Compassionate Senior Care LLC

Based on documentation review and interview, the health care institution’s chief administrative officer failed to implement tuberculosis infection control activities that annually assessed the health care institution’s risk of exposure to infectious tuberculosis. Findings include: 1. A review of the facility’s annual TB facility risk assessment documentation revealed no completed documentation of a TB facility risk assessment. 2. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the governing authority failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. Findings include: 1. A review of the facility’s quality management documentation revealed a quality management review completed for August 2023 and October 2023. However, further documentation was not available for review. 2. A review of the facility’s policies and procedures revealed a policy titled "Quality Management Program”. The policy stated, “A governing authority/licensee shall: Review and evaluate the effectiveness of the quality management program at least once every 12 months.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program, which included the frequency of submitting a documented report required in subsection (2) to the governing authority. Findings include: 1. A review of the facility’s quality management documentation revealed documentation of a report submitted to the governing authority on the following dates: June 2025, August 2025, and October 2025. However, further documentation was not available for review. 2. A review of the facility’s policies and procedures revealed a policy titled "Quality Management Program Record”. The policy stated, “At least every two (2) months, a quality management program must be reviewed and reported to the governing authority.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a manager provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for one of three personnel records sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2’s personnel record revealed a CPR and first aid certification from the American Heart Association, with an expiration date of December 2025. However, after further review, no documentation of a current CPR and first aid certification was revealed. 2. A review of the facility’s policies and procedures revealed a policy titled "Cardiopulmonary Resuscitation (CPR) and First Aid”. The policy stated, Each manager, caregiver, and applicable employees will provide a copy of their CPR and First Aid to the assisted living facility each time new documents are obtained. If for any reason the employee’s CPR or First Aid expires then the employee will immediately disqualify them self from working until CPR or First Aid is updated.” 3. A review of the facility’s work schedule revealed E2 was scheduled to work from 7:00 PM-7:00 AM on January 3, 2026. 4. In an exit interview, the findings were discussed 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) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a potential illness 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’s medical record revealed no documentation that assessed risks of prior exposure to TB. 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident’s needs. Findings include: 1. A review of R1’s medical record revealed no documentation that included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints before or at the time of admission. 2. A review of the facility’s policies and procedures revealed a policy titled "Resident Acceptance”. The policy stated, “A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendars before the individual is accepted by the assisted living facility.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident had a service plan that was signed and dated by the resident or resident’s representative and the manager, for two of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include:  1. A review of R1’s medical record revealed a service plan dated December 2025, which indicated R1 required directed care services. However, the service plan did not include a signature and date from the resident or resident representative, and the manager. 2. A review of R2’s medical record revealed a service plan dated February 2026 which indicated R2 required directed care services. However, the service plan did not include a signature and date from the resident or resident representative, and the manager. 3. A review of the facility’s policies and procedures revealed a policy titled "Service Plan”. The policy stated, “When initially developed and when updated, is signed and dated by: The resident or resident’s representative; the manager.” 4. In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility’s disaster plan documentation revealed documentation of an annual disaster plan review. However, all documentation was blank. 2. A review of the facility’s policies and procedures revealed a policy titled "Disaster Plan for Relocating Residents”. The policy stated, “The disaster plan required will be reviewed at least once every 12 months.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.