Caring for Loved Ones

Based on documentation review and interview, the manager failed to ensure that documentation of the caregivers and assistant caregivers schedule and days worked, including the hours worked by each, had been completed and was accurate. The deficient practice posed a risk as there was no documentation to identify if qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. A review of facility documentation revealed a posted work schedule for January 2026. According to the schedule, E2 was off; however, E2 was working. E4 was scheduled to work the second shift (6:00 PM - 6:00 AM). The schedule stated, "IF THERE ARE ANY CHANGES ON THE SCHEDULE, PLEASE WRITE IT UNDER REMARKS." 2. In an interview, E1 reported there had been several schedule changes, but nothing had been updated on the schedule yet. E1 confirmed that E2 was working on the day of the inspection, even though the schedule showed E2 was off. E1 also reported that E4, who was scheduled to work that evening, had been terminated on January 5, 2026. 3. Further review of the schedule revealed that E4 was documented as working on January 6-9, 2026, and on January 11, 2026; however, based on E1's previous statement, E4 was terminated on January 5, 2026. E4 was scheduled to work for the remainder of the month. 4. In an interview, E1 acknowledged that the schedule did not accurately reflect the caregivers and assistant caregivers who had worked each day.

Based on record review and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of three personnel records reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E3's personnel record (hired as a caregiver) revealed documentation of one negative Tuberculin skin test; however, there was no documentation of a second skin test or the Risk Assessment/Signs and Symptoms Screening form, as required in R9-10-113. 2. In an interview, E1 acknowledged E3 did not provide evidence of freedom from infectious TB on or before the date the E3 began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113.

Based on record review, documentation review, and interview, the manager failed to ensure that all employees had a personnel record as required, for one of four personnel records reviewed. The deficient practice posed a risk as required information could not be verified for E4. Findings include: 1. A review of personnel records revealed E4 did not have a personnel record. 2. A review of facility documentation revealed a posted work schedule for January 2026. According to the schedule, E4 was documented as working on January 1-4, 2026; January 6-9, 2026; and on January 11, 2026. E4 was scheduled to work the second shift (6:00 PM - 6:00 AM) on the day of the inspection, and a continued schedule for the remainder of the month. 3. In an interview, E1 stated that E4 had just been hired on January 1, 2026, as an assistant caregiver, but that E1 terminated E4 on January 5, 2026, for failure to comply with all of the hiring requirements. E1 stated E1 had requested all of the required information (completed application, fingerprint clearance card, proof of TB tests, etc.) but E4 failed to provide any of the documentation. 4. In an interview, E1 acknowledged that E4 did not have a personnel record and that E4 had worked at the home from January 1-4, 2026.

Based on record review and interview, the manager failed to ensure that a caregiver or an assistant caregiver documented the services provided in the resident’s medical record, for nine of nine residents. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. The Compliance Officer arrived on-site at approximately 1:00 PM on January 12, 2026. 2. A review of medical records revealed a binder titled "MAR ADL VITALS." The binder included the Activities of Daily Living (ADL) sheets for each of the nine residents. Further review revealed that services provided to the residents on January 11, 2026 and up until 1:00 PM on January 12, 2026, had not been documented. 3. In an interview, E1 acknowledged that services provided to all of the residents on January 11, 2026, and up until 1:00 PM on January 12, 2026 had not been documented in the residents' medical records.

Based on documentation review, observation, and interview, the manager failed to ensure that the means of exiting the facility alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. Upon arrival at the facility, the Compliance Officer observed the front door to have an alert device; however, the device was turned off. The Compliance Officer observed the side door to have an alert device; however, the device was turned off. In addition, the Compliance Officer observed a caregiver approach the back door to turn on the alert device that was on the back door. 3. While on-site for the complaint inspection, the Compliance Officer observed a caregiver's key left in the inside front door lock. 4. In an interview, E1 acknowledged that the alerts on the doors had been turned off, and therefore, the means of exiting the facility did not alert employees of the egress of a resident from the facility. 5. A review of department documentation revealed a Plan of Correction (POC) from the complaint inspection conducted on September 11, 2025, submitted to the Department on November 7, 2025, which stated: "Temporary Solution: The manager had the exit door alarms checked if they are working properly. The manager has instructed the staff in all shift to maintain the door alarm on all the time. Only staff has access with Door key. Permanent Solution: The manager and staff will conduct daily rounds in the facility to check if the door alarms are turned on all the time. Staff in all shifts shall check all exit doors and ensure that they are locked at all times. Day and Night staff to do regular Day and Night checks to ensure the whereabouts of all residents. Front door camera installed with notifications for monitoring in case Residents will come out of the home. Only staff has an access for the Door Key. Permanent Correction Date: 9/15/2025. Monitoring System: The manager and staff will conduct daily rounds in the facility to check if the door alarms are turned on. Staff in all shifts shall check all exit doors regularly and ensure that they are locked at all times. All shift staff to do regular day and night checks to ensure the whereabouts of all residents. Front door camera installed with notifications for monitoring in case Residents will come out of the home. Only staff has an access for the door key." 6. This is a repeat deficiency from the complaint inspection conducted on September 11, 2025.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident’s medical record, for nine of nine residents. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. The Compliance Officer arrived on-site at approximately 1:00 PM on January 12, 2026. 2. A review of medical records revealed a binder titled "MAR ADL VITALS." The binder included the medication administration records (MAR) for each of the nine residents. Further review revealed that medications administered to the residents on January 11, 2026, and up until 1:00 PM on January 12, 2026, had not been documented. 3. In an interview, E1 acknowledged that medications administered to all of the residents on January 11, 2026, and up until 1:00 PM on January 12, 2026, had not been documented in the residents' medical records.

Based on observation and interview, the manager failed to ensure that medication stored by the assisted living home was stored in a locked cabinet. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. Upon arrival to the facility, the Compliance Officer observed the medication cabinets in the kitchen. The top cabinet that contained the residents' daily medication was not secured by the self-locking device/magnet system. The cabinet door was left slightly ajar, leaving the medication accessible. The bottom cabinet that contained the full inventory of all of the residents' medication was not closed or locked. The cabinet door was left slightly ajar and the key was left in the lock. 2. In an interview, E1 acknowledged that the cabinets used to store the residents' medication were not secured or locked at the time of the inspection.