Crossroads Assisted Living

Based on observation, documentation review, and interview, the manager failed to ensure accurate documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings include: 1. Upon arriving at the facility, the Compliance Officers observed E2 and E4 working at the facility. 2 . A review of facility documentation revealed a document titled "Employee Schedule," dated July 2025. This work schedule indicated E3 had worked Monday through Friday, from 8 AM to 8 PM, between July 7, 2025 and August 1, 2025. However, E3 was not present at the facility on the day of this inspection as scheduled. 3. In an interview, E1 reported it was the first day of school and they had to change all the schedules around and had not updated the work schedule to reflect the change yet. 4. A review of Department records revealed E3 was working as a caregiver and was present at another facility during an inspection conducted on Friday, July 11, 2025, despite being on the work schedule for AL13191 on that day. 5. A review of Department records revealed the work schedule from the facility inspected on July 11, 2025 documented E3 worked from 8 AM to 8 PM on Tuesday through Friday between June 24, 2025 and July 18, 2025. 6 . In an exit interview, the findings were reviewed with E1. E1 reported the work schedules were accurate except for the day of the on-site inspection.

Based on record review and interview, the manager failed to ensure a resident's written service plan accurately included the amount, type, and frequency of assisted living services being provided to the resident, for two of two residents sampled. The deficient practice posed a risk if a resident's service plan did not include the services to be provided. Findings Include: 1. A review of R1’s medical record revealed a service plan for personal care services. The service plan for R1 stated R1 did not require assistance with turning; however, the service plan later stated, “Assist to change positions every 2-3 hours to help with circulation and lower skin breakdown risk.” 2. A review of R2’s medical record revealed a service plan for directed care services. The service plan included the following services that were not accurate: -The service plan states a caregiver will talk to the POA, but no POA was listed. -The service plan mentions a home health agency but R1 did not receive home health services. 3. A review of R1 and R2’s service plans revealed each resident's service plan included additional services the residents did not require. 4. 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 resident's representative was designated for a resident who was unable to direct self-care, for one of two residents receiving directed care services. The deficient practice posed a risk as no individual was designated to participate in decisions concerning the assisted living services the resident was to receive. Findings Include: 1. A review of R2’s medical record revealed a service plan for directed care services. 2. A review of R2’s medical record revealed a designation of a representative was not available for review. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, 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 monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings Include: 1. During an environmental tour of the facility, the Compliance Officers observed the door by room 7 was equipped with egress alerts; however, the egress alerts were turned off at the time of the inspection. 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 that a medication administered to a resident was documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings Include: 1. A review of R1’s medical record revealed a medication list which indicated the medication “Lidocaine 4% External Patch” was prescribed on March 21, 2025. The medication was prescribed as follows: “Apply 1 patch topically to intact skin of lower back daily. Leave on for 12 hours then remove”. 2. A review of R1’s medical record revealed the medication administration record (MAR), dated July 2025, did not list a Lidocaine Patch as given on any day in July 2025. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings Include: 1. During an environmental inspection of the facility, the Compliance Officers walked past the medication cabinet in the dining room area where no staff were present. The Compliance Officers observed the medication cabinet with a combination code that had not been scrambled. The Compliance Officers were able to open the medication cabinet which contained the medications of all residents. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, observation, record review, and interview, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. Findings Include: 1. A review of the facility’s policies and procedures covering medication administration, reviewed August 26, 2024, revealed a policy covering inventorying controlled substances, which stated, “Controlled substances: will be counted weekly, are stored with each resident’s medication, are dispensed in accordance with medication orders, a record of how often they are given”. 2. The Compliance Officers observed R1’s medication box which contained the medication “Tramadol”. 3. A review of R1’s medical record revealed a weekly count of R1's "Tramadol" was not available for review. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.