Marie's Board and Care II

Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder was contacted. Findings include: 1 . A review of R1's, R2's, R3's, R4's and R5's medical records revealed documentation of a maintained standardized form for the emergency responder was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two caregivers sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1 . A review of E3's personnel record revealed documentation of negative TB skin tests. However, documentation of a signs and symptoms screening and risk assessment was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on December 13, 2024.

Based on 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 three of five residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1 . A review of R1's and R3's medical records revealed no documentation of a negative TB test or signs and symptoms screening and risk assessment at the time of inspection. 2 . A review of R2's medical record revealed a negative TB test. However, documentation of a signs and symptoms screening and risk assessment was not available for review at the time of inspection. 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on December 13, 2024.

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, that was completed no later than 14 calendar days after the resident’s date of acceptance for one out of five residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R6's medical record revealed service plan updates dated December 1, 2024, June 1, 2025, and October 3, 2025. However, documentation of a service plan completed within 14 calendar days after the resident's acceptance was not available for review at the time of inspection. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on December 13, 2024.

Based on record review and interview, the manager failed to ensure a caregiver documented services provided in the resident's medical record, for two of six residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1 . A review of R1's medical record revealed a current service plan. The service plan listed R1 received assistance with dressing and grooming daily. However, review of R1's activities of daily living (ADL) sheet for the month of December 2025 revealed services not marked as provided on December 4, 2025. 2 . A review of R2's medical record revealed a current service plan. The service plan listed R2 received assistance with combing hair, washing face, nail care and oral hygiene daily. However, review of R2's ADL sheet for the month of December 2025 revealed services not marked as provided on December 4, 2025. 3 . In an exit interview, the findings were discussed with E1, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on December 13, 2024.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for three of five 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 R2's medical record revealed signed medication orders for the following: -Pantoprazole 40 MG, 1 tablet once daily; -Losartan 50 MG, 1/2 tablet once daily; and -Senokot 8.5 MG, 1 tablet once daily. However, a review of R2's medication administration record (MAR) sheet revealed all medications listed above were not documented as administered on December 4, 2025. 2 . A review of R3's medical record revealed signed medication orders for the following: -Prozac 10 MG, 1 tablet once daily; -Seroquel 25 MG, 1 tablet once daily; -Aspirin 81 MG, 1 tablet once daily; -Zyrtec 10 MG, 1 tablet once daily; -Losartan 50 MG, 1 tablet once daily; -Amlodipine 5 MG, 1 tablet once daily; -Flonase 50 MG, 2 puffs in each nostril daily; -Latanoprost one drop in each eye daily; -Wixela 25/50 inhaler, one puff twice daily; -Trazodone 100 MG, 1 tablet once daily; and -Senokot 8.5 MG, 1 tablet once daily. However, a review of R3's medication administration record (MAR) sheet revealed all medications listed above were not documented as administered on December 4, 2025. 3 . A review of R4's medical record revealed signed medication orders for the following: -Primidone 50 MG, 1 and a half tablets three times daily; -Hydroxyzine HCL 25 MG, 1 tablet three times daily; -Senokot 8.5 MG, 1 tablet twice daily; -Lispro 100 insulin three times daily; -Oxycodone 5 MG, 1 tablet four times daily; -Amlodipine 5 MG, 1 tablet once daily; -Bupropion 150 MG, 1 tablet once daily; -Donepezil 10 MG, 1 tablet once daily; -Farxiga 10 MG, 1 tablet once daily; -Fluoxetine 20 MG, 2 tablets once daily; -Isosorbide 30 MG, 1 tablet once daily; -Solifenacin 10 MG, 1 tablet once daily; -Tradjenta 5 MG, 1 tablet once daily; -Pramipexole 1 MG, 1 tablet once daily; -Pregabalin 50 MG, 1 tablet twice daily; and -Comtess 75 MG, 1 tablet once daily. However, a review of R4's medication administration record (MAR) sheet revealed all medications listed above were not documented as administered on December 4, 2025. 4 . In an exit interview, the findings were discussed with E1 and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on December 13, 2024.

Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separated locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a box of "Albuterol Sulfate" sitting on top of the TV stand in a resident room. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a bottle of "Downy" laundry detergent sitting on the shelf in the shower of the resident bathroom. Further inspection revealed a can of "Walgreens" disinfectant spray sitting on a shelf above the toilet. 2 . During an environmental inspection of the facility, the Compliance Officer observed a can of "Lysol" disinfectant spray sitting on the counter of the common hallway bathroom sink. Further inspection revealed a bottle of "Simple Green" cleaner in a basket behind a curtain in the same bathroom. 3 . In an exit interview, the findings were discussed with E1 and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on December 13, 2024.

Based on observation and interview, the manager failed to ensure the swimming pool was locked when the swimming pool was not in use. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a padlock on the door gate latch for the pool. However, the padlock was unlocked. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge was verified and documented before the caregiver provided physical health services and according to policies and procedures, for two of two caregivers sampled. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Job Description." This policy stated in the Employee Qualifications: "Include the specific skills and knowledge necessary for the caregiver or assistant caregiver to provide the expected assisted living services." 2. A review of E2's and E3's personnel record revealed no documentation of skills and knowledge. 3. In an interview, E1 acknowledged E2's and E3's record did not contain documentation of E2's and E3's skills and knowledge before E2 and E3 provided physical health services, and according to policies and procedures.

