Abundant Life Alh II

Based on observation, documentation review, record review and interview, the manager failed to ensure a caregiver’s or assistant caregiver’s skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services or behavioral health services, and according to policies and procedures, for one of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1 . A review of facility documentation revealed a policy titled "Employees and Volunteers Qualifications." The policy stated "The hiring person or manager will ensure, check, and document that each caregiver or assistant caregiver providing physical health services or behavioral health services have the required skills and knowledge before providing any services." 2 . In an interview, E1 reported E2 was an assistant caregiver. 3 . During an inspection at the facility, the Compliance Officer observed E2 providing physical health services to a resident under the supervision of E3. 4 . A review of E2's personnel record revealed documentation of a completed skills and knowledge verification form was not available for review at the time of inspection. 5 . In an exit interview, the findings were discussed with E1 and no additional information was added.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each, for one of three personnel sampled. Findings include: 1 . In an interview, E1 reported E2 was an assistant caregiver. 2 . During an inspection at the facility, the Compliance Officer observed E2 providing physical health services to a resident under the supervision of E3. 3 . A review of facility documentation revealed documentation titled "Employee work schedule" for July and August 2025. However, the hours worked by E2 were not included on the "Employee work schedule" for July and August 2025. 4 . In an exit interview, the findings were discussed with E1 and no additional information was added.

Based on record review and interview, the manager failed to ensure 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, provided evidence of freedom from infectious tuberculosis on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of three personnel sampled. Findings include: 1 . A review of E2's personnel record revealed documentation of a TB screening questionnaire and a negative TB skin test. However, documentation of a second negative TB skin test was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was added.

Based on observation, documentation review, record review, and interview, the manager failed to ensure before providing assisted living services to a resident, a caregiver or an assistant caregiver received orientation that is specific to the duties to be performed by the caregiver or assistant caregiver, for one of three personnel sampled. The deficient practice posed a risk if the employees were unable to meet residents’ needs. Findings include: 1 . A review of facility documentation revealed a policy titled "Orientation and In-Service Training." The policy stated, "New employee orientation is required to be completed by all new employees and volunteers before starting to provide assisted living services to the resident..." 2 . In an interview, E1 reported E2 was an assistant caregiver. 3 . During an inspection at the facility, the Compliance Officer observed E2 providing physical health services to a resident under the supervision of E3. 4 . A review of E2's personnel record revealed that documentation of a completed orientation was not available for review at the time of inspection. 5 . In an exit interview, the findings were discussed with E1 and no additional information was added.

Based on record review and interview, the manager accepted or retained an individual if the individual required restraints, including the use of bedrails, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet residents’ needs. Findings include: 1 . A review of R1's medical record revealed a "Preliminary Admission Summary." The documentation stated R1 "required restraints, including the use of bedrails." 2 . In an interview, E1 reported E1 was unsure why this was marked on this documentation, as R1 did not require restraints. In an exit interview, the finding was discussed with E1 and no additional information was documented.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed and updated 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 facility documentation revealed a policy and procedure manual created approximately November 2019. However, documentation to demonstrate the facility's policies and procedures were reviewed and updated at least once every three years was not available for review. 2. In an interview, E1 acknowledged policies and procedures were not reviewed and updated at least once every three years.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) and first aid training, for one of three employees sampled. The deficient practice posed a risk if an employee was unable to meet the needs of residents. Findings include: 1. A review of E2's personnel record revealed a CPR and first aid training card. However, the card expired in October 2023. No updated CPR or first aid training documentation was provided for review for E2. 2. In an interview, E1 acknowledged E2's documentation of CPR and first aid training was expired.

Based on observation, documentation review, and interview, the manager failed to ensure medication stored by the facility was stored in a locked area. 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, the Compliance Officer observed a box of "Lorazepam" and a container of "Amoxicillin" inside a lockable box in the fridge door in the kitchen. However, the box was not locked at the time of the observation. 2. A review of facility documentation revealed a policy titled "Medication services." The policy stated "All resident medications must be secured in a locked storage area." 3. In an interview, E1 acknowledged medication stored by the facility was not stored in a locked area at the time of the inspection.

Based on observation, documentation review, and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the poisonous or toxic materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a can of "Easy-Off" oven cleaner, "Weiman" stainless steel cleaner and polish, and a container of "Weiman" stainless steel wipes in a cabinet underneath the kitchen sink. The cabinet was not locked and was accessible to residents. 2. A review of facility documentation revealed a policy titled "Emergency, safety, and environmental standards." 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 interview, E1 acknowledged poisonous or toxic materials stored by the facility were not stored in a locked area and inaccessible to residents at the time of the inspection.