Senior Care Assisted Living LLC

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of E2’s and E3’s personnel records revealed annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. 2. A review of E2’s personnel record revealed a single-step Mantoux skin test (TST). However, a second-step TST was not available for review and a baseline screening to include a risk assessment and symptom screening, signed by an occupation health provider, was not available for review. E2’s personnel record did not contain documentation of a two-step skin test as recommended by R9-10-113.A.1.a 3. In an interview, E1 acknowledged the health care institution had not documented and implemented tuberculosis infection control activities as required in R9-10-113.A.2.a-f.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. 1. A review of R2's medical record revealed a service plan, dated December 13, 2024, for personal care services including medication administration. The service plan stated, "Oxygen Therapy 2LPM - Continuous... Check oxygen flow once each shift to make sure it is flowing at the rate ordered, per MAR (Medication Administration Record)." 2. A review of R2's medical record revealed a prescription dated August 9, 2024 for, "D/C Senna S BID. Start Senna S 8.5 mg/ 50 mg, Daily. Hold for loose stools." 3. A review of R2's medical record revealed a prescription dated July 10, 2024 for, "Nasal Cannula 4 Liters." 4. A review of R2's medical record revealed a medication administration record (MAR) sheet for April 2025 . The Mar included the following: For, "Senna S Tab 8.6-50 MG, Take 1 tablet by mouth once daily," the MAR documented this medication had been provided twice per day, at 8 AM and at 5 PM, on each day in April 2025; and Oxygen administration was not documented on the MAR. 5. In an interview, E1 acknowledged R2's medical record did not contain accurate documentation of the medications administered to R2. This is a repeat deficiency from the on-site compliance inspection conducted on March 14, 2024.

Based on observation and interview, the manager failed to ensure that foods requiring refrigeration were maintained at 41° F or below. Findings include: 1. During an environmental inspection of the facility, the Compliance officer observed a refrigerator in the kitchen contained items requiring refrigeration. However, a thermometer in the door of the refrigerator read 52° F. The Compliance Officer observed E1 placed a second thermometer in the refrigerator. However, after approximately one half hour, both thermometers read 54° F. 2 . The Compliance Officer used a non-contact infrared thermometer to check the temperature of the air vent inside the refrigerator and observed the air was entering the refrigerator at 51° F. The Compliance Officer also observed the vertical support between the refrigerator and freezer was warm to the touch. 3. In an interview, E1 acknowledged foods requiring refrigeration had not been maintained at 41° F or below.

Based on record review and interview, the manager failed to ensure a residency agreement included the date of occupancy, for one of two residents reviewed. Findings include: 1. A review of R2's medical record revealed a residency agreement. However, this residency agreement did not include documentation of R2's date of occupancy. Based on R2's acceptance date, this documentation was required. 2. In an interview, E1 and O1 acknowledged R2's residency agreement did not include the date of occupancy.

Based on documentation review, record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two sampled residents reviewed. Findings include: 1. A review of R1's medical record revealed a service plan, dated November 13, 2023, for personal care services. The service plan included the provision of the following service to R1: - "Foley Catheter: 1) Make sure collection bag is always below the level of the bladder 2) Empty bag each shift and as necessary 3) Report any of the following to nurse or [doctor]; cloudy urine, foul odor, fever, chills, loss of appetite, confusion, and/or no urine output for more than 8 hours. 4) Clean area around catheter daily. Make sure you do not pull on the catheter. 5) Put leg bag on in the morning and large bag at night. 6) Clean catheter bags daily, when they're removed, with a solution of 50% white vinegar, allow to air dry." 2. A review of R1's medical record revealed a form titled, "Activities of Daily Living Record," (ADL) dated March 2024. The ADL documented the services provided to R1, however, the form did not include documentation of foley catheter services provided to R1. 3. In an interview, E1 and O1 acknowledged the provided medical records did not include documentation of all of the services provided to R1.

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A documentation review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During a facility tour, the Compliance Officer observed the front door of the facility had a door alarm taped to the top side of the door. However, the door alarm did not sound when the Compliance Officer opened the door. The surveyor observed E1 attempt to repair the door alarm and replace the batteries, however, E1 was not able to fix the front door alarm during the on-site inspection 3. During a facility tour, the surveyor observed the front yard was fenced, however, the front gate did not have a lock. 4. During a facility tour, the surveyor observed the back door did not have an alarm and had a thumb turn latch on the interior side. 5. In an interview, E1 reported the back door alarm was broken and had been removed. E1 and O1 acknowledged a resident could egress through either the front or back door without alerting a caregiver to the egress of the resident.

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a service plan, dated November 13, 2023, for personal care services. The service plan indicated, "[R1] goes to dialysis on Monday, Wednesday, and Friday mornings. [R1] is appointment is at 7 AM. [R1] is picked up between 6-6:30 AM and returned between 11-11:30 AM." 2. A review of R1's medical record revealed a medication administration record (MAR) dated March 2024. The MAR indicated R1 had been provided the following medications every day at 8:00 AM to include Mondays, Wednesdays, and Fridays: - Pantoprazole Sodium, Phenytoin Sodium, Velphoro, Loratadine, Carbamazepine, Docusate Sodium, Ondansetron, and Sulfamethoxazole/Trimethoprim DS 3. In an interview, E1 reported E1 used to provide medications to R1 at 6:30 AM instead of 8:00 AM as scheduled on dialysis days. E1 reported after a recent transportation error, R1 is now going to dialysis around 9 AM and returning between 1:30-2:30 PM. E1 reported noon medications are administered after R1 returns from dialysis. E1 reported medication had been intentionally administered to R1 more than an hour before or after the scheduled time on dialysis days instead of moving R1's time of medication administration on all days to a time which would facilitate the dialysis schedule. 4. A review of R1's medical record revealed a medication administration record (MAR) dated March 2024. The MAR indicated R1 had been provided the following medication every day at 12:00 PM to include Mondays, Wednesdays, and Fridays: Carbamazepine. 6. A review of R2's medical record revealed a service plan, dated February 8, 2024, for personal care services including medication administration. 7. A review of R2's medical record revealed an order, dated October 25, 2023, for the following: "Medihoney 80% topical gel, apply topical in between affected toe every other day until gone for skin tear." 8. A review of R2's medical record revealed a list of orders, dated July 31, 2023, which included the following: "Hydralazine 25 mg tablet, take 1 tablet by oral rout every 8 hours as needed for SBP > 160. Recheck BP in one hour and call nurse practitioner if SBP > 160 after dose"; and "Diclofenac 1% Topical gel, apply 2 gram by topical route 4 times every day to the affected areas for PAIN HANDS." 9. A review of R2's medical record revealed an order, dated March 5, 2024, for the following: "D/C Medihoney." 10. A review of R2's medical record revealed a MAR, dated March 2024. However, the MAR indicated R2 had not been provided Medihoney or Diclofenac gel on any day in March, and indicated Hydralazine was discontinued. 11. A review of R2's November 2023, Decemb

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two sampled residents who received medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed a service plan, dated November 13, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed a prescription, dated March 4, 2024, which stated, "I prescribed an antibiotic - Cefpodoxime - that [R1] will take twice a day for 10 days. After that I will order another urine culture. [R1] needs to stop Protonix while [R1] takes the antibiotic, because there is an interaction between the two medications." 3. A review of R1's medical record revealed a Medication Administration Record (MAR) dated March 2024. The MAR documented the following: - "Pantoprazole Sodium Tabs, 20 MG (Protonix), take 1 tablet by mouth every morning 30 minutes before breakfast," had been administered on each day between March 1, 2024 and March 13, 2024, and had not been held as ordered; and - Cefpodoxime administration was not documented to have occurred as ordered on any day in March 2024. 4. The Compliance Officer observed R1's medications included an empty bottle of "Cefpodoxime Tab 100MG," filled on March 4, 2024. The Compliance Officer observed R1's bottle of Protonix had a red sticker on the cap with a hand written note to hold the medication. 5. In an interview, E1 and O1 reported the antibiotic order was followed, however, E1 and O1 acknowledged the provided documentation of medication administration for R1 was not accurate.

Based on record review and interview, the manager failed to ensure a current therapeutic diet manual was available for use by personnel members. Findings include: 1. The Compliance Officer requested the facility's therapeutic diet manual. However, a therapeutic diet manual was not provided for review. 2. A review of R2's medical record revealed a residency agreement which stated, "17....special diets will be provided only on Primary Care Provider's written order." 3. In an interview, E1 and O1 acknowledged a therapeutic diet manual had not been provided for review. Technical assistance for this rule was provided during the on-site compliance inspection conducted on March 20, 2023.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food contained a thermometer, accurate to plus or minus 3\'b0 F, which posed a health and safety risk if the refrigerator was not maintained at a proper temperature. Findings include: 1. During the facility tour with E1, the Compliance Officer observed that there was a thermometer in a refrigerator located in the kitchen. However, the thermometer was broken and could not be read. The Compliance Officer observed the glass tube was detached from the scale, and the red ethanol inside the capillary tube was missing. 2. In an interview, E1 and O1 acknowledged the thermometer in the refrigerator was broken and could not be used to determine the temperature of the refrigerator to within 3\'b0 F. O1 immediately moved a thermometer from the freezer compartment into the refrigerator compartment. This is a repeat deficiency from the on-site compliance inspection conducted on March 20, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure an individual who administered an opioid in treating a patient documented in the patient's medical record an identification of the patient's need for the opioid before the opioid was administered and the effect of the opioid administered, for one of one residents sampled who was administered an opioid. Findings include: 1. A review of the facility's policies and procedures, reviewed January 1, 2023, revealed a policy titled, "Opioid Policy and Procedure," which stated, "C. The Manager or Manager's Designee will ensure that the caregiver administering the opioid medication documents in the resident's medical record an identification of the resident's pain before the opioid was administered and the effect of the opioid administered." 2. A review of R2's medical record revealed a service plan, dated February 8, 2024, for personal care services including medication administration. The service plan indicated R2 did not receive hospice services. 3. A review of R2's medical record revealed a signed list of medication orders dated July 31, 2023. The list included the order, "tramadol 50 mg tablet, take 1 tablet by oral route every morning..for chronic arthritis pain." 4. A review of R2's medical record revealed a Medication Administration Record (MAR) dated March 2024. The MAR indicated R2 had been administered Tramadol on each day in March 2024. 5. A review of R2's medical record revealed a pain scale record, or other documentation of assessment and monitoring of R2 related to the administration of the opioid medication, was not available for review. 6. In an interview, E1 and O1 acknowledged the caregivers administering opioids to R2 had not documented the identification of R2's need for the opioid before every administered dose and had not documented monitoring of the effectiveness of the opioid in the manner prescribed by the facility's policies and procedures.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact and primary care provider when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of R1's medical record revealed a progress note dated June 23, 2023 which stated, "Around 12:00 send to [R1] to hospital. The reason is B/P's low 96/49 and chills and confused. The nurse recommending when coming and check on [R1]." However, the progress note did not document contact with R1's physician or with R1's representative. 2. In an interview, E1 reported E1 believed the nurse was in contract with the primary care physician, and reported R1's emergency contact was also notified. E1 acknowledged R1's medical record did not include documentation to show R1's emergency contact and primary care provider were immediately notified when R1 had an emergency.

Based on observation, documentation review, record review, and interview, the governing authority failed to ensure a caregiver who was able to read, understand, and communicate in English was on the assisted living facility's premises. The deficient practice posed a risk if the caregiver was unable to communicate with an English speaking resident in order to meet their needs. Findings include: 1. Upon arriving at the facility at approximately 9:30 a.m., the Compliance Officer observed E1 was the only staff member present at the facility. The Compliance Officer observed eight residents were present at the facility. However, E1 was not able to communicate in English. 2. The Compliance Officer observed a resident telling E1 repeatedly in English that the resident had not had breakfast yet and wanted breakfast, however, E1 did not respond to the resident and did not provide breakfast or a snack to the resident during the on-site inspection. 3. In an interview, E1 reported E1 does not speak English. E1 reported E2, the scheduled caregiver, had a personal emergency and was not able to work. The Compliance Officer asked if E1 could contact the manager or the governing authority. E1 contacted E2, who spoke with the Compliance Officer by phone and said O1 would be coming to the facility to assist with the inspection. 4. Approximately 20 minutes after entering the facility, O1 arrived at the facility. O1 reported O1 was not an employee of the facility but was consulting to assist the owner with paperwork because of issues with the previous manager. O1 agreed E1 was the designated caregiver responsible for the facility, and agreed O1 would assist E1 and the Compliance Officer to communicate at E1's request. 5. A review of the facility's policies and procedures, last reviewed on January 1, 2023, revealed a policy titled, "Caregiver Job Descriptions, Duties and Qualifications." The policy stated, "..h. If a caregiver is to be left alone to care for the residents they will be able to read, write, understand, and communicate in English." 6. A review of E1's personnel record revealed E1 was hired as a caregiver in June of 2022. 7. A review of the facility's policies and procedures, last reviewed on January 1, 2023, revealed a policy titled, "Staffing and Work Schedule." The policy stated, "The certified manager shall ensure that a personnel schedule: a) indicates the date, scheduled work hours, and name of each caregiver assigned; b) reflects actual work hours; and c) is maintained on the premises for at least twelve months from the last date on the schedule. d) Staffing schedule is updated monthly and maintained at the facility. The facility manager may choose to post a current work schedule or keep schedules in the Personnel Record Log. e) All staffing changes must be approved by the Manager or their Designee and documented on the staffing schedule....3. This assisted living facility has a Certified Manager, Caregiver(s) and Assistant Caregiver(s) with the qua

Based on documentation review and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident covering staffing and recordkeeping. Findings include: 1. Upon arriving at the facility at approximately 9:30 a.m., the Compliance Officer observed E1 was the only staff member present at the facility. The Compliance Officer observed eight residents were present at the facility. However, E1 was not able to communicate in English. 2. In an interview, E1 reported E1 does not speak English. E1 reported E2, the scheduled caregiver, had a personal emergency and was not able to work. The Compliance Officer asked if E1 could contact the manager or the governing authority. E1 contacted E2, who spoke with the Compliance Officer by phone and said O1 would be coming to the facility to assist with the inspection. 3. A review of the facility's policies and procedures, last reviewed on January 1, 2023, revealed a policy titled, "Caregiver Job Descriptions, Duties and Qualifications." The policy stated, "..h. If a caregiver is to be left alone to care for the residents they will be able to read, write, understand, and communicate in English." 4. A review of E1's personnel record revealed E1 was hired as a caregiver in June of 2022. 5. A review of the facility's policies and procedures, last reviewed on January 1, 2023, revealed a policy titled, "Staffing and Work Schedule." The policy stated, "The certified manager shall ensure that a personnel schedule: a) indicates the date, scheduled work hours, and name of each caregiver assigned; b) reflects actual work hours; and c) is maintained on the premises for at least twelve months from the last date on the schedule. d) Staffing schedule is updated monthly and maintained at the facility. The facility manager may choose to post a current work schedule or keep schedules in the Personnel Record Log. e) All staffing changes must be approved by the Manager or their Designee and documented on the staffing schedule....3. This assisted living facility has a Certified Manager, Caregiver(s) and Assistant Caregiver(s) with the qualifications, experience, skills and knowledge necessary to:...e) That one Caregiver is able to provide Personal and Directed Care services and speaks and understands English." 6. A review of facility work schedules revealed a work schedule from January 2023 and February 2023. However, work schedules from March 2023, April 2023, and May 2023 were not available for review. 7. A review of the facility work schedule for January 2023 revealed E1 worked alone at the facility from 8 p.m. until 8 a.m. on each Thursday, Friday, and Saturday in January 2023. 8. A review of the facility work schedule for February 2023 revealed E1 worked alone at the facility from 8 p.m. until 8 a.m. on each Thursday, Friday, and Saturday in February 2023. 9. The Compliance Officer observed E2 arrived at the facility at approximately 10:30 am. 10. In an interview with E2 and O1, E2 r

Based on record review and interview, the manager failed to ensure caregivers had the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. Findings include: 1. Upon arriving at the facility at approximately 9:30 a.m., the Compliance Officer observed E1 was the only staff member present at the facility. The Compliance Officer observed eight residents were present at the facility. However, E1 was not able to communicate in English. 2. The Compliance Officer observed a resident telling E1 repeatedly in English that the resident had not had breakfast yet and wanted breakfast, however, E1 did not respond to the resident and did not provide breakfast or a snack to the resident during the on-site inspection. 3. In an interview, E1 reported E1 does not speak English. E1 reported E2, the scheduled caregiver, had a personal emergency and was not able to work. The Compliance Officer asked if E1 could contact the manager or the governing authority. E1 contacted E2, who spoke with the Compliance Officer by phone and said O1 would be coming to the facility to assist with the inspection. 4. A review of the facility's policies and procedures, last reviewed on January 1, 2023, revealed a policy titled, "Caregiver Job Descriptions, Duties and Qualifications." The policy stated, "..h. If a caregiver is to be left alone to care for the residents they will be able to read, write, understand, and communicate in English." 5. A review of E1's personnel record revealed E1 was hired as a caregiver in June of 2022. 6. The Compliance Officer observed E2 arrived at the facility at approximately 10:30 am. 7. In an interview with E2 and O1, E2 reported E1 calls E2 for help communicating in English and E2 will either talk to someone over the phone or come in if necessary. E2 reported E1 works three nights per week. E2 reported the work schedule would be reworked so that E1 is no longer working alone. O1 and E2 acknowledged E1 cannot communicate in English and was working alone at the facility.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings include: 1. A review of the facility's policies and procedures, last reviewed on January 1, 2023, revealed a policy titled, "Staffing and Work Schedule." The policy stated, "The certified manager shall ensure that a personnel schedule: a) indicates the date, scheduled work hours, and name of each caregiver assigned; b) reflects actual work hours; and c) is maintained on the premises for at least twelve months from the last date on the schedule. d) Staffing schedule is updated monthly and maintained at the facility. The facility manager may choose to post a current work schedule or keep schedules in the Personnel Record Log. e) All staffing changes must be approved by the Manager or their Designee and documented on the staffing schedule." 2. A review of facility work schedules revealed work schedules from January 2023 and February 2023. However, work schedules from March 2023, April 2023, and May 2023 were not available for review. 3. In an interview, O1 reported when the former manager left, they must have taken some of the work schedules with them. 4. In an interview, O1 and E2 acknowledged documentation had not been maintained, per the facility's policies and procedures, of the caregivers and assistant caregivers working each day, including the hours worked by each.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the level of service the resident was expected to receive, for two of eight residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated February 21, 2023. The service plan included two check boxes to indicate whether the resident would receive, "Personal," or, "Directed" services. However, neither check box had been marked and the service plan did not indicate the level of care R1 was expected to receive. 2. A review of R3's medical record revealed a service plan dated January 26, 2023. The service plan included two check boxes to indicate whether the resident would receive, "Personal," or, "Directed" services. However, neither check box had been marked and the service plan did not indicate the level of care R3 was expected to receive. 3. In an interview with O1, with E4 present telephonically, O1 acknowledged the services plan for R1 and for R3 did not include the level of service each resident was expected to receive.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative, and the manager, when initially developed and when updated, for seven of eight residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated February 21, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, or the manager. 2. A review of R2's medical record revealed a service plan dated April 6, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, or the manager. 3. A review of R3's medical record revealed a service plan dated January 26, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, or the manager. 4. A review of R4's medical record revealed a service plan dated January 26, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, or the manager. 5. A review of R5's medical record revealed a service plan dated March 21, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, or the manager. 6. A review of R6's medical record revealed a service plan dated March 2, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, or the manager. 7. A review of R6's medical record revealed a service plan dated September 2, 2022. However, the service plan was not signed and dated by the resident or the resident's representative, or the manager. 8. A review of R7's medical record revealed a service plan dated March 12, 2023. However, the service plan was not signed and dated by the resident or the resident's representative, or the manager. 9. A review of R8's medical record revealed a service plan dated December 12, 2022. However, the service plan was not signed and dated by the resident or the resident's representative, or the manager. 10. In an interview with O1, with E4 present telephonically, O1 acknowledged the provided service plans had not been signed and dated by the resident or the resident's representative, or the manager when initiated or when updated.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for two of three directed care residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated February 21, 2023. The service plan did not include the level of service R1 was expected to receive. The service plan did not include documentation of R1's weight or documentation from a medical practitioner stating weighing R1 was contraindicated. 2. A review of R7's medical record revealed a service plan, dated March 12, 2023, for directed care services. However, the service plan did not include documentation of R7's weight or documentation from a medical practitioner stating weighing R7 was contraindicated. 3. A review of R7's medical record revealed a service plan, dated December 12, 2022, for directed care services. However, the service plan did not include documentation of R7's weight or documentation from a medical practitioner stating weighing R7 was contraindicated. 4. In an interview with O1, with E4 present telephonically, O1 acknowledged the service plans provided for R1 and R7 did not include documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.