Caveo Too, Premier Assisted Living

Based on record review, documentation review, and interview, the manager failed to ensure that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for one of two employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E1’s personnel record revealed a hire date of September 1, 2024. E1's latest documentation of fall prevention and recovery training was documented on October 29, 2024 and on September 1, 2024 during orientation. A fall prevention and fall recovery training was not available after October 29, 2024. 2. A review of the facility's documentation revealed a policy titled, "Fall Prevention and Recovery" that stated, "A Fall Recovery Program will be implemented to minimize 911 calls. Upon hire each caregiver will participate, through Orientation, our policy and procedures on fall prevention and recovery. Training will be reviewed annually (or more frequently as determined needed by the Manager) via in-service training and will be documented." 3. In an exit interview, the findings were reviewed with E1, no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were established, documented, and implemented to protect the health and safety of a resident that cover methods by which the assisted living facility was aware of the general or specific hereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. Findings include: 1. A review of the facility’s documentation revealed a policy that covered the general or specific whereabouts of a resident was not available. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident's date of occupancy, as stated in R9-10-113 for two of two residents sampled. The deficient practice posed a TB exposure risk to residents.  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 and R2's medical record revealed no documentation of assessing risks of prior exposure to infectious TB and a determination of whether R1 and R2 had signs or symptoms of TB. Based on R1 and R2's date of occupancy, this documentation was required. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was reviewed and updated at least once every six months for a resident receiving personal care services for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated for April 4, 2025. The service plan stated R1 received personal care services. A service plan after April 4, 2025, was not available. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the caregiver documented the services provided in a resident’s medical record according to the resident’s service plan for two of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1’s medical record revealed a service plan dated April 4, 2025, which included the following: Brush teeth twice a day. 2. A review of R1’s activities of daily living sheet revealed the following: Brushing of teeth only occurred once on December 5, 6, 12, 13, 18, 19, 22 and 23, 2025. 3. A review of R1's medical record also revealed there was no documentation of any services provided at all for R1 on January 13, 2026. 4. A review of R2’s medical record revealed a service plan dated November 16, 2025, which included the following: Shampoo, two times a week; Shower, two times a week; Oral care, once daily. 5. A review of R2’s activities of daily living sheet revealed the following: Hair only documented as washed once on Jan 9 during the week of January 1-12, 2026. No documentation of showering the resident on January 2- 25, 2026. Oral care not documented at all on January 2, 3, 4, 5, 9, and 10, 2026. 6. A review of R2's service plan also stated R2 was totally incontinent, however, there was no documentation of incontinence care in R2's medical record. 7. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 8. This is a repeat deficiency from the inspection conducted on January 23, 2025.

Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the following unlocked medications inside a box in a refrigerator with a code that was exposed: Lorazepam Oral Concentrate, 2mL. Medication was labeled as belonging to R2. 2. A review of R1, R2, and R3’s medical records revealed no resident was authorized to self-administer their own medication. 3. A review of R1, R2, and R3's medical records revealed all three residents were receiving personal care services and all were ambulatory. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided. 5. This is a repeat deficiency from the inspection conducted on January 23, 2025.

Based on interview, record review, and documentation review, the manager failed to ensure that when a resident has an accident, emergency, or injury that results in the resident needing medical services, a caregiver or assistant caregiver documented the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. Findings include: 1. In an interview, E1 reported R1 had passed away after being hospitalized due to a health emergency that occurred on January 14, 2026. 2. A review of R1’s medical record revealed documentation that reported R1 was admitted to the hospital on January 14, 2026. 3. A review of R1’s medical record revealed documentation from a human remains release form that documented R1’s date of death as January 25, 2026. 4. A review of R1's medical record revealed no documentation of R1’s health emergency that resulted in R1 being hospitalized. 5. During the inspection, E1 completed a new incident report for R1’s health emergency and dated it for January 26, 2026. 6. In an exit interview, the findings were reviewed with E1 and no additional information was provided.