Embrace Assisted Living, LLC

Based on record review and interview, the manager failed to ensure a service plan was signed and dated by the resident or the resident's representative when the service plan was initially developed or when updated, for one of two sampled residents. Findings include: 1. A review of R2's medical record did not include documentation R2's service plan was signed and dated by the resident or the resident's representative for the service plan dated October 1, 2025. 2. 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 resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one 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 no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 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 a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of two caregivers reviewed. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency. Findings include: 1. A review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of July 2, 2021. The personnel record revealed a first aid and CPR card with an expiration date of June 12, 2025. There was no other current documentation of first aid and CPR training in E2's record. 2. In an interview, E1 acknowledged E2 did not have current documentation of first aid and CPR training. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's disaster drill documentation revealed documentation of a disaster drill conducted on July 4, 2025. However, documentation of additional drills was not available for review. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.