Elliecare

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 and February 2026 work schedule revealed a calendar with accurate caregiver names and scheduled times but no dates indicated. 2. In an exit interview, the findings were reviewed with E1 and E4, 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 determining if the individual has signs or symptoms of tuberculosis (TB), as specified in R9-10-113, for two 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 E3's personnel record revealed a signs or symptoms document dated November 12, 2025. E3's signs and symptoms document was signed by E1, not a registered nurse, as required. 3. A review of E2's personnel record revealed no documentation determining if the individual had signs or symptoms of tuberculosis. 4. In an exit interview, 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 had a service plan that was established, documented, and implemented which included the requirements in R9-10-808.A.3.a-f, for one of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R2's medical records revealed an incomplete service plan dated December 18, 2025. However, the service plan did not include the following: A description of the resident’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments; The level of service the resident is expected to receive; The amount, type, and frequency of assisted living services and ancillary services being provided to the resident, including medication administration or assistance in the self-administration of medication; and For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner.  2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure 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 observed a bottle of Chlorhexidine Gluconate Oral Rinse in the closet of R4 and R5's shared room. 2. A review of the facility's policies and procedures revealed a policy titled "Receiving, Inventory, and Tracking of Medications." This policy stated, "Medications once verified as correct shall be placed in the resident's labeled medication box at the facility in a locked medication cabinet." 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. This is a repeat deficiency from the compliance inspection conducted on October 29, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure he premises and equipment used at the assisted living facility are free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour, the Compliance Officers observed the following: A bottle of Acetone Nail Polish Remover, four bottles of nail polish, a bottle of fine fragrance mist, an aerosol can of disinfecting spray, and a jar of disinfecting wipes in R6's and R7's shared room. 3. In an exit interview, the findings were discussed with E1, and no additional information was provided. 4. This is a repeat difference from the compliance inspection conducted on October 29, 2024.

Based on record review and interview, the manager failed to ensure medication administered to a resident is administered in compliance with a medication order for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan which indicated R1 received personal care, and medication administration. The medical record contained a doctor's order, dated October 16, 2023, directing R1 to discontinue "Lisinopril 40 mg." 2. A review of R1's Medication Administration Record (MAR) for January 2024 revealed a section documenting the administration of "Lisinopril 40 MG 1 Tab PO QD." The section contained documentation indicating the medication was administered to R1 daily, from January 1, 2024, through January 25, 2024. 3. In an interview E1 acknowledged R1 did not receive medication as ordered.

Based on record review and interview, the manager failed to ensure medication administered to a resident is documented in the resident's medical record for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan which indicated R1 received personal care and medication administration. The medical record contained a doctor's order, dated November 16, 2023, directing R1 to take "Olmesartan 40 MG 1 Tab PO QD." 2. A review of R1's Medication Administration Record (MAR) for January 2024 revealed a section documenting the administration of ordered medications. However, the MAR did not include a section for documenting the administration of "Olmesartan 40 MG 1 Tab PO QD." 3. In an interview E1 acknowledged medication administered to a resident was not being documented in the resident's medical record. This is a repeat citation from a compliance inspection conducted on May 20, 2022.

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. Findings include: 1. During a tour of the facility the Compliance Officer observed a kitchen cabinet, which was not secured and the Compliance Officer was able to open with minimal effort. Inside the cabinet was a single, unopened tablet of "REMERONSolTab Orally Disintegrating Tablets 45 mg. While in the kitchen, the Compliance Officer observed E1 to leave the kitchen area and go into a back room of the residence, out of sight of the kitchen. 2. In an interview, E1 agreed that the medication had not been stored in a separate locked cabinet the facility uses for medication storage.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed no fewer than three ambulatory residents. The Compliance Officer also observed a small desk located in a den with a sliding glass door leading to the back yard. Inside the desk was a plastic container of "Non-Acetone Nail Polish Remover," which was marked "EXTREMELY FLAMMABLE, KEEP OUT OF EYES...HARMFUL IF INGESTED...CONSULT WITH LOCAL POISON CONTROL...KEEP OUT OF REACH OF CHILDREN." On top of the desk was a bucket which contained various utensils and products for a manicure including several bottles of nail polish. Further, the Compliance Officer observed a bottle of "Clorox Plus Tilex Daily Shower" cleaner inside an unsecured cabinet in a common bathroom used by residents and guests. Lastly, the Compliance Officer observed a storage shed, with a locking door handle. However, the lock was not engaged and the Compliance Officer was able to open the door will little effort, and observe a 2.5 gallon plastic container of "Pendulum 3.3 EC Herbicide." 2. In an interview, E1 acknowledged the poisonous and toxic materials were not kept in a locked area, inaccessible to residents.