Christ-centered Care Assisted Living LLC

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregiver working each day, including the hours worked. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer observed E1 and E2 on the premises and working upon arrival at 10 AM. 2. A review of facility documentation revealed a staffing schedule dated April 2023. However, the schedule did not include documentation of E2 working each day, including the hours worked. 3. In an interview, E3 reported E2 started working at the facility at the beginning of April 2023. E3 reported E2 had not updated the staffing schedule. E2 acknowledged documentation was not maintained for an assistant caregiver working each day, including the hours worked.

Based on documentation review, record review, and interview, the manager failed to ensure documentation required by Article 8 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. A review of facility documentation revealed a staffing schedule dated April 2023. However, the schedule did not include documentation of E2 working each day, including the hours worked. 2. A review of R1's medical record revealed a chest x-ray document dated January 30, 2022. The document stated, "INDICATION: Dyspnea" and included a hand-written note which stated "NO TB." However, the medical record revealed no evidence R1 had a history of a positive skin test or other TB screening test recommended by the Centers for Disease Control and Prevention (CDC); and the chest x-ray was not an infectious TB screening test. 3. A review of R2's medical record revealed a document titled "Determination of Continuous Residency." However, the document was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 4. In an interview, E3 acknowledged documentation required by Article 8 was not provided to the Department within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy. The deficient practice posed a TB exposure risk to residents, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R1's (accepted in 2022) medical record revealed a chest x-ray document dated January 30, 2022. The document stated, "INDICATION: Dyspnea" and included a hand-written note which stated "NO TB." However, the medical record revealed no evidence R1 had a history of a positive skin test or other TB screening test recommended by the Centers for Disease Control and Prevention (CDC); and the chest x-ray was not an infectious TB screening test. 2. In an interview, E3 acknowledged R1 did not provide current documentation of freedom from infectious TB.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R2's (accepted in 2021) medical record revealed a document titled, "Determination of Continuous Residency." However, the document was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. In an interview, E2 acknowledged R2's aforementioned document was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'b0 F and 120\'b0 F in areas of the assisted living facility used by residents. The deficient pratice posed a burn risk to residents. Findings include: 1. The Compliance Officer observed the hot water temperature to be 134.6\'b0 F in the sink of a private resident bathroom using a Department issued thermometer. 2. The Compliance Officer observed the hot water temperature to be 135.4\'b0 F in the sink of R1's private bathroom using a Department issued thermometer. 3. The Compliance Officer observed the hot water temperature to be 135.2\'b0 F in the sink of a common bathroom used by residents, using a Department issued thermometer. 4. In an interview, E3 acknowledged the hot water temperature was not maintained between 95\'b0 F and 120\'b0 F. This is a repeat deficiencly from the onsite compliance inspection conducted on April 26, 2022.