk to residents if new employees were not provided orientation.

Findings Include:

1. A review of E1's personnel record revealed there was no documentation of E1's completed orientation, based E1's hire date and the facility's policy and procedure orientation was required.

2. A review of the facility's documentation revealed a policy titled "Employee Orientation" which reflected "Each new employee will attend general orientation within 10 days from the starting date of employment."

3. In an interview, E1 acknowledged there was no documentation of E1's completed orientation.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for three of seven residents sampled.

Findings include:

1. A review of R2's medical record revealed a service plan dated September 22, 2024 which reflected R2 would be provided assistance with wellness checks and toileting and incontinence care checks once every shift. R2's document titled "Documentation Survey Report" dated October 2024 reflected R2 was not provided toileting/incontinence checks on October 8, 2024 and October 28, 2024 during the night shift.

2. A review of R4's medical record revealed a service plan dated September 22, 2024 which reflected R4 would be provided assistance with oxygen management every AM and PM shift once every shift, wellness checks every night. R4's document titled "Documentation Survey Report" dated October 2024 reflected R4 was not provided oxygen management on October 21, 2024 day shift. Oxygen management was not provided on the day shift for the following days: October 7, 2024, October 12, 2024, October 14, 2024, October 15, 2024, and October 22, 2024. Wellness check were not provided on October 9, 2024 and October 29, 2024.

3. A review of R5's medical record revealed a service plan dated September 22, 2024 which reflected R5 would be provided assistance with wellness checks once every shift, escorts to and from meals and activities every am and pm. R5's document titled "Documentation Survey Report" dated October 2024 reflected R5 was not provided wellness checks on October 5, 2024, October 9, 2024, October 12, 2024, October 14, 2024, October 27, 2024 and October 29, 2024 during the night shift. R5 was not provided escorts to and from meals and activities on October 1, 2024 and October 16, 2024, nor was R5 marked for meal attendance on the days not escorted.

4. In an interview, E1 acknowledged R2's, R4's, and R5's documentation of services provided did not reflect the above were provided to the residents.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver was only assigned to provide the assisted living services the caregiver or assistant caregiver had the documented skills and knowledge to perform.

Findings included:

1. A review of E2's personnel record revealed E2 was hired as a caregiver. E2's record revealed a caregiver certification issued by "Platinum Training Services" with an ALTP number of 152. However, review of the NCIA board website revealed ALTP 152 belonged to "Comprehensive Training Program". There was no other documentation in E2's record to reflect E2 had valid a caregiver certification.

2. A review of R2's medical record revealed a document titled "Documentation Survey Report" dated October 2024 which reflected E2 assisted R2 with toileting, incontinence care and wellness checks.

3. A review of R4's medical record revealed a document titled "Documentation Survey Report" dated October 2024 which reflected E2 assisted R4 with oxygen management.

4. A review of R5's medical record revealed a document titled "Documentation Survey Report" dated October 2024 which reflected E2 assisted R5 with toileting, incontinence care and wellness checks.

5. A review of R7's medical record revealed a document titled "Documentation Survey Report" dated October 2024 which reflected E2 assisted R7 with dressing and wellness checks.

6. In an interview, E1 acknowledged there was no other documentation available for review to reflect E2 had the documented skills and knowledge to perform these services.

Based on record review, observation and interview, the manager failed to ensure that the premises and equipment used at the facility were cleaned and disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posted a risk to the physical health and safety of the residents.

Findings include:

1. A review of R1's medical record revealed a document titled "Resident Admission Agreement" March 17, 2024 which reflected "1.1.8. Weekly housekeeping, to include vacuuming of carpets, mopping of floors, cleaning of sinks and tub/shower, dusting, and emptying the trash."

2. A review of R1's medical record revealed a service plan dated June 17, 20224, which reflected "[R1] will be provided a clean and healthy environment to live in. Provide housekeeping and laundry service weekly, pick up trash daily, and daily bed making.

3. A review of R1's medical record revealed a document titled "Point of Care Audit Report" which reflected R1 was provided "Pick up trash and check apartment daily to prevent clutter. Daily bed making." There was no documentation to reflect weekly housekeeping (as defined in R1's residency agreement) was completed, according to R1's service plan.

4. The compliance officer observed various color grime spots on R1's bathtub floor, a dead brown bug with six legs with an oval shaped body.

5. In an interview, R1 reported housekeeping come daily to pick up the trash, make up the bed and sweep the floors.

6. In an interview, E1 acknowledged there was no documentation to reflect weekly housekeeping was conducted.

This is a repeat deficiency from the complaint investigation and compliance inspection conducted on August 29, 2023.

Based on observation and interview, the manager failed to ensure the premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Findings include:

1. The compliance officer observed R1's residential unit floor to have various holes in R1's vinyl floor tiles. The compliance officer observed 23 holes in R1's vinyl flooring, torn and lifting vinyl flooring in the entrance of R1's bathroom. The presence of the holes, torn and lifting flooring may cause a trip hazard and cause a resident or other individuals to suffer physical injury.

