Peaceful Haven Assisted Living L L C

Based on observation, record review, and interview, the manager failed to ensure an assistant caregiver interacted with residents only under the supervision of a manager or caregiver. The deficient practice posed a risk if the individuals were not qualified to provide the required services. Findings include: Upon arriving at the facility on February 26, 2026, at 09:40 AM, the Compliance Officer observed E2 was the only employee present at the facility and was providing services to the residents of the facility. A review of E2's personnel record revealed E2 was an assistant caregiver. At approximately 09:55 AM on February 11, 2026, E1 arrived at the facility. E1 acknowledged the residents had been present without a certified caregiver. E1 reported E1 was at the facility earlier in the day and was the caregiver scheduled to work and responsible for the facility, but had left to run an errand. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is an uncorrected deficiency from the on-site compliance inspection conducted on February 11, 2026.

Based on observation, record review, and interview, the manager failed to ensure at least the manager or a caregiver was present at the assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as the uncorrected violation shows a pattern of noncompliance to ensure the health and safety of residents and posed a risk as no qualified employee was present to meet a resident's needs. Findings include: Upon arriving at the facility on February 26, 2026, at 09:40 AM, the Compliance Officer observed E2 was the only employee present at the facility. A review of E2's personnel record revealed E2 was an assistant caregiver. At approximately 09:55 AM on February 26, 2026, E2 arrived at the facility. E2 acknowledged the residents had been present without a manager or certified caregiver available. In an exit interview with E2, the findings were reviewed and no additional information was provided. This is an uncorrected deficiency from the on-site compliance inspection conducted on February 11, 2026.

Based on record review and interview, the manager failed to ensure, before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement for one of two sampled residents, and failed to ensure a documented residency agreement included the manager's signature and date, for two of two sampled residents. Findings include: A review of R1's medical record revealed a residency agreement. However, the residency agreement had been signed and dated by the governing authority 19 days after R1's date of acceptance. A review of R2's medical record revealed a residency agreement was not available for review. In an interview, E1 reported a residency agreement for R2 had not been completed yet. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, for one of one sampled residents with a service plan, the manager failed to ensure a service plan included the level of service a resident was expected to receive. Findings include: A review of R1's medical record revealed a service plan, dated November 25, 2025. However, the service plan did not include the level of service R1 was expected to receive. In an exit interview with E1, the finding was reviewed and no additional information was provided.

Based on record review and interview, for one of one sampled residents who required behavioral care, the manager failed to ensure a service plan included the psychosocial interactions or behaviors for which the resident required assistance, the psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors. Findings include: A review of R1's medical record revealed a history and physical from a hospital, dated three weeks prior to R1's date of acceptance. The history and physical stated, "...past medical history of chronic back pain on hydrocodone and depression who presented to the ED due to unwitnessed fall with head laceration and subsequent severe anemia since earlier today. History obtained from chart as patient is minimally cooperative. She reportedly received Ativan on the behavioral unit prior to the fall, was found on the floor with actively bleeding scalp laceration and skin tears on both arms, refused wound care and vital signs, and was transferred for CT head and further workup. On my exam today, [R1] was resting, arousable, and not participating in interview...[R1] has poor appetite with ~20 lb weight loss over 3 months and severe depression; lives with a roommate; urine tox previously positive for opiates.....Depression (F32.A): History of Depression. Was a BH title 36 admit before the fall....Discharge Planning: Behavior Health." A review of R1's medical history revealed progress notes from a hospital dated a week prior to R1's date of acceptance. The progress notes stated, "Depression (F32.A): History of Depression. Was a BH title 36 admit before the fall. Patient denies symptoms of depression today. Started quetiapine. Started trazodone for sleep. 11/3 Patient got agitated and confused, tried to leave. Verbal deescalating attempts was unsuccessful, given Haldol." A review of R1's medical record revealed a medical administration record (MAR) dated February 2026. The MAR indicated R1 was administered the following psychotropic medications: "Trazodone," "Sertraline," and "Haloperidol." A review of R1's medical record revealed a service plan, dated November 25, 2025. The service plan included a list of medical diagnoses, including "Depression." However, the service plan did not include the psychosocial interactions or behaviors for which the resident required assistance, the psychotropic medications ordered for the resident, planned strategies and actions for changing the resident’s psychosocial interactions or behaviors, and goals for changes in the resident’s psychosocial interactions or behaviors. