Deficiency #1
Rule/Regulation Violated:
R9-10-808.A.4.b.ii. Service Plans<br> A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: <br>4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): <br>b. As follows: ii. At least once every six months for a resident receiving personal care services, and
Evidence/Findings:
<p>Based on record review and interview, the manager failed to ensure a resident had a service plan that was reviewed at least once every six months for a resident receiving personal care services, for one of two residents sampled. </p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed a service plan completed on December 27, 2024. However, documentation of a service plan completed after December 27, 2024 was not available for review. Based on R1's level of care, a review of R1's service plan was required. </p><p><br></p><p><br></p><p><br></p><p>2. In an interview, E1 acknowledged R1's updated service plan was not available for review at the time of inspection, and reported E1 had sent it to get signed by the resident's representative on August 7, 2025. </p><p><br></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:
The overdue residents service plan was reviewed, updated, and signed by the manager and residents representative on 8/11to bring the record into compliance
Permanent Solution:
The manager will ensure that all residents service plans are reviewed and updated per their level of care. A calendar tracking log has been created filling in when each residents service plan is due. The manager and designee have been trained on the requirement and will review the log at the beginning of every month
Person Responsible:
Anthony Tippett, Manager
Deficiency #2
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 poisonous or toxic materials were maintained in a locked area and 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 the environmental inspection, the Compliance Officers observed that the right cabinet door under the kitchen sink had a broken lock that was not functional, and toxic chemicals (Colorox bleach, Lysol All Purpose Cleaner, dishwasher detergent, and dishwasher pods) were stored in the cabinet.</p><p><br></p><p><br></p><p>2. In an exit interview, the findings were reviewed with E1, and no additional information was added.</p>
Temporary Solution:
All toxic cleaning supplies were immediately removed from the cabinet and stored in a locked storage area, the laundry room. Residents had no access during this rime
Permanent Solution:
A new functional lock was installed on the kitchen sink cabinet on 8/11/2025, and all toxic materials were returned to the locked cabinet. Staff have been retrained on the requirement to keep all toxic and poisonous materials locked and inaccessible to residents and if there is a defect in the lock to immediately remove materials into a locked stored area.
Person Responsible:
Anthony Tippett, Manager
Summary:
The following deficiencies were found during the on-site compliance inspection conducted on August 8, 2025: