ALL STARS ASSISTED LIVING

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 stating whether the individual required intermittent nursing services or restraints, for one of three residents reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. In record review, R2's medical record did not include documentation signed by a Physician, Registered Nurse practitioner, Registered nurse, or Physician assistant, which included whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2's acceptance date, this documentation was required to be in the record.

2. During an interview, E1 acknowledged the required documentation was not available for review.

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 within 24 hours of acceptance, for one of three residents reviewed. 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 R3's medical record revealed no documentation of orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours of acceptance. Based on R3's date of acceptance, this documentation was required.

2. In an interview, E1 acknowledged documentation was not available that showed R3 was oriented to the facility's evacuation plan within 24 hours of acceptance.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas.

Findings include:

1. During the facility tour with E1, the Compliance Officer observed a large oxygen tank unsecured in the garage.

2. During an interview, E1 acknowledged the oxygen tank was not secured in an upright position.

Based on observation and interview, the manager failed to ensure 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 a resident.

Findings include:

1. During the facility tour with E1, the Compliance Officer observed Fabulous all purpose cleaner, and a bottle of Spray and wash unlocked in the garage. The garage door had a thumb lock device, however the door was not locked.

2. During an observation, E1 and E2 were the only employees at the facility when the Compliance Officer arrived and was not accessing the toxic materials at the time of arrival.

3. During an interview, E1 and E2 acknowledged toxic materials were stored unlocked.

Based on observation, documentation review, and interview, the manager allowed more than two individuals to reside in a bedroom.

Findings include:

1. The Compliance Officer observed two beds in the master bedroom and two beds in the master closet.

2. A review of Department documentation revealed the facility's first license was effective March 3, 2015.

3. In an interview, E1 provided the Compliance Officer with the names of the residents occupying the bedroom and the names of the staff occupying the master closet.

4. In an interview, E1 acknowledged more than two individuals were allowed to reside in a bedroom in a facility not in operation since before November 1, 1998.