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure the service plan for a resident who required behavioral care was reviewed by a medical practitioner or behavioral health practitioner, for one of one sampled residents who required behavioral care. Findings include: A review of R1's medical record revealed a history and physical from a hospital, dated three weeks prior to R1's date of acceptance. The history and physical stated, "...past medical history of chronic back pain on hydrocodone and depression who presented to the ED due to unwitnessed fall with head laceration and subsequent severe anemia since earlier today. History obtained from chart as patient is minimally cooperative. She reportedly received Ativan on the behavioral unit prior to the fall, was found on the floor with actively bleeding scalp laceration and skin tears on both arms, refused wound care and vital signs, and was transferred for CT head and further workup. On my exam today, [R1] was resting, arousable, and not participating in interview...[R1] has poor appetite with ~20 lb weight loss over 3 months and severe depression; lives with a roommate; urine tox previously positive for opiates.....Depression (F32.A): History of Depression. Was a BH title 36 admit before the fall....Discharge Planning: Behavior Health." A review of R1's medical history revealed progress notes from a hospital dated a week prior to R1's date of acceptance. The progress notes stated, "Depression (F32.A): History of Depression. Was a BH title 36 admit before the fall. Patient denies symptoms of depression today. Started quetiapine. Started trazodone for sleep. 11/3 Patient got agitated and confused, tried to leave. Verbal deescalating attempts was unsuccessful, given Haldol." A review of R1's medical record revealed a medical administration record (MAR) dated February 2026. The MAR indicated R1 was administered the following psychotropic medications: "Trazodone," "Sertraline," and "Haloperidol." A review of R1's medical record revealed a service plan, dated November 25, 2025. The service plan included a list of medical diagnoses, including "Depression." However, the service plan did not include documentation of review by a medical practitioner or behavioral health professional. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan was signed by the resident or resident's representative, when the service plan was initially developed or when updated, for one of one sampled resident. Findings include: A review of R1's medical record revealed a service plan, dated November 25, 2025. However, the service plan was not signed by the resident or the resident's representative. In an exit interview with E1, the finding was reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in a resident's medical record, for one of two sampled residents. Findings include: A review of R1's medical record revealed a service plan, dated November 25, 2025. The service plan indicated R1 required "partial/complete" assistance with bathing, "reminders" for oral care, "partial/complete assist" with nail care, and "partial/complete assist" with skin care, including "check skin daily with brief changes," and "routine skin care (non-medicated OTC lotion/cream to body)." A review of R1's medical record revealed a form used for documenting the services provided to R1 in February 2026. The form included sections to document bathing, lotion, oral care, and nail care. However, these sections were blank for every day in February 2026 between February 1, 2026, and the day of the on-site inspection. A review of R1's medical record revealed documentation of services provided to R1 in November 2025, December 2025, and January 2026 were not available for review. In an interview, E1 reported R1 was on hospice and hospice was providing showers to R1; however, the service plan did not document hospice services and included a plan for the facility staff to shower R1. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure, at the time of acceptance, a resident or the resident's representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (C), for one of two sampled residents. Findings include: A review of R2's medical record revealed a form titled "Receipt of required documents." This form included a list of required notifications the facility would provide to the resident upon acceptance and had a place to document the resident's name, date of birth, acceptance date, signature, and date signed. However, the form had been left blank. In an exit interview with E1, the finding was reviewed and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance inspection conducted on February 11, 2026.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's date of acceptance. Findings include: A review of R2's medical record revealed documentation of R2's date of acceptance was not provided for review. Multiple forms included a spot to document R2's date of admission or date of acceptance, however, none of the forms had been filled out with this information. A review of R2's medical record revealed a form titled "Controlled Substance Log," which documented "Diazepam" had been removed from R2's medication storage on February 24, 2026, February 25, 2026, and February 26, 2026, indicating R2 had been present at the facility since at least February 24, 2026. In an exit interview with E1, the finding was reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility. Findings include: A review of R2's medical record revealed a form titled "Receipt of required documents." This form included a list of required notifications the facility would provide to the resident upon acceptance, including orientation to the exits, and had a place to document the resident's name, date of birth, acceptance date, signature, and date signed. However, the form had been left blank. A review of R2's medical record revealed a form titled "Controlled Substance Log," which documented "Diazepam" had been removed from R2's medication storage on February 24, 2026, February 25, 2026, and February 26, 2026, indicating R2 had been present at the facility for more than 24 hours. In an exit interview with E1, the finding was reviewed and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance inspection conducted on February 11, 2026.

