Mayfair Eden Homes Inc..

“Based on documentation review and interview, the manager failed to submit a documented report 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.   Findings include:   1. A review of the facility's policies and procedures revealed a policy titled "Quality Management" reviewed in May 2023. The policy stated "...A documented report is submitted that includes an identification of each concern about the delivery of services related to resident care, any change made or action taken as a result...of the concern...the report...are maintained for 12 months after the date the report is submitted..." 2. A 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.”

“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 that stated whether the individual required continuous medical services, continuous or 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. Review of R2's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2’s acceptance date, this documentation was required.  2. In an interview, E1 acknowledged R2's medical record did not contain documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.”