Dignified Carehome LLC.

“Based on interview and documentation review, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder (EMS). The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. In an interview, E2 reported R1 had an accident, emergency, or injury on March 21, 2026, that resulted in facility personnel contacting EMS on behalf of R1. 2. A review of facility documentation revealed an incident report dated March 21, 2026. The report stated that facility personnel called 911. 3. In an interview, when the Compliance Officer requested a copy of the documentation given to EMS in compliance with this statute, E2 reported not having any documentation that was provided to EMS. When the Compliance Officer asked if facility personnel gave EMS a document in compliance with this statute, E1 stated: "I am not sure." 4. In an exit interview with E2, the findings were reviewed, and no additional paperwork was available for review.”

“Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of three personnel sampled. The deficient practice posed a potential TB exposure 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel. The webpage states, "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing." 3. A review of E1 and E2's personnel records revealed one TB test, risk assessment, and signs and symptoms screening. 4. In an interview, E2 acknowledged that E1 and E2's personnel records did not have a second TB test. This is a repeat deficiency from a complaint investigation conducted on March 21, 2024. 5. In an exit interview with E2, the findings were reviewed, and no additional paperwork was provided.”

“Based on record review and interview, the manager failed to ensure medical records were maintained for two of two residents sampled. The deficient practice posed a risk as the required information could not be verified.   Findings include:   1. The Compliance Officer requested to review the medical records for R1 and R2.   2. The medical records for R1 and R2 were not provided for review.   3. In an interview, E2 revealed that the files were off-site with the manager. E2 acknowledged that the manager did not ensure the medical records for R1 and R2 were maintained as required.  4. In an exit interview with E2, the findings were reviewed, and there was no additional paperwork provided.”

“Based on observation and interview, the manager failed to ensure that medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication.      Findings include:       1. During the environmental inspection of the facility with E2, the Compliance Officer observed a small medication cabinet in the dining area, which contained a latch and was unlocked. The padlock was observed on the table next to the medication cabinet. The medication cabinet contained bottles of Lantus.       2. In an interview, E12 acknowledged that the medication cabinet was unlocked and accessible to residents at the time of inspection.  3. In an exit interview with E2, the findings were reviewed, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that 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 an environmental inspection of the facility with E2, the Compliance Officer observed an oxygen tank in the garage that was standing in an upright position; however, the oxygen tank was not properly secured. 2. In an exit interview, the findings were reviewed with E2 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area 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 with E2, the Compliance Officer observed that the door leading out to the garage was propped open, which allowed residents access to the garage area. The garage had the following poisonous or toxic materials in an unlocked cabinet: -Easy-Off Degreaser -Bleach -Comet Cleaner 2. In an exit interview with E2, the findings were reviewed, and no additional information was provided. This is a repeat deficiency from the compliance inspection conducted on April 2, 2025.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated September 11, 2025. R1's service plan reflected that R1 required an ostomy bag emptied daily and as needed. However, a review of R1's services provided between August 2025 through November 4, 2025, the activities of daily living (ADL) sheets did not document that this service was provided. There was no other documentation available for review. 2. In an interview, E2 reported R1's ostomy bag was emptied daily. However, it was not documented. E2 acknowledged that there was no documentation for this service provided.”

“Based on record review and interview, the manager failed to ensure a written service plan included the signature and date from the resident or representative, for one of two residents reviewed. The deficient practice posed a health and safety risk if the resident or representative did not acknowledge the services that were to be provided. Findings include: 1. Review of R1's record revealed the most recent written service plan. However, this service plan did not include a signature and date from the resident or representative. 2. In an interview, E1 acknowledged R1's service plan did not include a signature and date from the resident or representative.”

“Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of two residents reviewed receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Review of R2's medical record revealed a current written service plan for directed care services dated February 2025. This service plan revealed no documentation of R2's weight. In addition, R2's record revealed no documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 2. During an interview, E1 acknowledged R2's service plan did not include documentation of R2's weight, and documentation was not available in R2's record from a medical practitioner stating weighing R2 was contraindicated.”

“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 inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include:  1. During the facility tour, the Compliance Officer observed the following in an unlocked laundry room: -A gallon of bleach -A gallon of paint -Awesome multi-purpose cleaner 2. In an interview, E1 acknowledged that poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents.”

“Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three caregivers. The deficient practice posed a potential TB exposure 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. Review of E3's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E3's hire date, this documentation was required. 4. In an interview, E1 acknowledged E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113.”

“Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, at the onsite of the condition, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents reviewed who were confined to a bed or chair. 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 a service plan dated January 26, 2024 for personal care services. The service plan revealed R1 required assistance of one or two for transfers and was bed-bound. 2. A further review of R1's medical record revealed no documentation whether R1's primary care provider or other medical practitioner examined R1, reviewed the assisted living facility's scope of services, and signed and dated a determination stating R1's needs could be met by the assisted living facility. 3. In an interview, E1 reported R1 was bedbound. E1 reported having overlooked the required documentation for R1. E1 acknowledged no documentation was included whether R1's primary care provider or other medical practitioner examined R1, reviewed the assisted living facility's scope of services, and signed and dated a determination stating R1's needs could be met by the assisted living facility”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated January 2024. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated February 2024. This medication order stated "Oxycodone 5 mg every 8 hours". 3. Review of R1's medical record revealed a February 2024 medication administration record (MAR). This MAR stated "Oxycodone 5mg every eight hours". However, only two administration times were identified for 7am and 7 pm. 4. In an interview, E1 acknowledged R1's medication was not administered in compliance with the available medication order.”