Deficiency #1
Rule/Regulation Violated:
R9-10-806.A.8.a-b. Personnel<br> A. A manager shall ensure that: <br>8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: <br>a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;
Evidence/Findings:
<p>Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two personnel sampled. The deficient practice posed a potential illness risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>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)..."</p><p><br></p><p><br></p><p>2. A review of E3's personnel revealed documentation of E3's freedom from infectious TB that was less than 12 months old. However, based on E3's date of hire, this documentation was not completed before E3 began providing services at the facility.</p><p><br></p><p><br></p><p>3. In an interview, E3 reported that E3 provided physical health services at the facility prior to obtaining the freedom from infectious TB documentation.</p><p><br></p><p><br></p><p>4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p>
Temporary Solution:
Maryam Rashid will ensure that all employees receive tb tests before they can start their shift. Percilla Amezcua started her shift on 1/2/25. Her skin tb tests were done on 12/20/24 and 1/2/25. For Beatrice Obaigwa, she started her shift on 7/27/25 and had a positive skin tb test on 4/17/23 and did a chest x ray on 02/08/2025 and tested negative on it since if a blood test was taken the blood test will show positive results based on the one that was done in the past.
Permanent Solution:
Maryam Rashid will ensure that all employees receive tb tests before they can start their shift.
Person Responsible:
Maryam Rashid, Office Manager
Deficiency #2
Rule/Regulation Violated:
R9-10-808.C.1.g. Service Plans<br> C. A manager shall ensure that: <br>1. A caregiver or an assistant caregiver: <br>g. Documents the services provided in the resident’s medical record; and
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure that a caregiver or an assistant caregiver documented the services provided according to the resident's service plan for one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R2's service plan lists the following services to be provided by the facility:</p><p><br></p><ul><li>bathing, twice daily and as needed;</li></ul><p><br></p><ul><li>laundry, daily and as needed.</li></ul><p><br></p><p><br></p><p>2. A review of R2's medical record revealed documentation of R2's activities of daily living (ADL) for the month of August 2025. This ADL documentation revealed only the following:</p><ul><li>bathing, however, it was only documented as completed on August 8 and August 15 instead of being completed twice daily and as needed.</li><li>laundry, however, it was only documented as completed on August 8 and August 15 instead of being completed daily and as needed.</li></ul><p><br></p><p><br></p><p>3. In an interview, R2 reported R2 received all required services in the month of August 2025.</p><p><br></p><p><br></p><p>4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>
Temporary Solution:
Maryam Rashid collected the updated service plan to show that the laundry and bathing are done twice a week. We confirmed that both tasks were done by Beatrice Obaigwa, caregiver on August 11th and 18th as well on top of August 11th and 18th.
Permanent Solution:
Maryam Rashid will double check to ensure that the service plan accurately reflect how often the ADLs are completed and Frances Parra, floater will ensure that caregivers chart accurately on the days that ADLs are supposed to be completed.
Person Responsible:
Maryam Rashid, Office Manager
Deficiency #3
Rule/Regulation Violated:
R9-10-817.F.1. Medication Services<br> F. When medication is stored by an assisted living facility, a manager shall ensure that: <br>1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;
Evidence/Findings:
<p>Based on observation, record review, and interview, the manager failed to ensure that medication stored by the 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 residents who were not prescribed the accessible medication.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental inspection of the facility with E1, the Compliance Officers observed medicated ointment in the bedroom of R3 labeled "Diclofenac Sodium Topical Gel, 1% (NSAID)".</p><p><br></p><p><br></p><p>2. A review of R3's medical record revealed no documentation that R3 self-administered medication. </p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>
Temporary Solution:
Dustin Godfrey took the medication out of the resident's room and put it in the locked medication closet and informed the caregiver that all medications need to be locked up at all times. We also reached out to the her doctor and got an order that she may self administer and keep at bedside
Permanent Solution:
Frances Parra and Mataeo Ramos, floaters will check during their rounds to ensure that no medications are being left in the residents rooms. If any medications are found not locked in medication closet, it will be addressed with the caregiver immediately.
