Deficiency #1
Rule/Regulation Violated:
R9-10-803.B.3.a-b. Administration<br> B. A manager: <br>3. Except as provided in subsection (A)(6), designates, in writing, a caregiver who is: a. At least 21 years of age, and b. Present on the assisted living facility’s premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises.
Evidence/Findings:
<p><span style="color: black;">Based on observation, documentation review, and interview, the manager failed to ensure a designated caregiver was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises.</span><strong style="color: black;"> </strong><span style="color: black;">The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility.</span></p><p><span style="color: black;"> </span></p><p><span style="color: black;">Findings include:</span></p><p><span style="color: black;"> </span></p><p><span style="color: black;">1. Upon arrival at the facility, the Compliance Officer was greeted by E2. E3 was also present at the facility.</span></p><p><br></p><p><span style="color: black;">2. A documentation review of the manager designation form listed E4 as authorized to be designated manager in the absence of E1. E4 was not on the premises when the Compliance Officer arrived. </span></p><p><span style="color: black;"> </span></p><p><span style="color: black;">3. In an interview, E2 revealed, the employee was not listed as a designed manager when E1 was not present. </span></p><p><span style="color: black;"> </span></p><p><span style="color: black;">4. In an interview, E4 acknowledged that no manager or designee was p</span>resent on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises.</p>
Temporary Solution:
The Manager reviewed the documentation after the survey and made sure that all caregivers who were present in the facility sign the delegation of authority that they are accountable when the manager is not present.
Permanent Solution:
The Manager immediately corrected the deficiency cited during the inspection. The manager ensured that all designated certified caregivers on duty/present in the ALF premises have signed the delegation of authority that they are accountable when the manager is not present in the facility.
Person Responsible:
Assisted Living Facility Manager
Deficiency #2
Rule/Regulation Violated:
R9-10-821.C.3.a-g. Physical Plant Standards<br> C. A manager shall ensure that: <br>3. A resident bathroom provides privacy when in use and contains: <br>a. A mirror; <br>b. Toilet tissue for each toilet; <br>c. Soap accessible from each sink; <br>d. Paper towels in a dispenser or a mechanical air hand dryer for a bathroom that is not in a residential unit and used by more than one resident; <br>e. A window that opens or another means of ventilation; <br>f. Grab bars for the toilet and, if applicable, the bathtub or shower and other assistive devices, if required to provide for resident safety; and <br>g. Nonporous surfaces for shower enclosures and slipresistant surfaces in tubs and showers.
Evidence/Findings:
<p>Based on observation and interview, the manager failed to ensure g<span style="background-color: rgb(255, 255, 255);">rab bars for the toilet and, if applicable, the bathtub or shower and other assistive devices, if required to provide for resident safety. </span><span style="color: black;">The deficient practice posed a risk to the physical health and safety of a resident.</span></p><p><br></p><p><span style="color: black;">Findings include: </span></p><p><br></p><p><span style="color: black;">1. During the environmental inspection, a resident's shower area was observed in which no grab bars were present. </span></p><p><br></p><p><span style="color: black;">2. In an interview, E4 acknowledged the manager did not ensure grab bars were placed in the in the shower area as required, </span></p><p><span style="color: black;"> </span></p>
Temporary Solution:
The resident's safety is the utmost priority of the facility. Immediately after the survey, the administrator installed the grab bar for the toilet.
Permanent Solution:
The resident's safety is the utmost priority of the facility. Immediately after the survey, the administrator installed the grab bar for the toilet. The manager ensure that the required grab bars are now in placed.
Person Responsible:
Administrator, ALFM, Caregivers
Summary:
The following deficiencies were found during the on-site compliance inspection conducted on September 18, 2025.