Welcome Home.

“Based on documentation review, record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1 . A review of facility documentation revealed a policy titled "Orientation and In-Service Training." The policy stated, "Fall Prevention and Recovery Training is required upon hire and at least every 12 months thereafter." 2 . A review of E2's personnel record revealed Fall Prevention and Fall Recovery training completed in 2024. However, documentation of Fall Prevention and Fall Recovery training completed in 2025 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.”

“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. Findings include: 1 . A review of R1's and R2's medical records revealed that 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 documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented according to policies and procedures, for one of two caregivers sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1 . A review of facility documentation revealed a policy titled "Employees and Volunteers Qualification." The policy stated, "The hiring individual will check and document qualification, skills and knowledge for each employee and volunteer to ensure the meet criteria....Documentation of such check is going to be kept in the employees' record upon hiring ("Employee Orientation" and "Employee Qualification and Skills.")" 2 . A review of E3's personnel record revealed documentation of "Employee Qualification and Skills" 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.”

“Based on observation, record review and interview, the manager failed to ensure that a caregiver or an assistant caregiver received orientation that was specific to the duties to be performed by the caregiver or assisted caregiver before they provided assisted living services to a resident, for one of the two caregivers sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1. When the Compliance Officer arrived at the facility at approximately 9 AM, the Compliance Officer observed E3 providing services to residents. 2. A review of E3's personnel record revealed completed documentation of orientation specific to the duties to be performed by the caregiver was not available for review at the time of inspection. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.”

“Based on observation, record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a manager or caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults, for one of two caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1 . A review of E3's personnel record revealed documentation of a CPR card. However, the card had expired January 2026. 2 . During an inspection of the facility, the Compliance Officer observed E3 providing services to residents. 3 . 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 resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1 . A review of R1's medical record revealed a negative TB signs and symptoms screening and risk assessment. However, documentation of a negative TB test 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 that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility which included if the individual was expected to receive supervisory care services, personal care services, or directed care services, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of ten residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1 . A review of R2's medical record revealed documentation that was dated within 90 calendar days before the individual was accepted by the assisted living facility which included if the individual was expected to receive supervisory care services, personal care services, or directed care services, and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant 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 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 R1's medical record revealed 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.”

“Based on document review and interview the manager failed to ensure that policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1 . A review of facility documents revealed a policy and procedure for medication administration. However, the policy was not reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 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 that a resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility within 24 hours after the resident’s acceptance by the assisted living facility, for one of two residents sampled. Findings include: 1 . A review of R2's medical records revealed that no documentation of an orientation to the exits of the facility was 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 observation and interview, the manager failed to ensure that 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 an unlocked cabinet under the sink in the kitchen. The Compliance Officer was able to access the following: -A can of "Lysol" disinfectant spray; -A container of "Kirkland" dishwasher detergent pods; and -A bottle of "Goo Gone" goo and adhesive remover. 2 . During an environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet in the common hallway area. The Compliance Officer was able to access the following: -A jug of "Fabuloso" multi-purpose cleaner; -A bottle of "Liquid-Plumr" gel; and -A container of "Kirkland" dishwasher detergent pods. 3 . During an environmental inspection of the facility, the Compliance Officer observed a can of "Lysol" disinfectant spray sitting on the dresser in a resident's room. 4 . In an exit interview, the findings were discussed with E1, and no additional information was provided.”