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for two of three employees who were expected to have more than eight hours of direct interaction with residents, which posed a potential health and safety risk to residents and staff of TB exposure. Findings include: 1. A review of facility's policies and procedures revealed a policy titled "Facility Job Description, Duties, and Qualifications." The policy stated, "Documentation of free of pulmonary tuberculosis within six (6) months of the hire date and then within plus or minus thirty (30) days of the twelve (12) month anniversary date of the most recent test." 2. A review of E2's personnel record revealed two negative TB skin tests. However, E2's personnel record did not contain a TB risk assessment and signs and symptoms questionnaire as required. 3. A review of E3's personnel record revealed a chest xray for TB dated July 2023. No additional documentation of freedom from infectious TB was available to review. E3's personnel record did not contain the TB risk assessment and signs and symptoms questionnaire as required. 4. In an interview, E1 acknowledged E2's and E3's personnel record did not contain a TB screening test and TB risk assessment and signs and symptoms questionnaire as recommended by the CDC. E1 acknowledged E2 and E3 had more than eight hours of direct interaction with residents and did not have current documentation of freedom from infectious TB. .

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 orientation. Findings include: 1. A review of the facility's policies and procedures stated, "Before providing assisted living services to a resident, a manager, caregiver or assistant caregiver receives orientation that is specific to the duties to be performed by the manager, caregiver or assistant caregiver" 2. A review of E1's personnel record revealed a hire date of July 15, 2024. 3. A review of E1's personnel record revealed no documentation to demonstrate E1 completed orientation prior to providing services to residents. 4. In an interview, E1 reported E1 did not know that a manager needed an orientation. E1 acknowledged E1 did not complete orientation.

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 two of two residents reviewed, which posed a potential health and safety risk to residents and staff of TB exposure. Findings include: 1. A review of the facility's policies and procedures stated, "Documentation of freedom from pulmonary tuberculosis" was required in the resident's record. 2. A review of R1's and R2's record revealed no documentation of freedom from infectious TB. 3. In an interview, E1 reported E1 was new and did not know if R1 and R2 had submitted evidence of freedom from infectious TB and could not find any evidence in R1's and R2's medical record. E1 acknowledged R1's and R2's medical record did not contain evidence of freedom from infectious TB.

Based on record review and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance, for one of two residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed no service plan was available for review. Based on the resident's date of acceptance, this documentation was required. 2. In an interview, E1 acknowledged R2's medical record did not contain a completed service plan.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided. Findings include: 1. A review of R1's medical record revealed Activities of Daily Living (ADL) documentation was not available for the months of October 2024, November 2024, and December 2024. 2. A review of R2's medical record revealed ADL documentation was not available for review. 3. In an interview, E1 reported E1 was unsure where R1's ADL documentation for the months of October, November and December were located. E1 acknowledged the caregiver did not document the services provided in R1's and R2's medical record.

Based on record review and interview, the manager failed to ensure a medical record was maintained at the facility, for one of two resident records requested. The deficient practice posed a risk as required information could not be verified for one of two sampled residents. Findings include: 1. In an on-site compliance investigation, the Compliance Officers requested R2's medical record. However, R2's medical record was not available for review. 2. In an interview, E1 reported the hospice documentation was the only record available for R2. E1 acknowledged R2's medical record was not available.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of two residents reviewed, which posed a health and safety risk to the resident if a caregiver did not know if a medication was administered. Findings include: 1. A review of R2's medical record revealed a medication order dated September 26, 2024 for Senna 50mg, 2 tablets by mouth at bedtime. 2. A review of R2's medical record revealed documentation of a current medication administration record (MAR). However, the MAR indicated Senna was not administered from December 9, 2024 to December 12, 2024. 3. In an interview, E1 reported E2 forgot to fill out the MAR. E1 acknowledged medication was not accurately documented in R2's medical record as administered.

Based on observation, documentation review, and interview, the manager failed to ensure a food menu was prepared at least one week in advance and conspicuously posted at least one calendar day before the first meal on the food menu was served. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. In an environmental inspection of the facility, the Compliance Officers observed a menu dated November 2024. 2. A review of the facility's policies and procedures stated, "Menus are prepared at least one week in advance, dated and conspicuously posted." 3. In an interview, E1 reported there was not a December 2024 menu available for review. E1 acknowledged the menu was not posted.

