Willow Wind Assisted Living.

“Based on record review and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at or on behalf of the assisted living facility as specified in R9-10-113. Findings include: 1 . A review of E3's employee record revealed no evidence of a tuberculosis test before providing services on behalf of the assisted living facility. 2 . In an exit interview, E1 acknowledged that a caregiver was missing evidence of freedom from infectious tuberculosis before providing services to residents in the assisted living facility.”

“Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident's date of occupancy. Findings include: 1 . A review of R1, R2, and R3's medical records revealed that no tuberculosis tests were provided to the assisted living facility before or within seven calendar days after the resident's date of occupancy. 2. In an exit interview, the findings were reviewed with E1, and no further information was provided.”

“Based on record review and interview, the manager failed to ensure that, before or at the time of acceptance of an individual, the individual submitted the required documentation dated within 90 calendar days before the individual was accepted by an assisted living facility, for three of three residents reviewed. Findings include: 1 . A review of R1, R2, and R3's medical records revealed no documentation dated within 90 days of being admitted to the Assisted Living Facility that indicated the expected level of care (Directed, Personal or Supervisory) and if the resident required continuous medical services, continuous or intermittent nursing services or restraints that was signed and dated by a physician, Registered Nurse practitioner, Registered Nurse, or Physician assistant. 2 . In an exit interview, E1 acknowledged that there were no 90-day determination forms for three of three residents sampled.”

“Based on document review, observation, and interview, the manager failed to ensure that a facility authorized to provide directed care services had policies and procedures established, documented, and implemented that ensured the safety of a resident who may wander. Findings include: 1 . A review of facility documents revealed a policy and procedure titled Scope of Practice and Services with a section titled, Directed Care Services which stated that Directed Care Services included: Ongoing supervision appropriate to resident needs Assistance with decision making and daily routines Cueing, redirection, and prompting Interventions to prevent unsafe behaviors However, there were no procedures for checking on residents when they went out to the patio. 2 . The Compliance Officer observed the front entry to be unsecured. There was no alarm or person to notify staff if a resident wandered out the front door. 3 . In an exit interview, the findings were reviewed with E1, and no further information was provided.”

“Based on observation and interview, the administrator failed to ensure that a facility authorized to provide directed care services had a means of exiting the facility that monitored or alerted employees of the egress of a resident from the facility. Findings include: 1 . During a tour of the facility, the Compliance Officer observed the main entrance to the facility to be unsecured. The entry door was not alarmed and had no one to monitor who was coming in or out of the facility. 2. In an exit interview, the findings were reviewed with E1, and no further information was provided.”

“Based on observation and interview the administrator failed to ensure that a facility authorized to provide directed care services had policies and procedures for monitoring residents receiving memory care services in outdoor areas on the premises. Findings include: 1 . During a tour of the facility, the Compliance Officer observed the main entrance to the facility to be unsecured. The entry door was not alarmed and had no one to monitor who was coming in or out of the facility. 2 . The Compliance Officer observed an enclosed courtyard; however, there was no system for monitoring residents who received memory care services in outdoor areas on the premises. 3 . In an interview, E1 reported that there are alarms on the door to the patio to alert staff; however, there was no policy or procedure that outlined staff responsibilities for responding to the door alarms, to include amount of time for resident checks. 4 . In an exit interview, the findings were reviewed with E1, and no further information was provided.”

“Based on document review and interview, the manager failed to ensure that policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1 . A review of facility documents revealed a policy and procedure for medication administration; however, the policy was not reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 2 . In an exit interview, E1 acknowledged that their medication administration policies and procedures were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.”

“Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1 . A review R1 and R2's medical records revealed that there were medication orders that were not signed by a medical practitioner. 2 . In an exit interview, E1 acknowledged that the medication orders were not signed by a medical practitioner.”

“Based on observation and interview the manager failed to ensure that 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 a tour of the facility, the Compliance Officer observed four oxygen tanks in a resident room that were not secured or in a holding device. 2 . In an exit interview, the findings were reviewed with E1, and no further information was provided.”