Person Responsible:
Dustin Godfrey, Director of Operations
Deficiency #4
Rule/Regulation Violated:
R9-10-818.C.5. Food Services<br> C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: <br>5. A refrigerator used by an assisted living facility to store food or medication contains a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator;
Evidence/Findings:
<p>Based on observation and interview, the manager failed to ensure that a refrigerator used by an assisted living facility to store food contained a thermometer, accurate to plus or minus 3° F, placed at the warmest part of the refrigerator. The deficient practice posed a risk for potential food borne illnesses.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental inspection of the facility with E1, the Compliance Officers observed a refrigerator in the dining room area that did not contain a thermometer.</p><p><br></p><p><br></p><p>2. During an environmental inspection of the facility, E1 confirmed the refrigerator was actively being used to store food for residents.</p><p><br></p><p><br></p><p>3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>
Temporary Solution:
Thermometers were ordered and placed in the warmest part of the fridge.
Permanent Solution:
Frances Parra and Mataeo Ramos, floaters will ensure to check the fridge and freezers to make sure that the thermometers have not been removed
Person Responsible:
Maryam Rashid, Office Manager
Deficiency #5
Rule/Regulation Violated:
R9-10-819.D.2.a-f. Emergency and Safety Standards<br> D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: <br>2. Documents the following: a. The date and time of the accident, emergency, or injury; <br>b. A description of the accident, emergency, or injury; <br>c. The names of individuals who observed the accident, emergency, or injury; <br>d. The actions taken by the caregiver or assistant caregiver; <br>e. The individuals notified by the caregiver or assistant caregiver; and <br>f. Any action taken to prevent the accident, emergency, or injury from occurring in the future.
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the caregiver documented the date and time of the accident, emergency, or injury; a description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R2's medical record revealed an incident report concerning a recent fall dated for August 17, 2025. This fall resulted in the resident needing medical services.</p><p><br></p><p><br></p><p>2. A review of R2's medical record revealed R2's incident report was missing documentation of the names of individuals who observed the accident, the actions taken by the caregiver or assistant caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future.</p><p><br></p><p><br></p><p>3. R2's incident report contained a section labeled "Based on investigational findings, describe prevention measures implemented", however, the answer was left blank.</p><p><br></p><p><br></p><p>4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>
Temporary Solution:
Maryam Rashid went through the incident report and found a computer glitched between what was entered in Synkwise under the view section that outlined the details that were missing in the print version of the incident report. Maryam Rashid contacted Synkwise's support team and brought up this discrepancy between the information that is being entered by the caregivers and what appeared in the printable version of the report.
Permanent Solution:
Since the caregiver was not at fault, contacting Synkwise's support team should fix this issue from occurring in the future for future incident reports.
Person Responsible:
Maryam Rashid, Office Manager
Deficiency #6
Rule/Regulation Violated:
R9-10-820.A.11. Environmental Standards<br> A. A manager shall ensure that: <br>11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;
Evidence/Findings:
<p>Based on observation and interview, the manager failed to ensure that 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.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. During an environmental inspection of the facility, the Compliance Officers found a bottle of disinfectant spray in an unlocked laundry room. The Compliance Officers also found two cans of Febreze air freshener spray in a kitchen drawer.</p><p><br></p><p><br></p><p>2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.</p>
Temporary Solution:
Dustin Godfrey addressed this problem by reiterating to the caregiver on duty that all poisonous and harmful chemicals need to be placed in the laundry room with the door closed at all times. The laundry room door was closed to ensure that the chemicals were locked and the febreeze in the kitchen cabinet was removed.
Permanent Solution:
Frances Parra and Mataeo Ramos, floater will ensure that all chemicals and poisonous materials are locked up when she goes for her rounds in the homes.
Person Responsible:
Dustin Godfrey, Director of Operations
Summary:
The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00105086, 00104982, and 00102489 conducted on August 19, 2025: