Crossroads Assisted Living

Based on observation and interview, for a facility authorized to provide directed care services, 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 double sliding glass doors off the dining room were equipped with an egress alert; however, the egress alert was turned off at the time of the inspection. 2. During an environmental tour of the facility, the Compliance Officers observed a second door off the dining room was not equipped with a means to monitor or alert employees of the egress of a resident from the facility. 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 the hot water temperatures were maintained between 95°F and 120° F in areas of an assisted living facility used by residents. Findings Include: 1. During an environmental tour of the facility, the Compliance Officer observed the water temperature in the bathroom of room 8 measured 124.5°F. 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 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 and R2’s medical records revealed current service plans for personal care services. Each resident's service plan indicated the resident did not require assistance with turning; however, the service plans later indicated, “Assist to change positions every 2-3 hours to help with circulation and lower skin breakdown risk”. 2. A review of R1 and R2’s service plans revealed each resident's service plan included additional services the residents did not require. The same service plan was used for every resident whether female or male. 3. 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 “alendronate” was prescribed on April 26, 2025. The medication was prescribed as follows: “70 MG tablet, take one tablet every week by oral route.” 2. A review of R1’s medical record revealed a medication administration record (MAR) dated July 2025. The MAR documented “alendronate 70 MG” as being administered daily rather than every week as prescribed. 3. A review of R1’s medical record revealed a medication list which indicated the medication “diclofenac 1% topical gel” was prescribed on March 21, 2025. The medication was prescribed as follows: "Apply 2 grams to the affected areas by topical route 4 times per day." 4. A review of R1’s MAR revealed the medication “diclofenac 1% topical gel” was not listed on the MAR. However, the medication was available on-site for use. 5. In an exit interview, the findings were reviewed with E1. E1 reported they were administering the medications as prescribed, but failed to document it correctly.

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident's date of occupancy and 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. A review of R2’s medical record revealed a negative TB skin test; however, documentation of a baseline screening to include risk assessment and symptom screening was not available for review. 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 who was expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis as specified in R0-10-113, on or before the date the individual began providing services at the assisted living facility for one of two personnel sampled. The deficient practice posed a potential TB exposure risk to residents. Findings Include: 1. A review of E3’s personnel record revealed a baseline screening and first-step skin test were conducted; however, a second-step skin test was not available for review. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered to a resident in compliance with a medication order for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings Include: 1. A review of R2’s medical record revealed a signed medication list which included the following: - "Trazodone 50 mg tablet: Take 0.5 tablet(s) every day by oral route at bedtime" prescribed on July 22, 2025. 2. The Compliance Officer observed R2’s medication box did not include "Trazodone 50mg tablet". 3. In an exit interview, the findings were reviewed with E1. E1 acknowledged R2's Trazodone prescription had not been filled or administered as ordered. No additional information was provided.

Based on observation, record review, 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. A review of R1’s medical record revealed a service plan which indicated R1 received medication administration. 2. During an environmental tour, the Compliance Officers observed the medication, “alendronate” in R1’s nightstand along with a Ziploc bag of loose pills. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.