Crescent Surprise Assisted Living

Based on observation, documentation review, and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. Findings include: 1 . When the Compliance Officer arrived at the facility at approximately 9:15 am, the Compliance Officer observed E3 working on site by themselves. 2 . A review of facility documentation revealed a "Delegation of Authority" form dated August 30, 2025. The delegation of authority included E2, but did not include E3. 3 . In an interview, both E3 and E1 reported E2 was currently at the grocery store. 4 . In an exit interview, the findings were discussed with E1 and no additional information was added. This is a repeat deficiency from the inspection conducted on August 29, 2025.

Based on record review and interview, the manager failed to ensure an assisted living home maintained a standardized form for each resident that included the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted. Findings include: 1 . A review of resident medical records revealed, for two of two residents sampled, documentation of a standardized emergency medical services (EMS) form was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to designate, in writing, that a caregiver was present on the assisted living facility’s premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. During an environmental inspection, the Compliance Officers observed E3 working alone at the facility. 2. A review of the facility’s designee documentation did not list E3 as a designee. 3. A review of the facility’s August 2025 personnel schedule revealed E3 was scheduled to work every Monday to Friday from August 11, 2025 to August 29, 2025. 4. 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 a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services, and according to policies and procedures, for one of two caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1 . A review of facility documentation revealed a "Caregiver Schedule" for August 2025. Further review revealed E3 was scheduled to work multiple days throughout August 2025. 2 . A review of facility documentation revealed a policy titled "Verifying Caregiver's Skills and Knowledge." The policy stated, "The manager or manager's designee should ensure that before the caregiver provides physical health services or behavioral health services, his or her skills and knowledge are verified and documented." 3 . A review of E3's personnel record revealed documentation of skills and knowledge verification was not available for review at the time of inspection. 4 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a caregiver who was expected to have more than eight hours per week of direct interaction with the residents provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three personnel sampled. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1 . A review of E2's personnel record revealed documentation of a TB skin test conducted on September 3, 2024. However, the second skin test was documented as conducted on October 25, 2025. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation, documentation review, record review and interview, the manager failed to ensure before providing assisted living services to a resident, a caregiver received orientation that is specific to the duties to be performed by the caregiver, for one of two caregivers sampled. Findings include: 1 . When the Compliance Officers arrived at the facility at approximately 9:00 AM, the Compliance Officers observed E3 working and providing services without supervision. 2 . A review of facility documentation revealed a "Caregiver Schedule" for August 2025. Further review revealed E3 scheduled to work multiple days throughout August 2025. 3 . A review of facility documentation revealed a policy titled "Orientation, In-Service Trainings for Employees." The policy stated, "No individual should work unsupervised or alone in the facility until thoroughly familiar with all items listed on the New Employee Orientation form." 4 . A review of E3's personnel record revealed documentation of an orientation that was specific to the duties to be performed by the caregiver was not available for review at the time of inspection. 5 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that the bathroom near the common area had a window that opens or another means of ventilation. Findings include: 1. During an environmental inspection, the Compliance Officers (CO) observed the bathroom near the kitchen and resident rooms did not have a working fan. The CO pressed all the switches on the wall to turn on the fan. The fan never turned on or made any type of noise. 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 a caregiver documented the services provided to a resident in the resident's medical record, for one of two sampled residents. The deficient practice posed a risk as services were unable to be verified as provided against a service plan, and the facility provided false or misleading information. Findings include: 1. A review of R2's medical record revealed a service plan dated May 22, 2024. The service plan indicated R2 required showers 3-4 times per week and a partial bath on days when a shower was not given. Further review of R2's medical record revealed documentation of services provided to R2 (ADL sheet). The ADL sheet indicated R2 received a partial bath every day during the week of June 1-6, 2024. The ADL sheet did not indicate R2 received any showers during the week of June 1-6, 2024. 2. In an interview, R2 stated R2 did not receive either a full or partial bath on June 6, 2024. R2 stated R2 is fully independent with showers and does not need assistance from the caregivers for showers. 3. In a joint interview, E1 and E2 confirmed R2 was independent with bathing/showers and reported E2 pre-filled R2's ADL sheet on June 6, 2024.

Based on documentation review and interview, the manager failed to ensure documentation was maintained of the caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. Review of the September 2023 personnel schedule revealed E3 worked the 7pm - 7am shift September 2nd - 6th. 2. In an interview via telephone, E2 reported E3 had not worked at the facility since early May 2023. E1 and E2 acknowledged accurate documentation was not maintained of the caregivers working each day.

Based on documentation review, record review, observation, and interview, the manager failed to ensure an individual authorized by policies and procedures to administer an opioid, documented in the resident's medical record the identification of the resident's need for the opioid and the effect of the opioid administered, for one of one resident reviewed. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Opioid/Controlled Substances Administration and Assistance in the Self Administration Policy and Procedure" that stated "...4. The resident's need for the opioid administration will be assessed by the trained caregiver based on the specific parameters defined in the physician's order. 5. A combination of a Wong-Baker FACES scale and numeric rating...will be used to assess pain level prior to administer opioids ...9. Resident relief of pain will be assessed by the trained caregiver between 30 minutes to one hour after administration and response must be documented in the Control Substance Administration record and Inventory flowsheet..." 2. Review of R2's medical record revealed a signed medication order dated August 1, 2023. This medication order stated "Tramadol 50mg 1 tablet by mouth every 6 hours as needed." 3. Review of R2's medical record revealed a September 2023 medication administration record (MAR). This MAR stated "Tramadol 50mg 1 tablet by mouth every 6 hours as needed" and indicated one tab was administered at 8am, 2pm, and 8pm September 1st - present. However, documentation was not available showing the identification of R2's need for the opioid and the effect of the opioid administered. 4. During an observation of R2's medications Tramadol 50mg was observed. 5. Review of R2's medical record revealed no documentation stating R2 had an end of life condition or an active malignancy. 6. In an interview, E1 acknowledged the caregiver did not document in R2's medical record the identification of R2's need for the opioid and the effect of the opioid administered.