Caring for Generations Corner LLC

Based on record review, documentation review, and interview, the chief administrative officer failed to ensure tuberculosis infection control activities were implemented, including baseline screening of residents and employees, annual training and education related to recognizing the signs and symptoms of tuberculosis, and annually assessing the health care institution's risk of exposure to infectious tuberculosis, for two of two sampled residents and three of three sampled employees. Findings include: 1. A review of R1's medical record revealed baseline screening, to include assessing R1's risk of prior exposure to infectious tuberculosis, a determination if R1 had signs or symptoms of tuberculosis, and documentation of R1's freedom from infectious tuberculosis, dated within seven days after R1's date of acceptance, was not available for review. R1's medical record contained a single Mantoux skin test (TST) dated 13 months after R1's date of acceptance. 2. A review of R2's medical record revealed baseline screening, to include assessing R2's risk of prior exposure to infectious tuberculosis, and a determination if R2 had signs or symptoms of tuberculosis, dated within seven days after R2's date of acceptance, was not available for review. R2's medical record contained a single TST dated approximately one month prior to R2's date of acceptance. 3. A review of E2's personnel file revealed E2 had been hired in January of 2022. E2's personnel record included documentation of annual TB education in 2023. However, documentation of annual training related to recognizing the signs and symptoms of tuberculosis in 2024 and 2025 was not available for review. 4. A review of E3's personnel file revealed E3 had been hired as a caregiver in February of 2025. 5. A review of E3's personnel file revealed a baseline screening document, dated in July 2025, five months after E3's date of employment. The baseline screening document indicated E3 had one TST prior to employment and had the required second TST and baseline screening questionnaire completed in July 2025. 6. A review of E4's personnel file revealed E4 had been hired as a caregiver in October of 2025. 7. A review of E4's personnel file revealed a baseline screening, to include assessing E4's risk of prior exposure to infectious tuberculosis, and a determination if E4 had signs or symptoms of tuberculosis, dated prior to E4 providing services to residents, was not available for review. E4's medical record contained a negative blood test dated approximately two months prior to E4's date of hire. 8. A review of facility documentation revealed an annual assessment of the facility's risk of exposure to infectious tuberculosis, dated within the calendar year prior to the on-site inspection, was not available for review. 9. In an exit interview with E1, the findings were reviewed, and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance conducted on

Based on record review and interview, the manager failed to ensure, before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement which included the date of occupancy or expected date of occupancy, for two of two sampled residents. Findings include: 1. A review of R1's medical record revealed a residency agreement which had been signed and dated by the manager and by the resident or resident's representative on the day of R1's acceptance. However, the residency agreement did not include R1's date of occupancy or expected date of occupancy. The residency agreement included a space to document this date; however, it had been left blank. 2. A review of R2's medical record revealed a residency agreement which had been signed and dated by the manager and by the resident or resident's representative on the day of R2's acceptance. However, the residency agreement did not include R2's full date of occupancy or expected date of occupancy. The residency agreement included a space to document this date; however, it contained a partial date. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

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 and documented. Findings include: 1. A documentation review of facility disaster drills conducted during the 12 months prior to the onsite inspection revealed the following drills: January 2025, on both shifts; April 2025, on both shifts; July 2025, only on the night shift. An evacuation drill was conducted during the day shift in July, but documentation of a disaster drill conducted during the day shift was not available for review; October 2025, two on the day shift and one on the night shift; and January 2026, no disaster drills conducted. An evacuation drill had been conducted on both shifts, but documentation of disaster drills was not available. 2. Technical Assistance for this rule was provided during the on-site compliance inspection conducted on January 21, 2025, including to document disaster drills and evacuation drills discretely and separately and to stop combining the documentation of different types of drills, as there was no documentation on the evacuation drills which would indicate they were also disaster drills or elopement drills, or documentation of the times the different drills had been conducted. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a quality management plan was implemented to include the frequency of submitting a documented report to the governing authority. Findings include: 1. A review of the facility's policies and procedures, last reviewed January 4, 2023, revealed a policy titled quality management. This policy stated, "One time on a bi-annually basis the Manager will evaluate the date utilizing a graph to identify trends and specific concerns about the delivery of services related to resident care. The Manager will evaluate and identify changes or actions necessary to prevent recurrence of the incident. This information will be documents in a report that does NOT specifically identify a particular person or contains protected health information. This statistical data and evaluation will be reported to the Governing Authority on a bi-annual basis. The Governing Authority will need to sign and date they have reviewed this report." 2. A review of the facility's quality management reports revealed a quality management report was not available for review. 3. In an interview, O1 acknowledged a bi-annual quality report and graph had not been provided for review.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled. The deficient practice posed a risk as there was no timely service plan to direct services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan was not available for review. However, the date of the on-site inspection was more than 14 calendar days after R1's date of acceptance and a previous service plan was not available for review. 2. In an interview, O1 acknowledged a completed service plan, dated no later than 14 days after R1's date of acceptance, had not been provided for review.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled who received medication administration. Findings include: 1. A review of R1's medical record revealed a list of hospice orders, faxed to the facility on January 13, 2025, which included the following: - "guaiFENesin 100 mg/5 mL liquid 10 milliliter orally every 4 hours"; - "ondansetron 4 mg tablet 1 tablets orally every 6 hours"; and - "Oxygen (O2) 2 liter/min inhaled continuous for shortness of breath." 2. A review of R1's medical record revealed a Medication Administration Record (MAR) dated January 2025. The MAR documented the following: - "Guaifenesin," had been transcribed from the order incorrectly as "P.R.N." (as needed) on the MAR and had not been administered in January 2025; - "Ondansetron," had been transcribed from the order incorrectly as "P.R.N." (as needed) on the MAR and had not been administered in January 2025; and - "Oxygen" had been transcribed from the order incorrectly as "2L/Min at Bedtime," and was not marked PRN, but had been administered only on January 4, 5, 11, 18, and January 19, 2025. 3. In an interview, O1 acknowledged R1's medical record did not document medication had been administered to R1 in compliance with the available medication orders.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the water temperature measured at 70.9\'b0 F in the southernmost resident bedroom. 2. During the on-site inspection, O1 adjusted the thermostat on a small water heater serving the southernmost resident bedroom. 3. During the on-site inspection, the Compliance Officer rechecked the water temperature in southernmost resident bedroom and observed the water temperature measured 124.1\'b0 F. 4. In an interview, O1 acknowledged the hot water temperatures had not been maintained between 95 \'b0F and 120 \'b0F in an area of the assisted living facility used by residents.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area and inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a laundry room located by the kitchen had a door with a lock. However, the door was found to be unlocked during the inspection. Inside the laundry room, the Compliance Officer observed a closet containing cleaning chemicals. The cabinet had a padlock, however, the padlock was found to be unlocked during the inspection. 2. In an interview, E1 acknowledged poisonous or toxic materials were not stored in a locked area and inaccessible to residents.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained for at least 12 months of the caregivers working each day, including the hours worked by each. Findings include: 1. The Compliance Officer requested to review a daily staffing schedule maintained for at least 12 months of the caregivers working each day, including the hours worked by each. However, work schedules were not provided for review. 2. In an interview, E1 acknowledged being unable to locate the documentation of the caregivers working each day, including the hours worked by each, since the facility opened.