Based on observation, record review, and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer. The deficient practice posed a health and safety risk if the refrigerator was not maintained at a proper temperature. Findings include: 1. In an environmental inspection of the facility, the Compliance Officers observed a thermometer in the refrigerator in the kitchen. The thermometer was broken. This refrigerator contained food used for the residents. 2. During the environmental inspection of the facility, the Compliance Officers observed a second refrigerator. This refrigerator did not have a thermometer and contained food used for the residents. 3. In an interview, E2 reported the refrigerator was used to store food for the residents. E2 reported E2 did not know that the thermometer was broken. In a telephone interview, E3 reported there was a thermometer in the second refrigerator but E3 was not present to find it. E1 acknowledged the refrigerators did not contain a thermometer.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months; and included all individuals on the premises except for a resident whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident. The deficient practice posed a health and safety risk to residents and employees if the employee were unable to implement the evacuation plan. Findings include: 1. In a documentation review, the most recent evacuation drill was dated October 15, 2024. However, the documentation indicated no residents participated in the drill. 2. In an interview, E1 acknowledged the evacuation drills for employees and residents were not conducted at least once every six months.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents, which posed a health and safety risk if a resident inappropriately used the toxic material. Findings include: 1. In an environmental inspection of the facility, the Compliance Officers observed a closet in the bathroom. However, the closet was not locked. The unlocked closet contained a bottle of Household disinfectant cleaner from Walgreens. 2. The Compliance Officers observed a cabinet under the kitchen sink. However, the cabinet was not locked and contained a bottle of bleach. 3. In an interview, E1 reported that E1 told E2 to keep the poisonous or toxic materials under lock and key. E1 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents.

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a personnel member was unable to meet the needs of a resident. Findings include: 1. A review of facility documentation revealed revealed no evidence to indicate a training program regarding fall prevention and fall recovery was developed and administered to all staff. 2. A review of the personnel records for E1, E2, and E3 revealed documentation of initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 reported a fall prevention and recovery training program was developed. However, no documentation of a fall prevention and recovery training program was provided for review.

Based on observation, documentation review, record review, and interview, the manager failed to ensure three of three current caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services. Findings include: 1. The Compliance Officer arrived at the facility at 9:40 AM. At the time of arrival, the Compliance Officer observed E2 working alone at the facility. E1 arrived to the facility approximately thirty (30) minutes later. 2. A review of facility documentation revealed a daily staffing schedule dated June 2023. The June 2023 schedule indicated the facility operated on three (3) shifts: 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM. 3. A review of the June 2023 daily staffing schedule revealed E1 was scheduled to work on June 1, 2, 7, 8, and 9, 2023 from 7:00 AM to 3:00 PM. 4. A review of the June 2023 daily staffing schedule revealed E2 was scheduled to work on June 3, 10, 17, and 24, 2023 from 7:00 AM to 3:00 PM. 5. A review of the June 2023 daily staffing schedule revealed E3 was scheduled to work on June 1, 2, 8, and 9, 2023 from 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM, and June 5, 6, 12, and 13, 2023 from 7:00 AM to 3:00 PM. 6. A review of E1's, E2's, and E3's personnel records revealed no documentation of verification of skills and knowledge. 7. In an interview, E1 reported E1 was unaware a skills and knowledge verificaiton document was required in each personnel file.

Based on documentation review, record review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers who worked each day, including the hours worked by each. Findings include: 1. The Compliance Officer arrived at the facility at 9:40 AM. At the time of arrival, the Compliance Officer observed E2 working alone at the facility. E1 arrived to the facility approximately thirty (30) minutes later. 2. A review of facility documentation revealed a daily staffing schedule for June 2023. The June 2023 schedule indicated E2 was scheduled to work on June 3, 10, 17, and 24, 2023 from 7:00 AM to 3:00 PM. The June 2023 schedule did not indicate E2 was scheduled to work on June 14, 2023, the day of the inspection. 3. In an interview, E2 stated E1 called E2 to have E2 come to the facility to cover E1's shift while E1 took a resident to a medical appointment. 4. In an interview, E1 stated E1 was only gone for about an hour and E2 is a regular staff member. E1 stated E1 didn't think the schedule needed to be modified, since E1 was returning to cover the remainder of the shift.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of three personnel members sampled. Findings include: 1. A review of facility documentation revealed a daily staffing schedule for June 2023. The June 2023 schedule indicated E2 was scheduled to work the "First Shift" from 7:00 AM to 3:00 PM every Saturday in June 2023. 2. A review of E2's personnel record revealed documentation of first aid and CPR training. However, the training expired in March 2023. No current first aid or CPR training documentation was available for review. 3. In a joint interview, E2 reported E2 would renew E2's first aid and CPR training as soon as possible. E1 reported E1 was unaware E2's first aid and CPR training was expired. E1 stated E1 would monitor staff files and expiration dates more closely going forward. This is a repeat citation from the previous on-site compliance inspection conducted on February 24, 2022.

Based on documentation review, observation, record review and interview, the manager of a facility authorized to provide directed care services failed to ensure a means of exiting the facility, allowing the resident to be at least 30 feet away from the facility, was controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed AL9283 was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed four doors exiting the facility allowing residents to be at least 30 feet away from the facility. However, none of the doors observed controlled or alerted employees of the egress of a resident from the facility. 3. In an interview, E1 acknowledged the doors exiting the facility did not control or alert employees of the egress of a resident from the facility.