Chester's House, LLC

Based on documentation review and interview, the manager failed to ensure a training program was developed to include initial training and continued competency training in fall prevention and fall recovery. Findings include: 1 . A review of E2's personnel record revealed documentation of fall prevention and fall recovery training was not available for review. 2. In an interview, E1 acknowledged E2's personnel record had not included documentation of fall prevention and fall recovery training.

Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities as specified in R9-10-113. 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)... c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution...(d) Annually assessing the health care institution's risk of exposure to infectious tuberculosis" A Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." Findings include: 1. A review of E2's personnel record revealed that E2 was hired in March 2025 as a housekeeper. E2's personnel record included documentation of a negative test for infectious TB. However, E2's personnel record did not include a TB risk assessment or symptom screening prior to employment at the facility. 2. A review of E3's personnel record revealed that E3 was hired in November 2024 as a caregiver. E3's personnel record included documentation of a negative test for infectious TB. However, E3's personnel record did not include a TB risk assessment or symptom screening prior to employment at the facility. 3. A review of R2's medical record revealed R2 had resided at the facility for more than seven calendar days. R2's medical record included documentation of a negative test for infectious TB. However, R2's medical record did not include a TB risk assessment or symptom screening within seven calendar days after R2's date of acceptance. 4. A review of facility records revealed an annual risk assessment per R9-10-113(A)(2)(d) was not available for review. 5. In an interview, E1 acknowledged the facility had failed to implement tuberculosis (TB) infection control activities as specified in R9-10-113. Technical assistance was provide

Based on observation, documentation review, and interviews, the manager failed to ensure at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. Upon arriving at the facility, the Compliance Officer was greeted by E2. The Compliance Officer observed E2 calling E1 to advise E1 the Compliance Officer was on-site. 2. The Compliance Officer observed E2 was the only employee on-site. The Compliance Officer observed multiple residents were present at the facility. 3. The Compliance Officer observed a resident requesting assistance with toileting and being told by E2 to wait for E1. The Compliance Officer observed E1 arrive at the facility approximately ten minutes after being contacted by E2. 4. A review of E2's personnel record revealed E2 had been hired as a housekeeper in March of 2025 and did not have a caregiver certificate. 5. In an interview, E1 acknowledged that there was no certified caregiver onsite while a resident was present.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the water temperature was 123.5º F in a common bathroom using the Compliance Officer's thermometer. 2. In an interview, E1 showed the Compliance Officer the instant hot water heater was set to 119º F. E1 acknowledged the temperature in the common bathroom was not maintained between 95º F and 120º F.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed care instructions from a hospice agency, dated December 22, 2023, which stated, "reinforced Q2H turning with pillows, Proper positioning of pillows while lying on one side to prevent injuries to ankles with [E1], frequent reinforcement required." and dated January 25, 2024, which stated, "Reinforced Q2hr turning, [E1] verbalized understanding 2. A review of R1's medical record revealed a service plan, updated February 14, 2024, for directed care services. The service plan included a list of services which would be provided to R1 each day, including 2 hour turning and documentation of intake at each meal. 3. A review of R1's medical record revealed a document titled, "Vital Signs & ADL Sheet," (ADL) dated April 2024, which documented the services provided to R1 on each shift. However, the ADL had been left blank and no services were documented on April 29, 2024 on all shifts; and April 30, 2024 on all shifts. The ADLsheet included documentation of intake at breakfast and dinner on each day between April 1, 2024 and April 28, 2024, however, the box designated to enter R1's intake at lunch each day in April had been left blank. Additionally, documentation of turning R1 every 2 hours was not available for review. 4. In an interview, E1 reported R1 refuses to eat lunch every day and R1 would begin marking refused at every lunch period. E1 reported the ADL does document cleaning and toileting R1 every 2 hours and R1 is turned during this service. E1 reported E1 would modify the ADL chart to indicate turning is part of the two hour toileting service. 5. A review of R2's medical record revealed a service plan, updated December 29, 2024, for personal care services. The service plan included a list of services which would be provided to R2 each day. 6. A review of R2's medical record revealed a document titled, "Vital Signs & ADL Sheet," (ADL) dated April 2024, which documented the services provided to R2 on each shift. However, the ADL had been left blank and no services were documented on April 29, 2024 on all shifts; and April 30, 2024 on all shifts. 7. In an interview, E1 acknowledged the services provided to each resident had not been documented in each resident's medical record.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a documented residency agreement, signed by the manager's designee. However, the signature was not dated. 2. A review of R2's medical record revealed a documented residency agreement. However, the residency agreement was missing the signature page and did not include the manager's signature or date signed. 3. In an interview, E1 acknowledged the manager had not signed and dated the residency agreements provided for R1 and R2.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the resident or resident's representative requested the resident remain in the facility and the facility obtained a written determination from a medical practitioner every six months stating they have examined the resident and the resident's needs were met by the facility and the resident's needs were within the facility's scope of services, for one of two residents sampled who were confined to a bed or chair. Findings include: 1. A review of R1's medical record revealed a service plan for directed care services updated February 2, 2023, which indicated R1 was wheelchair bound. 2. A review of R1's medical record revealed a document titled, "Determination for Admission." The document was signed and dated by a medical practitioner and stated, "6. Is this person confined to a chair or bed and is unable to ambulate without assistance: Yes." 3. A review of R1's medical record revealed a documented titled, "Determination for residency to continue in the facility," dated June 6, 2022. The document was signed and dated by R1's representative and R1's primary care provider and stated the facility's scope of services had been reviewed and R1's needs could be met by the assisted living facility. 4. A review of R1's medical record revealed a "Determination for residency to continue the in the facility" form, signed and dated by a medical practitioner within six months prior to the on-site inspection, was not available for review. 5. In an interview, E1 reported R1 was non-ambulatory. E1 acknowledged R1's medical record did not include the required documentation to accept and retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance dated every six months during R1's residence at the facility. E1 reported when R1 began hospice services, E1 did not think the determination was still necessary.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed the front door of the facility was equipped with a door alarm. However, the door alarm was switched off and no audible alert was heard upon opening the door. 3. During an environmental inspection of the facility, the Compliance Officer observed a sliding glass door leading to the back yard did not have a door alarm and no alert was heard when the door was opened. 4. In an interview, E1 acknowledged a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility did not control or alert employees of the egress of a resident from the facility.

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: 1. During a facility tour, the Compliance Officer observed a posted food menu, dated September 2022. 2. In an interview, E1 acknowledged the date on the posted menu indicated a current menu had not been posted.