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“Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility’s policies and procedures manual revealed a review of the policies conducted on February 14, 2022. However, no documentation of a policies and procedures review from the past three years was revealed.  2. A review of the facility’s policies and procedures revealed a policy titled "R9-10-803.C.3”. The policy stated, “It is reviewed at least once every three years and updated as needed.” 3. 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 provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at the assisted living facility and as specified in R9-10-113, for one of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..."    2. A review of the facility’s policies and procedures revealed a policy titled "Tuberculosis (TB) Testing”. The policy stated, “On or before the date the individual begins providing services at the facility (employee), or is admitted to the facility (resident), one of the following as evidence of freedom from infectious tuberculosis: i. Documentation of a negative Mantoux skin test administered within six months before the date the employee begins providing services…” 3. A review of the facility's employee work schedule revealed a schedule for March 2026. The schedule indicated E2 was scheduled to work everyday from 6:00 AM - 6:00 PM.  4. A review of E2’s personnel record revealed no documentation of a TB skin test, risk assessment, or signs and symptoms. 5. In an interview, R1 reported E2 assists at the facility. 6. In an interview, E1 reported E2 had not received their TB test yet. 7. In an exit interview, the findings were discussed with E1 and no additional information was provided. 8. Technical assistance was provided on this rule during the compliance inspection conducted on January 22, 2024.”

“Based on documentation review, record review, and interview, the manager failed to ensure that 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 residents sampled. The deficient practice posed a potential illness risk to residents. Findings include:  1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R1’s medical record revealed no documentation that assessed risks of prior exposure and signs and symptoms of TB.  3. In an exit interview, the findings were discussed with E1 and no additional information was provided. 4. Technical assistance was provided on this rule during the compliance inspection conducted on January 22, 2024.”

“Based on record review, documentation 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 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for one of two 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’s medical record revealed documentation that included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints before or at the time of admission. However, the documentation was not signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. A review of the facility’s policies and procedures revealed a policy titled "Residency Agreement”. The policy stated, “The manager or manager’s designee shall ensure that before or at the time of the acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by the facility…”  3. In an exit interview, the findings were discussed with E1 and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on January 29, 2024.”

“Based on record review, documentation review, and interview, the manager failed to ensure that a resident had a service plan that was signed and dated by the nurse or medical practitioner, for one of two residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include:  1. A review of R2’s medical record revealed a service plan dated January 10, 2026, for directed care services. The service plan revealed R2 received medication administration. However, the service plan did not include a signature and date from a nurse or medical practitioner. 2. A review of the facility’s policies and procedures revealed a policy titled "Service Plan”. The policy stated, “For a resident who requires intermittent nursing services or medication administration, review by a nurse or medical practitioner.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on record review, documentation review, and interview, the manager failed to ensure that a caregiver documented the services provided in the resident’s medical record, for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include:  1. A review of R2's medical record revealed a service plan dated January 10, 2026. After further review, it was revealed that R2 received the following services: Bed bath, two times a weeks Dressing, two times a day Incontinence care every 2-3 hours (includes skin care) 2. A review of R2's medical record revealed documentation of activities of daily living for R2. However, no documentation of aforementioned activities of daily living was revealed for March 1, 2026 through March 16, 2026. 3. A review of the facility’s policies and procedures revealed a policy titled "Service Plan”. The policy stated, “1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident’s medical record.” 4. In an interview, E1 reported services were provided. 5. 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 that the service plan for a resident receiving directed care services included strategies to ensure a resident’s personal safety, for one of two residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident.  Findings include: 1. A review of R2’s medical record revealed a current service plan dated January 10, 2026. The service plan indicated R2 received directed care services. R2’s service plan did not include strategies to ensure a resident’s personal safety. 2. A review of the facility’s policies and procedures revealed a policy titled, “Directed Care Services”. The policy stated, “The amount, type and frequency of assisted living services being provided to the resident shall include direct services including: ii. Strategies to ensure a resident’s personal safety…" 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that monitored or alerted employees of the egress of a resident from the facility. This deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include:  1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During an environmental tour, the Compliance Officer observed an unmonitored exit door in the kitchen that led to the backyard. After further observation, the Compliance Officer observed that the monitor was not working as no sound was produced.  3. In an interview, E1 reported that E1 would get the alarm fixed.  4. In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months.  Findings include: 1. A review of the facility’s evacuation drills revealed documentation of an evacuation drill being conducted in February 2025 and August 2025. After further review, it was revealed that there was a blank evacuation drill document with a note to be completed in February 2026. 2. A review of the facility’s policies and procedures revealed a policy titled "Emergency and Safety Standards”. The policy stated, “An evacuation drill for employees and residents on the premises is conducted at least once every six months..."  3. In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and 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 tour, the Compliance Officer observed the following:  Disinfectant Spray in an unlocked upper cabinet located in the laundry room Three containers of Weed and Grass Killer in a box, located in the backyard 2. A review of the facility’s policies and procedures revealed a policy titled "Safety of the Facility and Grounds”. The policy stated, “Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas.” 3. In an exit interview, the findings were discussed with E1 and no additional information was provided.  4. Technical assistance was provided on this rule during the compliance inspection conducted on January 22, 2024.”

“Based on observation and interview, the manager failed to ensure a swimming pool was locked when the swimming pool was not in use. The deficient practice posed a risk if residents had unsupervised access to the swimming pool.  Findings include: 1. During an environmental tour, the Compliance Officer observed that the gate latch for the pool was unlocked at the time of the inspection and residents were not using the pool. 2. In an interview, E1 reported residents did not use the pool. 3. In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on documentation review, observation, and interview, the licensee failed to provide complete acquiescence in any entry or inspection of the premises during the term of the license. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. Review of the Department documentation revealed the facility's perpetual license was effective on June 15, 2022. 2. The Compliance Officer arrived at the facility on January 22, 2023, at 8:58am to conduct a compliance inspection. The Compliance Officer observed a fence completely surrounding the facility with a locked gate crossing the driveway and a locked gate crossing the walking path to the front door. One vehicle was observed parked in the driveway. The Compliance Officer was not able to access the front door. The Compliance Officer attempted to contact E1 by telephone on one telephone number provided to the Department at 9:01am. The telephone number was not operational. Additionally, the Compliance Officer attempted to contact E1 by telephone at 9:12am with the telephone number listed on the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers website. The telephone number was a wrong number. The Compliance Officer departed from the facility at 9:15am after not gaining entry to the facility.”

“Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of one resident reviewed accepted by the assisted living facility on or after October 1, 2013. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R1's medical record revealed no documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1's acceptance date, this documentation was required. 2. In an interview, E1 acknowledged documentation was not available that showed R1 provided documentation signed by a medical practitioner or a registered nurse stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.”

“Based on observation and interview, the manager failed to ensure a fire extinguisher labeled as rated at least 2A-10-BC by the Underwriters Laboratories was mounted and maintained in the assisted living home. The deficient practice posed a health and safety risk to the residents if a fire extinguisher was needed. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed a fire extinguisher with a rating of 1A-10-BC. A fire extinguisher with a rating of 2A-10-BC was not available. 2. In an interview, E1 acknowledged a fire extinguisher with a rating of at least 2A-10-BC was not available.”