Based on record review and interview, the manager failed to ensure a written order verifying a verbal order was obtained from a medical practitioner within 14 calendar days after receiving a verbal order, for one of two sampled residents. Findings include: A review of R1's medical record revealed medication orders from a medical practitioner were not available for review. A review of R1's medical record revealed verbal orders from a hospice nurse had been received on December 31, 2025. However, orders from a medical practitioner, dated within 14 calendar days after receiving the verbal order, were not provided for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review, interview, and observation, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: A review of R2's medical record revealed a verbal order for medications, dated February 25, 2026. The verbal order included the following orders: "Diazepam 5 mg (1 tab) 4 times a day, oral, anxiety." "Diazepam 5 mg every 6 hours as needed, oral, anxiety." "Seroquel 100 mg, at bedtime, by mouth, Anxiety, sleep." "Gabapentin 300 mg, at bedtime, by mouth, pain." "Senna 8.6 MG, 1 time a day, oral, Constipation." A review of R2's medical record revealed a medication administration record (MAR) dated February 2026. The MAR had been initiated on February 25, 2026. The MAR included the following issues: For "Diazepam 5 mg (1 tab) 4 times a day, oral, anxiety," this medication was not documented on the MAR. For "Diazepam 5 mg every 6 hours as needed, oral, anxiety," this medication was not documented on the MAR. For "Seroquel 100 mg, at bedtime, by mouth, Anxiety, sleep," this medication was not documented on the MAR. For "Gabapentin 300 mg, at bedtime, by mouth, pain," this medication was listed on the MAR but had not been documented as administered. For "Senna 8.6 MG, 1 time a day, oral, Constipation," this medication was transcribed incorrectly as "Sena Tab 8.6 MG, Take 1 tablet by mouth every evening (as needed)," and had been administered one time at 5 PM on February 25, 2026. A review of R2's medical record revealed a controlled substance log for "Diazepam 5 MG Tab." The controlled substance log contained entries showing a pill had been removed from R2's medication storage; however, the log did not indicate the time or if the medication had been administered to R2. However, insufficient Diazepam had been decremented to meet the ordered dosage. The log included the following entries: "02-24-26 Starting #... 30, Ending #... 29, Signature... [E1]" "02-25-26 Starting #... 29, Ending #... 28, Signature... [E1]" "02-25-26 Starting #... 28, Ending #... 27, Signature... [E1]" "02-26-26 Starting #... 27, Ending #... 26, Signature... none" "02-25-26 Starting #... 26, Ending #... 25, Signature... none" In an interview, E1 reported E1 thought the controlled substance log was sufficient to document administration of the medication. E1 reported the nurse said the Senna was supposed to be as needed (PRN); however, E1 did not have documentation of the verbal order to change the Senna to PRN. E1 reported the Seroquel had not been delivered yet The Compliance Officer observed R2's physical medications included a multi-dose package of 300 milligram Gabapentin capsules with no capsules removed from the packaging. In an exit interview with E1, the findings were reviewed, and no additional information was received.

Based on observation, documentation review, and interview, the manager failed to ensure a food menu was conspicuously posted and was maintained for at least 60 calendar days after the last day included in the food menu. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: During an environmental inspection of the facility, the Compliance Officer observed a food menu was not posted in the facility. In an interview, E1 reported E1 had contacted a company who would provide menus, but had not yet obtained or posted any menus. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is an uncorrected deficiency from the on-site compliance inspection conducted on February 11, 2026.

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, for two of two sampled staff. Findings include: On February 11, 2026 at 10:25 AM, the Compliance Officer provided a written request to E3 for facility documentation including complete personnel records with all required documents for E2 and E3, and policies and procedures. However, policies and procedures were not provided for review. A review of E2's and E3's personnel files revealed documentation of initial and ongoing training in fall prevention and fall recovery were not available for review. On February 11, 2026 at 12:13 PM, E1 arrived at the facility, by which time all provided documents had been reviewed and the Compliance Officer was ready to begin the exit interview. The Compliance Officer advised E1 many of the requested items had not yet been provided. E1 searched for the still outstanding items for the remainder of the on-site inspection. However, by the time the exit interview concluded, at approximately 2:20 PM, documentation of fall prevention and fall recovery training had not been provided. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the assisted living home failed to maintain a standardized form for each resident which included the information in subsection A of this section, for two of two sampled residents. Findings include: A review of R1's emergency responder forms revealed a one-page form titled, "ALF Emergency Responder / Evacuation Resident Transfer Form." However, the form was not completely filled out and did not include the resident's primary care physician, power of attorney, medication list, basic physical and mental conditions, allergies, and did not include a HIPAA release. A review of R2's emergency responder forms revealed no documentation was available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation, record review, and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice posed a risk to health and safety. Findings include: Upon arriving at the facility on February 11, 2026 at 10:20 AM, the Compliance Officer observed E3 was the only employee present at the facility. During the on-site inspection, the Compliance Officer observed E3 providing services to the residents of the facility as needed, including assisting residents with toileting, transferring, ambulating, dressing, and eating. A review of E3's personnel record revealed E3 was an assistant caregiver. In an interview, E3 reported E3 had gone to a caregiver school but had not taken the test to become a certified caregiver. During the on-site inspection, the Compliance Officer advised E3 a manager or caregiver must be present at all times for the safety of the residents. In a telephonic interview, E1 reported E1 was a certified caregiver, but had an emergency and was two hours away from the facility. E1 reported E1 had left the facility at around 4 AM. E1 reported there was an overnight caregiver, but they also worked somewhere else during the day and had to leave at around 6 AM. E1 reported E1 had called in a backup caregiver, but the backup caregiver had a sick child and did not show up. E1 reported the manager, E2, is a nurse and has a job during the day and cannot leave that job to respond to the facility. At approximately 12:13 PM on February 11, 2026, E1 arrived at the facility. E1 reported their emergency was that someone they knew was in the hospital, and that person had no other emergency contacts so E1 was notified had to go and assist with locating and contacting that person's relatives. E1 stated multiple times they had no responsibility, custody, or obligation to that person, but that person had no other known contact besides E1. E1 acknowledged the residents had been left without any certified caregiver available between the time the overnight caregiver left and when E1 arrived at 12:13 PM, and E1 was aware this was occurring. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure an assistant caregiver interacted with residents only under the supervision of a manager or caregiver. The deficient practice posed a risk if the individuals were not qualified to provide the required services. Findings include: Upon arriving at the facility on February 11, 2026, at 10:20 AM, the Compliance Officer observed E3 was the only employee present at the facility. During the on-site inspection, the Compliance Officer observed E3 providing services to the residents of the facility as needed, including assisting residents with toileting, transferring, ambulating, dressing, and eating. A review of E3's personnel record revealed E3 was an assistant caregiver. In an interview, E3 reported E3 had attended a caregiver school but had not taken the test to become a certified caregiver. At approximately 12:13 PM on February 11, 2026, E1 arrived at the facility. E1 acknowledged the residents had been present without a certified caregiver available between the time the overnight caregiver left and when E1 arrived at 12:13 PM. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before the assistant caregiver provided physical health services, for one of one sampled assistant caregivers. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: Upon arriving at the facility on February 11, 2026 at approximately 10:20 AM, the Compliance Officer observed E3 was the only employee present at the facility. Throughout the on-site inspection, the Compliance Officer observed E3 providing services to residents as needed. A review of E3's personnel record revealed documentation of verification of E3's skills and knowledge was not available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure the facility had a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to meet the needs of the residents and to ensure the health and safety of the residents. The deficient practice posed a risk as no qualified staff were present to provide the required services. Findings include: Upon arriving at the facility on February 11, 2026, at 10:20 AM, the Compliance Officer observed E3 was the only employee present at the facility. During the on-site inspection, the Compliance Officer observed E3 providing services to the residents of the facility as needed, including assisting residents with toileting, transferring, ambulating, dressing, and eating. A review of E3's personnel record revealed E3 was an assistant caregiver. In an interview, E3 reported E3 had gone to a caregiver school but had not taken the test to become a certified caregiver. During the on-site inspection, the Compliance Officer advised E3 a manager or caregiver must be present at all times for the safety of the residents. In a telephonic interview, E1 reported E1 was a certified caregiver, but had an emergency and was two hours away from the facility. E1 reported E1 had left the facility at around 4 AM. E1 reported there was an overnight caregiver, but they also worked somewhere else during the day and had to leave at around 6 AM. E1 reported E1 had called in a backup caregiver, but the backup caregiver had a sick child and did not show up. E1 reported the manager, E2, is a nurse and has a job during the day and cannot leave that job to respond to the facility, even during the emergency situation when no caregivers were available. At approximately 12:13 PM on February 11, 2026, E1 arrived at the facility. E1 acknowledged the residents had been present without a certified caregiver available between the time the overnight caregiver left and when E1 arrived at 12:13 PM. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregiver's and assistant caregivers working each day. Findings include: During the on-site inspection, at 10:25 AM on February 11, 2026, the Compliance Officer provided a written request to E3 for facility documentation including the previous 12 months of work schedules. During the on-site inspection, at 12:13 PM, on February 11, 2026, the Compliance Officer advised E1 numerous items from the written request had not yet been provided for review. During the on-site inspection, at 2:20 PM, by the conclusion of the exit interview, work schedules had not been provided for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure an assistant caregiver's orientation was documented before the assistant caregiver provided assisted living services to a resident, for one of one sampled assistant caregivers. Findings include: Upon arriving at the facility on February 11, 2026, at approximately 10:20 AM, the Compliance Officer observed E3 was the only employee present at the facility. Throughout the on-site inspection, the Compliance Officer observed E3 providing assisted living services to residents as needed. A review of E3's personnel record revealed documentation of E3's orientation was not available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation, record review, and interview, the manager failed to ensure at least the manager or a caregiver was present at the assisted living home when a resident was 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: Upon arriving at the facility on February 11, 2026 at 10:20 AM, the Compliance Officer observed E3 was the only employee present at the facility. During the on-site inspection, the Compliance Officer observed E3 providing services to the residents of the facility as needed, including assisting residents with toileting, transferring, ambulating, dressing, and eating. A review of E3's personnel record revealed E3 was an assistant caregiver. In an interview, E3 reported E3 had gone to a caregiver school but had not taken the test to become a certified caregiver. During the on-site inspection, the Compliance Officer advised E3 a manager or caregiver must be present at all times for the safety of the residents and requested E3 take any action necessary to ensure a caregiver or the manager respond immediately to the facility to avoid an emergency situation. In a telephonic interview, E1 reported E1 was the owner and a certified caregiver, but had an emergency and was two hours away from the facility. E1 reported E1 had left the facility at around 4 AM. E1 reported there was an overnight caregiver, but they worked somewhere else during the day and had to leave at around 6 AM. E1 reported E1 had called in a backup caregiver, but the backup caregiver had a sick child and did not show up. E1 reported the manager, E2, is a nurse and has a job during the day and cannot leave that job to respond to the facility. At approximately 12:13 PM on February 11, 2026, E1 arrived at the facility. E1 acknowledged the residents had been present without a manager or certified caregiver available between the time the overnight caregiver left and when E1 arrived at 12:13 PM. In an exit interview with E1, the findings were reviewed and no additional information was provided.

