Crestlane Care Assisted Living

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Fall Prevention.” However, the policy did not include how the facility would develop and administer a training program for all staff regarding fall prevention and fall recovery. 2. A review of E1's personnel record revealed E1’s hire date of September 1, 2021. A review of E1’s personnel record revealed the following: Fall prevention training completed on November 6, 2025. No fall recovery training. 3. A review of E2's personnel record revealed E2’s hire date of November 16, 2025. A review of E2’s personnel record revealed the following: Fall prevention training completed on October 19, 2025. No fall recovery training. 4. In an exit interview, the findings were reviewed with E1 and O1, and no additional information was provided. 5. Technical Assistance was provided on this rule during the inspection conducted on November 14, 2024.

Based on record review, documentation review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution and annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of E1’s personnel record revealed a hire date of September 1, 2021, and no documentation of training and education related to recognizing the signs and symptoms of TB. 2. A review of E2’s personnel record revealed a hire date of October 16, 2025, and no documentation of training and education related to recognizing the signs and symptoms of TB. 3. A review of E3’s personnel record revealed a hire date of March 19, 2022, and no documentation of training and education related to recognizing the signs and symptoms of TB. 4. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment. 5. In an exit interview, the findings were reviewed with E1 and O1, and no additional information was provided. 6. Technical assistance was provided on this rule during the inspection conducted on November 14, 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 what staff was present each day to ensure the health and safety of residents. Findings include: 1. A review of the facility’s January 2026 work schedule revealed E2’s name on the calendar with no hours indicated. E3 was not included on the schedule. 2. In an exit interview, the findings were reviewed with E1 and O1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for one of three personnel sampled. The deficient practice posed a potential 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 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." 3. A review of E2’s personnel record revealed a chest X-ray. However, documentation was not available indicating E2 had a previous positive TB skin test or blood test, and without such documentation, a chest x-ray is not acceptable as documentation of freedom from TB. Based on E2's date of hire, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and O1, and no additional information was provided. 5. This is a repeat deficiency from the compliance inspection on November 29, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified 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's medical record revealed the following: No documentation of assessing risks of prior exposure to infectious TB No documentation of determining if the individual had signs or symptoms of TB Based on R1's admission date, this documentation was required. 3. A review of R2's medical record revealed the following: No documentation of assessing risks of prior exposure to infectious TB No documentation of determining if the individual had signs or symptoms of TB Based on R2's admission date, this documentation was required. 4. In an exit interview, the findings were reviewed with E1 and O1, and no additional information was provided. 5. Technical Assistance was provided on this rule during the inspection conducted on November 14, 2024.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services provided to the resident, for one of two residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a current written service plan dated December 1, 2025, which indicated R1 received personal care services. R1’s service plan did not include the frequency of assistance with dressing, elimination, grooming, skin check, reposition, and medication administration. 2. In an exit interview, the findings were reviewed with E1 and O1, and no additional information was provided.

Based on observation, record review, and interview, for one of two residents reviewed, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated. Findings include: 1. The Compliance Officers observed a lock at the top of R1's bedroom door facing the interior hallway. 2. Review of R1's medical record revealed a service plan dated August 2, 2024. The service plan indicated R1 had a diagnosis of dementia. 3. In an interview, E1 reported R1 was locked in R1's room when the caregivers would help other residents with their activities of daily living. E1 acknowledged R1 was not treated with dignity, respect, and consideration.

Based on observation, record review, and interview, the manager failed to ensure a resident was not subjected to seclusion. The deficient practice posed a risk if a resident or other individuals could be locked in a bedroom. Findings include: 1. R9-10-101.207 defines "Seclusion" as the involuntary solitary confinement of a patient in a room or an area where the patient is prevented from leaving. 2. The Compliance Officers observed a lock at the top of R1's bedroom door facing the interior hallway. 3. Review of R1's medical record revealed a service plan dated August 2, 2024. The service plan indicated R1 had a diagnosis of dementia. 4. Review of R1's medical record revealed a document titled "Consent for Door Lock" which stated, "Consent for Outside door lock to prevent resident going to other resident's room while ADLs are being provided. Door lock to be used when doing early ADLs with other residents. Oversight/supervision provided through out shift without use of door lock." 5. In an interview, E1 reported R1 was locked in R1's room when the caregivers would help other residents with their activities of daily living. E1 reported R1 wandered into another resident's room which resulted in a confrontation between the residents. E1 reported the lock was put up after the confrontation and was used to keep R1 safe. E1 acknowledged R1 was subjected to seclusion.

Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures were implemented ensuring the safety of a resident who may wander. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officers observed a lock at the top of the door. This lock was located on R1's bedroom door facing the interior hallway. 3. A review of the facilities policies and procedures revealed a policy titled "VII. Behaviors; Negotiated risk assessments" which stated the following procedures "3. Caregivers will maintain security locks on the front door, yards and hazardous areas at all times," and "4. Residents who cannot be safely secured within the facility will be referred to another facility of higher care in an effort to provide for their personal health and safety." This policy was not followed. 4. In an interview, E1 reported the lock on R1's door was installed due to R1 walking into another resident's room which caused an altercation between residents. E1 continued to report R1 would be locked in R1's room when the other residents were receiving care for their activities of daily living. E1 acknowledged the policy and procedure that ensured the safety of a resident who may wander was not implemented.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a service plan dated August 2, 2024. This service plan revealed R1 received directed care services. A further look into the service plan revealed a line running through a box indicating "staff controls, secures, and administers medications". 2. Review of R1's medical record revealed medication orders dated October 2, 2024 for Buspirone 10 mg and Lumigan .01%. However, a signature from a medical practitioner was not available for review. 3. Review of R1's medication administration record MAR for October 2024 revealed the following: Buspirone 10 mg was administered at 7 AM and 7PM October 1-31. Lumigan .01% was administered at 7 PM October 1-31. 4. In an interview, E1 acknowledged the medication orders were not signed by a medical practitioner.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for one of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed a progress note dated November 2024. The progress note stated, "... reviewed camera & noted pt having what appears like seisure at 3:54 AM..." The progress note later stated that paramedics were called, "...talk with [family member] and [family member] and they agree that I should call the paramedics," The description of event did not include documention of a call being made to R1's primary care provider. 2. In an interview, E1 acknowledged R1's medical record did not include documentation that showed a caregiver immediately notified the resident's primary care provider.

Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed a progress note dated November 2024. The progress note stated, "... reviewed camera & noted pt having what appears like seisure at 3:54 AM..." The progress note later stated that paramedics were called, "...talk with [family member] and [family member] and they agree that I should call the paramedics," The description of events did not include any action taken to prevent the incident from occurring in the future. 2. In an interview, E1 acknowledged R1's medical record did not include documentation of any action taken to prevent the incident from occurring in the future.

Based on record review and interview, the manager failed to provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of four employees reviewed. 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. 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." 3. Review of E4's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E4's hire date, this documentation was required. 4. In an interview, E1 acknowledged E4 did not provide documentation of freedom from infectious TB as specified in R9-10-113. 5. Technical assistance was provided on this Rule during the compliance inspection conducted on October 24, 2022.