2. In an interview, E1 acknowledged the holes in R1's vinyl flooring, along with the torn and lifting flooring in the entrance of R1's bathroom. E1 reported maintance would be made aware.

Based on documentation review, interview, and record review, the manager failed to ensure one of three sampled medical record contained accurate documentation of assisted living services provided to a resident. The deficient practice posed a risk as the Department was provided false and misleading information..

Findings include:

1. A review of Department documentation revealed a document titled "Intake Information" which reflected R1 went missing on May 9, 2024.

2. In an interview, E1 reported R1 left the facility on May 9, 2024 and has not returned as-of May 13, 2024.

3. A review of R1's medical record revealed a service plan dated March 21, 2024. R1's service plan reflected R1 required assistance with bathing/showering ("verbal cues twice weekly one to five times by request"), skin maintenance, and medication administration. Further review of R1's medical record revealed a document titled "Task Schedule for May 2024". The document indicated R1 was observed attending meal service at 9:23 AM, 12:26 PM, and 5:16 PM on May 10, 2024; 10:08 AM, 12:33 PM, and 5:00 PM on May 11, 2024; 11:13 AM and 7:03 PM on May 12, 2024; and 4:47 AM on May 13, 2024. The document also reflected R1 was provided skin integrity reminders to check skin at 10:08 AM on May 11, 2024 and verbal cueing for a bath or shower at 10:08 AM on May 11, 2024.

4. In an interview, E1 reviewed the aforementioned documentation and acknowledged the services documented were not provided to R1.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training that included a demonstration of the individual's ability to perform CPR, before providing assisted living services, for two of eight caregivers reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.

Findings include:

1. Review of the facility's policy and procedure revealed a policy titled "CPR and First Aid Certification" that stated "..2. Will have and maintain current CPR training specific to adults which includes a demonstration of the individual's ability to perform CPR."

2. Review of E6's personnel record revealed E6 worked as a caregiver and had a hire date of June 5, 2023. The personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on November 9, 2023, and valid for two years. There was no other current documentation of CPR training available for review that documented E6 had attended an approved CPR training course that included a demonstration of the individual's ability to perform CPR.

3. Review of E10's personnel record revealed E10 worked as a caregiver and had a hire date of January 17, 2023. The personnel record revealed a CPR card that was obtained from "NationalCPRFoundation" issued on January 23, 2023, and valid for two years. There was no other current documentation of CPR training available for review that documented E10 had attended an approved CPR training course that included a demonstration of the individual's ability to perform CPR.

4. Review of the November 2023 personnel schedule revealed the following:
-E6 worked the 6am-2pm shift November 10th-13th, 15th-22nd, and 24th-27th.
-E10 worked the 10pm-6am shift November 1st-3rd, 5th-10th, 12th-17th, 19th-24th, and 26th-29th.

5. In an email exchange, a representative from NationalCPRFoundation stated "Our courses are online only."

6. In an interview, E1 and E2 acknowledged E6 and E10 did not have current documentation of CPR training, that included a demonstration of the individual's ability to perform CPR.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's written service plan included the psychosocial interactions or behaviors for which the resident required assistance; the psychotropic medications ordered for the resident; the planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and the goals for changes in the resident's psychosocial interactions or behaviors, for three of three resident reviewed who required behavioral care. The deficient practice posed a risk as a service plan directs the services to be provided to a resident.

Findings include:

1. R9-10-101(29) defines "Behavioral care" a. means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services.

2. Review of R1's medical record revealed a document from a behavioral health professional dated November 7, 2023. This document revealed R1 had a diagnosis of depression, bipolar disorder, and anxiety disorder. In addition, the medical record revealed R1 received administration of psychotropic medications including Alprazolam, Trazodone, Aripiprazole, and Venlafaxine. However, R1's written service plan for personal care dated October 27, 2023 did not include the following required components:
-the psychosocial interactions or behaviors for which the resident required assistance;
-psychotropic medications ordered for the resident;
-planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and
-goals for changes in the resident's psychosocial interactions or behaviors.

3. Review of R3's medical record revealed a service plan for personal care dated October 24, 2023. This service plan revealed R3 had a diagnosis of bipolar disorder, depression, and anxiety disorder. In addition, the medical record revealed R3 had a behavioral health professional and received administration of psychotropic medications including Quetiapine, Wellbutrin, Clonazepam, and Buspirone. However, R3's written service plan did not include the following required components:
-the psychosocial interactions or behaviors for which the resident required assistance;
-psychotropic medications ordered for the resident;
-planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and
-goals for changes in the resident's psychosocial interactions or behaviors.

4. Review of R8's medical record revealed a document from a behavioral health professional dated November 7, 2023. This document revealed R8 had a diagnosis of depression and adjustment disorder. In addition, the medical record revealed R8 received administration of psychotropic medication including Doluxetine. However, R8's written service plan for personal care dated June 14, 2023 did not include the following required components:
-the psychosocial interactions or behaviors for which the resident required assistance;
-psychotropic medications ordered for the resident;
-planned strategies and actions for changing the resident's psychosocial interactions or behaviors; and
-goals for changes in the resident's psychosocial interactions or behaviors.