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, before or within seven calendar days after the resident's date of occupancy, for one of two sampled residents. Findings include: A review of R1's medical record revealed baseline screening, to include an assessment of R1's risk of prior exposure to TB, and a determination if R1 had symptoms of TB, was not available for review. R1's medical record included a baseline screening form; however, the form had not been filled out, signed, or dated. R1's medical record included a negative TB skin test. Based on R1's date of occupancy, completed TB baseline screening was required. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident accepted by the assisted living facility submitted documentation dated within 90 calendar days before a resident was accepted by the assisted living facility, signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a form titled "Determination for Admission." The form had boxes to indicate, yes or no, whether R3 required Continuous Medical Services, Continuous Nursing Services, Intermittent Nursing Services, or Restraints. The form had been signed, however, the form had not been dated. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident or resident's representative signed and dated a service plan when initially developed and when updated, for two of two sampled residents. Findings include: A review of R1's medical record revealed a service plan, dated January 15, 2026, for personal care services. However, the service plan had not been signed by the resident or resident's representative. A review of R2's medical record revealed a service plan, dated November 12, 2025, for personal care services. However, the service plan had not been signed by the resident or resident's representative. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure services provided to a resident were documented in the resident's medical record, for two of two sampled residents. Findings include: A review of R1's medical record revealed a service plan, dated January 15, 2026, for personal care services. The service plan indicated R1 required assistance with bathing, oral care, transferring, room maintenance, and laundry. A review of R1's medical record revealed a form which documented the services provided to R1 during the month of February 2026. However, this form did not document any assistance had been provided for bathing, oral care, room maintenance, or laundry during the month of February 2026, between February 1, 2026 and February 11, 2026, the day of the on-site inspection. A review of R2's medical record revealed a service plan, dated November 12, 2025, for personal care services. The service plan indicated R2 required assistance with transferring, bathing, grooming, nail care, incontinence care, room maintenance, and laundry. A review of R2's medical record revealed documentation of services provided to R2 during the month of January 2026 and February 2026 were not available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure a resident's medical record contained documentation of a resident's orientation to exits from the assisted living facility, for two of two sampled residents. Findings include: A review of R1's and R2's medical records revealed documentation of each resident's orientation to exits from the assisted living facility was not available for review. A review of the facility's policies and procedures revealed a form titled, "Reciept of Required Documents," which included a space to document orientation to exits from the facility. However, the two sampled resident records did not include this form. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager accepted and retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, and failed to obtain documentation from a medical practitioner who had examined the resident within 30 calendar days before acceptance, and had signed and dated a determination stating the resident's needs could be met by the assisting living facility within the facility's scope of services, for one of two sampled residents. Findings include: A review of R1's medical record revealed a form titled, "Determination for Admission." This form was signed by a medical practitioner and was not dated. The form indicated, "Is this person confined to a chair or bed and is unable to ambulate without assistance? Yes." A review of R1's medical record revealed a service plan, dated January 15, 2026, for personal care services. The service plan stated, "Resident required total assistance and is confined to bed or wheelchair: YES," and, "Does resident have Continued Residency Agreement from PCP: Yes." A review of R1's medical record revealed a "Continued Residency Agreement" or other documentation from a medical practitioner who had examined R1 within 30 calendar days before acceptance, and had signed and dated a determination stating the resident's needs could be met by the assisting living facility within the facility's scope of services, was not available for review. In an exit interview with E1, the finding was reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available and accessible in a bedroom or residential unit being used by a resident receiving personal care services. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed bells, intercoms, or other mechanical means to alert employees to a resident's needs were not available in any bedroom at the facility. 2. In an interview, E3 reported one of the residents takes of all the bells continuously from every room. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a service plan, for one of two sampled residents receiving personal services, included skin maintenance or incontinence care. Findings include: A review of R1's medical record revealed a service plan, dated January 15, 2026, for personal care services. The service plan included sections to document "skin care," "bowel," "bladder," and "toileting" services; however, these sections had been left blank. The service plan had been signed and dated by the facility manager and a nurse, despite the service plan being incomplete. In an exit interview with E1, the findings were reviewed and no additional information was provided.

