Immaculate Assisted Living, LLC

Based on observation, documentation review, record review and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. When the Compliance Officer arrived, E3 was the only staff member present at the facility. 2. Review of facility documentation revealed a document titled "Delegation of Manager's Authority" which revealed E5 was the only caregiver designated in writing to be accountable for the assisted living facility when the manager is not present on the assisted living facility premises. 3. Review of E3's personnel record revealed that E3's position was "assistant caregiver". 4. In an interview, E1 acknowledged a caregiver who was designated in writing was not present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present.

Based on observation, record review, and interview, the manager failed to ensure that at least the manager or a caregiver was present at the assisted living home when residents were present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. When the Compliance Officer arrived, E3 was the only staff member present at the facility. 2. Review of E3's personnel record revealed that E3's position was "caregiver assistant" and that E3 was not a certified caregiver. 3. In an interview, E1 acknowledged that at least the manager or a caregiver was not present at the assisted living home when residents were present.

Based on record review and interview, the manger failed to ensure that the residency of a resident was terminated with a 30-calendar-day written notice of termination. The deficient practice posed a risk as R1's rights were violated. Findings include: 1. The Compliance Officer observed that R1 was not present at the facility during the inspection. 2. Review of R1's medical record revealed no documented date of termination or written notice of termination. 3. In an interview, E1 reported that R1 went to the hospital but did not provide the date. E1 reported that R1's residency was terminated due to behaviors and was not allowed to return to the facility from the hospital. 4. In an interview, E1 acknowledged that the residency of R1 was terminated without a 30-calendar-day written notice of termination.

Based on record review and interview, the manager failed to ensure that a written notice of termination was provided to a resident. The deficient practice posed a risk as R1's rights were violated. Findings include: 1. The Compliance Officer observed that R1 was not present at the facility during the inspection. 2. Review of R1's medical record revealed no documented date of termination or written notice of termination. 3. In an interview, E1 reported that R1 went to the hospital but did not provide the date. E1 reported that R1's residency was terminated due to behaviors and was not allowed to return to the facility from the hospital. 4. In an interview, E1 acknowledged that R1 was not provided a written notice of termination.

Based on record review and interview, the manger failed to ensure that a resident's medical record contained the date of termination for a resident for 1 of 1 terminated residents reviewed. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. The Compliance Officer observed that R1 was not present at the facility during the inspection. 2. Review of R1's medical record revealed no documented date of termination or written notice of termination. 3. In an interview, E1 reported that R1 went to the hospital but did not provide the date. E1 reported that R1's residency was terminated due to behaviors and was not allowed to return to the facility from the hospital. 4. In an interview, E1 acknowledged that R1's medical record did not contain the date of termination.

Based on observation and interview, the manger failed to ensure that the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers to residents. Findings include: 1. In an unlocked caregiver room, the Compliance Officer observed a mattress propped up against a wall which blocked a door to the outside that had an "EXIT" sign above it. 2. In an interview, E1 acknowledged that the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on observation and interview, the manager failed to ensure heating and cooling systems maintained the assisted living facility at a temperature between 70° F and 84° F at all times. The deficient practice posed a risk to health and safety. ​ Findings include: ​ 1. The Compliance Officer observed the facility thermostat reading 31.5℃ (88.7 ℉). On a Department issued thermometer, the Compliance Officer observed a temperature of 87.8℉ in the facility. 2. In an interview, E1 acknowledged that heating and cooling systems did not maintain the assisted living facility at a temperature between 70° F and 84° F at all times.