5. In an interview, E1 and E2 acknowledged R1, R3, and R8 received behavioral care and the service plans did not include the required components.

Based on record review and interview, the health care institution failed to administer a training program including initial training and continued competency training in fall prevention and fall recovery for one of four personnel sampled.

Findings Include:

1. A review of E4's personnel record revealed no documentation of initial training or continued competency training in fall prevention and fall recovery.

2. In an interview, E1 acknowledged the health care institution failed to administer a training program including initial training and continued competency training in fall prevention and fall recovery for all personnel. O3 reported E4 completed the training but it may not have been documented.

Based on record review and interview, the manager failed to ensure at the time of admission, a resident or resident's representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (C), for eight of nine residents sampled. The deficient practice posed a risk if residents were not informed of their rights and requirements.

Findings include:

1. A review of R1's, R2's, R4's, R5's, R6's, R7's, R8's, and R9's medical records revealed no documentation to indicate the resident or resident's representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (C).

2. In an interview, E1 acknowledged there was no documentation to indicate R1, R2, R4, R5, R6, R7, R8, or R9 or their representatives received a written copy of the requirements in subsection (B) and the resident rights in subsection (C).

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for one of nine residents sampled. The deficient practice posed a potential illness risk to residents.

Findings include:

1. A review of R1's medical record revealed documentation to indicate R1 was notified of the availability of vaccination for influenza and pneumonia in September 2021. However, the medical record did not contain current documentation of notification of the resident of the availability of vaccination for influenza and pneumonia.

2. In an interview, E1 acknowledged R1's medical record did not contain current documentation to indicate R1 was notified of the availability of vaccination for influenza and pneumonia after September 2021.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the facility, for eight of nine residents sampled.

Findings include:

1. A review of R1's, R2's, R4's, R5's, R6's, R7's, R8's, and R9's medical records revealed no documentation of the residents' orientation to exits from the facility.

2. In an interview, E1 acknowledged R1's, R2's, R4's, R5's, R6's, R7's, R8's, and R9's medical records did not contain documentation of the residents' orientation to exits from the facility.

Based on observation, documentation review, and interview, the manager failed to ensure for a facility authorized to provide directed care services, 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 and provided access to an outside area which allowed the resident to be 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 egress of a resident from the facility.

Findings include:

1. A review of facility documentation revealed the facility was authorized to provide directed care services.

2. During the environmental inspection of the facility, the Compliance Officer observed a door leading to a side yard for residents receiving directed care services. The Compliance Officer observed the door was not controlled and did not have a means to alert employees of egress of a resident from the facility.

3. In an interview, E1 reported the side yard was designated for residents who received directed care services. E1 acknowledged the door to the side yard was not controlled and did not have a means to alert the employees of the egress of a resident from the facility.

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. The deficient practice posed a risk if employees were unable to implement a disaster plan.

Findings include:

1. A review of facility documentation revealed a staff schedule. The schedule indicated there were three shifts:
-"1st shift" from 6:00 AM to 2:00 PM;
-"2nd shift" from 2:00 PM to 10:00 PM; and
-"3rd shift" from 10:00 PM to 6:00 AM.

2. A review of facility documentation revealed disaster drills were conducted at the facility on the following dates and shifts:
-July 18, 2022 on second and third shift;
-October 28, 2022 on second and third shift; and
-June 20, 2023 on all shifts.
No other documentation of disaster drills conducted at the facility was provided for review.

3. In an interview, E1 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months.

This is a repeat citation from the previous on-site compliance inspection conducted on July 12, 2023.

Based on observation and interview, the manager failed to ensure an evacuation path was conspicuously posted in each hallway of the assisted living facility. The deficient practice posed a risk to the safety of residents as a way to exit the facility in the event of an emergency was not conspicuously posted.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed an evacuation path was not conspicuously posted in one hallway of the facility where residents receiving personal care services resided.

2. In an interview, E1 acknowledged an evacuation path was not conspicuously posted in each hallway of the assisted living facility.

Based on observation, documentation review, and interview, the manager failed to ensure the premises of the facility were kept clean according to policies and procedures. The deficient practice posed a risk as the facility had not established or documented a policy and procedure to reinforce and clarify standards expected of employees.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed R3's residential unit. In the bedroom and bathroom, the Compliance Officer observed clothes and items cluttered on the floor and in the shower. The Compliance Officer futher observed clutter around the bathroom sink, and the toilet had feces stains with used toilet paper.

2. A review of facility policies and procedures revealed a policy titled "Maintenance Services". The policy stated "It is the policy of this facility to maintain a clean and safe facility and grounds".

3. In an interview, R3 stated "Are you sure you want to go in there? It's not cleaned yet."

4. In an interview, E1 acknowledged R3's unit was not kept clean according to policies and procedures.