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 two of two sampled residents. Findings include: A review of R1's medical record revealed a service plan, dated January 15, 2026, for personal care services including medication administration. A review of R1's medical record revealed a signed list of medication orders dated January 12, 2026. A review of R1's medical record revealed documentation of medications administered to R1, at any time since R1's date of admission, was not available for review. A review of R2's medical record revealed a service plan, dated November 12, 2025, for personal care services including medication administration. A review of R2's medical record revealed a signed list of medication orders dated October 10, 2025. A review of R2's medical record revealed documentation of medications administered to R2 in January and February 2026 were not available for review. The most recent documentation of medication administered to R2 was dated December 2025. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure medication was stored in a locked area. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed an office area. The office area was located between the dining room and resident rooms, meaning the office area was a common area residents needed to pass through. Inside the office, the Compliance Officer observed a black mini refrigerator, which did not have a lock. Inside the refrigerator, the Compliance Officer observed two plastic Ziploc bags of pre-filled syringes containing haloperidol. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure a food menu was conspicuously posted and was maintained for at least 60 calendar days after the last day included in the food menu. Findings include: During the on-site inspection, at 10:25 AM on February 11, 2026, the Compliance Officer provided a written request to E3 for facility documentation including the previous 60 days of menus, including documentation of all substitutions. During an environmental inspection of the facility, the Compliance Officer observed a food menu was not posted in the facility. During the on-site inspection, at 12:13 PM, on February 11, 2026, the Compliance Officer advised E1 numerous items from the written request had not yet been provided for review. During the on-site inspection, at 2:20 PM, by the conclusion of the exit interview, menus had not been provided for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure a refrigerator used to store food contained a thermometer, accurate to plus or minus 3° F, for three of three refrigerators observed. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a refrigerator in the kitchen. The refrigerator was being used to store food that required refrigeration. The refrigerator contained a thermometer; however, the thermometer was broken. 2. During an environmental inspection of the facility, the Compliance Officer observed a second refrigerator against the west wall of the kitchen. The refrigerator was being used to store food that required refrigeration. However, the refrigerator did not contain a thermometer. 3. During an environmental inspection of the facility, the Compliance Officer observed a refrigerator in the backyard right outside the kitchen door. The refrigerator was being used to store food that required refrigeration. However, the refrigerator did not contain a thermometer. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure the disaster plan was reviewed at least once every 12 months. Findings include: During the on-site inspection, at 10:25 AM on February 11, 2026, the Compliance Officer provided a written request to E3 for facility documentation including the annual disaster plan review. During the on-site inspection, at 12:13 PM, on February 11, 2026, the Compliance Officer advised E1 numerous items from the written request had not yet been provided for review. During the on-site inspection, at 2:20 PM, by the conclusion of the exit interview, an annual review of the disaster plan had not been provided for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure a disaster drill 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: During the on-site inspection, at 10:25 AM on February 11, 2026, the Compliance Officer provided a written request to E3 for facility documentation including the previous 12 months of disaster drills. During the on-site inspection, at 12:13 PM, on February 11, 2026, the Compliance Officer advised E1 numerous items from the written request had not yet been provided for review. During the on-site inspection, at 2:20 PM, by the conclusion of the exit interview, disaster drills had not been provided for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure an evacuation drill was conducted at least once every six months and documented. The deficient practice posed a risk if employees were unable to implement an evacuation plan. Findings include: During the on-site inspection, at 10:25 AM on February 11, 2026, the Compliance Officer provided a written request to E3 for facility documentation, including the previous 12 months of evacuation drills. During the on-site inspection, at 12:13 PM, on February 11, 2026, the Compliance Officer advised E1 numerous items from the written request had not yet been provided for review. During the on-site inspection, at 2:20 PM, by the conclusion of the exit interview, evacuation drills had not been provided for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure a rechargeable fire extinguisher was serviced at least once every 12 months. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a wall mounted, rechargeable fire extinguisher near the office area. The fire extinguisher had a tag indicating the fire extinguisher had last been serviced in October of 2024, more than 12 months prior to the on-site inspection. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure smoke detectors were tested at least once a month and the tests were documented. Findings include: During the on-site inspection, at 10:25 AM on February 11, 2026, the Compliance Officer provided a written request to E3 for facility documentation including the previous 12 months of smoke detector tests. During the on-site inspection, at 12:13 PM, on February 11, 2026, the Compliance Officer advised E1 numerous items from the written request had not yet been provided for review. During the on-site inspection, at 2:20 PM, by the conclusion of the exit interview, smoke detector tests had not been provided for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure an electrical cord, including an extension cord, was not run from one room to another in the assisted living home. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a thin, brown, residential extension cord was plugged into the same outlet as the refrigerator on the west wall of the kitchen. The Compliance Officer observed the extension cord ran over some push pins, then under the kitchen door to the back patio. On the back patio, the Compliance Officer observed the extension cord was being used to power another full size refrigerator. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure the premises and equipment were free from a condition or situation which may cause a resident or other individual to suffer physical injury. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a closet located outside of Bedroom #3. The closet was carpeted and did not appear to have any venting. However, the closet contained a large hot water heater. The Compliance Officer observed a strong odor of mold in the closet. The Compliance Officer observed the carpet and walls in the closet were damp, and observed black mold on every surface inside the closet. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the water temperature, in a shared bathroom located between the dining room and the office, measured 130.1º F on a Department issued thermometer. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, poisonous or toxic materials were not maintained in labeled containers inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a shared bathroom located in room five. The Compliance Officer observed a bottle of nail polish removed next to the sink and a bottle of peroxide on a shelf. Both poisonous or toxic materials were accessible to residents at the facility. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.