Based on observation, documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, evidence of freedom from infections tuberculosis (TB), the individual's completed orientation and in-service education required by policies and procedures, for one of two personnel records sampled. The deficient practice posed a risk if E2 was not able to meet the needs of residents. Findings include: 1. A review of the facility work schedules revealed work schedules were not available for review. 2. In an interview, E1 reported the facility works on two twelve hour shifts per day and reported E2 is currently working on the overnight shift. 3. A review of E2's personnel record revealed E2's hire date was not documented. Additionally, E2's personnel record did not include the following documentation: - evidence of freedom from TB; - documentation of orientation; - documentation of verification of E2's skills and knowledge; - documentation of good faith efforts to contact previous employers to obtain information or recommendations relevant to E2's fitness to work in a residential care institution; and - documentation of initial fall prevention and fall recovery training. 4. In an interview, E1 acknowledged the personnel record provided for E2 did not include all required documents.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents reviewed. Findings include: 1. R9-10-113.A states "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...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)..." 2. A review of R1's medical record revealed documentation of a signed doctor's note stating R1 was free of active TB. However, baseline screening documentation to include a risk assessment of prior exposure to infectious TB and a determination if R1 had signs or symptoms of TB, signed by an occupational health provider or medical practitioner, and a CDC recommended test for TB, such as a Mantoux skin test or a blood test, was not available for review. Based on R1's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R1 had not provided documentation of baseline screening as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, the manager, if a review was required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan, and if a review was required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan, when initially developed and when updated, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated September 1, 2023, which included medication administration. However, the service plan had not been signed by the manager or the nurse or medical practitioner who reviewed the service plan. 2. A review of R2's medical record revealed a service plan dated September 1, 2023, which included medication administration. However, the service plan had not been signed by the resident or resident's representative, the manger, or the nurse or medical practitioner who reviewed the service plan. 3. In an interview, E1 acknowledged the service plans provided for R1 and R2 had not been signed and dated by the resident or resident's representative, the manager, and, if a review was required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan.

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 and documented. Findings include: 1. In an interview, E1 reported the facility works on two 12 hour shifts per day. 2. A review of facility disaster drills conducted during the previous ten months since the facility opened revealed no documented disaster drills were available for review. 3. In an interview, E1 acknowledged documentation of disaster drills conducted on each shift at least once every three months for the previous ten months had not been provided to the Compliance Officer upon request.

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. Findings include: 1. A review of facility documentation revealed no documented evacuation drills during the previous ten months since the facility opened. 2. In an interview, E1 acknowledged documentation of evacuation drills conducted at least once every six months had not been provided to the Compliance Officers upon request.

Based on observation and interview, the manager failed to ensure smoke detectors were tested at least once a month. Findings include: 1. The Compliance Officer requested documentation of monthly testing of the facility's smoke detectors. However, documentation was not provided for review. 2. In an interview, E1 acknowledged documentation of monthly testing of the facility's smoke detectors had not been provided for review.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the hot water temperature measured at 126.1\'b0 F in a shared bathroom. 2. In an interview, E1 acknowledged the hot water temperature had not been maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents.