Asov Borrower, LLC.

“Based on documentation review, record review, and interview, for one of two residents sampled, the manager failed to sign and date a residency agreement as required.     Findings include:       1.  A review of R3’s and R7's medical records revealed residency agreements, signed by R3 and R7 before their acceptance at the facility. The residency agreement included a signature line for the facility’s “Representative,” which had been signed by E3. However, neither document had been signed by the facility manager.       2. In an interview, E1 advised while they were aware E3 had signed R3’s and R7’s residency agreements, E1 had not provided written permission for E3 to do so.      3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record for one of seven residents sampled.        Findings include:       1. A review of R1's medical record revealed a current service plan for directed care services. The service plan included sections titled “Meal Consumption” and “Grooming/Personal Hygiene,” which indicated R1 required total assistance with eating, grooming, and hygiene services.       2. A review of R1’s medical record revealed a document used for tracking and documenting activities of daily living (ADL’s) for R1 during March 2026. The document included sections titled “Meal Consumption” and “Grooming/Personal Hygiene.”  However, daily documentation within each section read, “INF.” According to the document Legend, INF stands for “Information Only.” Evidence of documentation indicating the services had actually been provided was unavailable for review.       3. In an interview, E1 indicated R1 did receive assisted living services as outlined in R1’s service plan for March 2026.         4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure documentation of medication administered to a resident included the date and time of administration, or the name and signature of the individual administering the medication. The deficient practice posed a risk as medication administration could not be verified against a medication order, and the Department was provided false and misleading information.     Findings include:     1. A review of R2’s medical record revealed an order, dated March 10, 2026, for wound care. The order indicated caregivers were to “…cleanse area on chest with mild soap and water, pat dry, apply TAO [triple antibiotic ointment], cover with a non-stick dressing QD until healed.”     2. A review of R2’s medical record revealed an electronic Medication Administration Record, eMAR, used for documenting medication administration services for the month of March 2026. The record included a section for “Wound Care” which read “Same time per day, Every day at 3:00 PM. Special Instructions: Leave the applied dressing on until 3/11/26, then cleanse area on chest with mild soap and water, pat dry, apply TAO, cover with a non-stick dressing QD until healed.” The section included documentation indicating R2’s wound was cleaned and TAO applied as ordered, on the dates indicated, by the following caregivers:   March 11: SG1; March 12: blank; March 13: PB; March 14: eg; March 15, 16, 17: SG1; March 18, 19: blank; March 20: AG!; March 21: PB; March 22: eg; March 23, 24: SG1; March 25, 26: PB; March 27: eg; March 28, 29: blank; and March 30: SG1.     3. In an interview, E2 advised that the caregivers who signed E2’s MAR did not actually provide R2’s wound care. E2 said R2’s wound care was provided by E2, and E2 asked the caregiver on duty to sign that the wound care had been provided. E2 indicated R2’s wound care had been provided daily, as ordered, but documentation of R2’s wound care was missing on the dates noted. E2 acknowledged that E2 did not document the wound care E2 had performed.     4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of five 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 E3 was hired as a caregiver in April 2023. 2. A review of E3's personnel record revealed a National CPR Foundation CPR/Automated External Defibrillator (AED)/First Aid training certification. The course was taken on August 4, 2022. 3. An online search of the National CPR Foundation revealed this is an online course. 4. A review of documentation titled, "Staffing Training" revealed .... 1. Training on the following topics is included during caregiver orientation training and ongoing in-services. ... 3. Training for CPR and First aid will be done by a certified trainer to give CPR instruction. (American Red Cross, American Heart Assoc, The National Safety Council, etc..). Staff will be required to submit a copy of their CPR and First aid card upon employment. Staff will be required to update the CPR and First aid card every 2 years or by the expiration date on the care". 5. In an interview, E8 reported not realizing E3's CPR certification was an online course, and a hands-on demonstration was not performed. E8 and E1 reported E3 will be taken off caregiver duties until current proof of CPR training is provided.”

“Based on record review, documentation review, and interview, the manager failed to ensure an individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility including whether the individual requires restraints for eight of eight 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 R1, R2, R3, R4, R5, R6, R7, and R8's medical records revealed a document titled "Determination for Admission". This document did not include the following: - if an individual is requesting or is expected to need restraints. 2. In an interview, E1 reported being unaware the verbiage for restraints was not on the admission paperwork. E1 acknowledged the document was missing this information.”

“Based on observation, documentation review, and interview, the manager failed to ensure medication stored by the facility was in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During a tour of the facility the Compliance Officer observed in the medication closet stored with medications the following: - seven document boxes titled "Assisted Living Thinned Charts"; and - an unsecured oxygen tank in its upright position. 2. In an interview, E1 reported being unaware these documents were being stored in the medication closet and acknowledged that they were in the medication closet.”

“Based on documentation review and interview, the manager failed to ensure a disaster drill for employees 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: 1. A review of the facility's staffing schedule revealed three shifts: - 6:00 am - 2:00 pm (First Shift), - 2:00 pm to 10:00 pm (Second Shift), and - 10:00 pm - 6:00 am (Third Shift). 2. A review of documentation titled, "Disaster Drill" revealed the following information: - January 28, 2023, time: 10:00 am (first shift), - February 16, 2023, time: 2:00 pm (second shift), - March 7, 2023, time 5:00 am (third Shift), - April 13, 2023, 10:00 am (first shift), and - August 16, 2023, time 3:00 pm (second shift). There was no additional documentation or evidence to indicate a disaster drill was conducted on each shift at least once every three months and documented. 3. In an interview, E1, acknowledged the documentation was unavailable for review. Technical assistance was given on the last compliance survey completed on November 14, 2023.”

“Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During a tour of the facility, the Compliance Officer observed in the facility's medication closet a tall oxygen container was standing upright and unsecured. 2. In an interview, E1 acknowledged the oxygen container was not secured in an upright position.”