Faith Assisted Living

Based on observation and interview, the manager failed to ensure a resident bedroom was not used as a passageway to another sleeping area. The deficient practice posed a privacy rights risk to a resident. Findings include: 1. A review of Department documentation revealed the perpetual license for AL12070 was effective on December 13, 2021. 2. The Compliance Officer observed and walked through the master bedroom, occupied by one resident, and then through the master bathroom where the master bedroom closet was located. 3. The Compliance Officer observed a sleeping area, with a bed, in the master bedroom closet. 4. In an interview, E1 reported the master bedroom closet was used as a rest area for E1. 5. In a joint interview, E1 and E2 acknowledged a resident bedroom was used as a passageway to another sleeping area.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed in-service education, for one of six personnel records sampled. Findings include: R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review of the facility's policies and procedures revealed a policy titled "STAFFING and RECORDKEEPING" (dated March 21, 2022). The policy and procedure stated "...Establishing Personnel Record Filing are the following...Continuing Education Credits..." 2. A review of E3's (hired in 2021) personnel record revealed current in-service education was not available for review. 3. In a joint interview, E1 and E2 acknowledged E3's in-service education was not included in the personnel record and was not provided to the Compliance Officer for review.