Affirmative Care Home

Based on documentation review and interview, the assisted living home failed to maintain a standardized form for each resident which included all of the information prescribed in subsection A of this section. Findings include: 1. A review of facility documentation revealed standardized emergency responder forms for each resident. However, the forms did not include a copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge, for any resident. 2. In an interview, E1 acknowledged the prepared forms did not include the required HIPAA release for each resident.

Based on record review and interview, the chief administrative officer failed to implement tuberculosis infection control activities to include baseline screening consisting of assessing risks of prior exposure to infectious tuberculosis and determining if an individual had signs or symptoms of tuberculosis, on or before the date specified in R9-10-807.A, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a Mantoux skin test (TST) for tuberculosis. However, documentation of baseline screening within seven days after R1's admission, to include an assessment of the resident's risks of prior exposure to infectious tuberculosis and a determination if the resident had signs or symptoms of tuberculosis, was not available for review. 2. In an interview, E1 acknowledged a baseline screening document for R1 had not been provided for review. Technical assistance for this rule was provided during the on-site compliance inspection conducted on May 3, 2024.

Based on record review and interview, the manager failed to ensure a medication was administered to a resident in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan for personal care services including medication administration. 2. A review of R2's medical record revealed signed orders for the medications required to be administered to R2. 3. A review of R2's medical record revealed a Medication Administration Record (MAR), dated July 2025. However, the medications documented to have been administered to R2 did not match the orders for medications in R2's medical record. 4. In an interview, E1 reported ongoing reconciliation issues between R2's eye doctor and primary care provider had resulted in the current orders on file being incomplete or outdated. E1 acknowledged medications administered to R2 were not in compliance with the available orders.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for one of two personnel records sampled. Findings include: 1. A review of facility documentation revealed a policy titled "Caregiver Orientation and Continuing Education." The policy stated "At the time of hire of a new employee the Manager or Manager's Designee will ensure that the employee received the appropriate training and orientation needed, based on the assignment of duties, prior to providing services in this facility....This documentation will be maintained in the employee's personnel record." 2. A review of E3's personnel record revealed documentation of individual's completed orientation required by policies and procedures was not available for review. 3. In an interview, E1 and E2 acknowledged E3's personnel record did not include documentation of E3's completed orientation required by policies and procedures.

Based on record review, observation, and interview, the manager failed to ensure each resident's written service plan accurately included the amount, type and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medications, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a current service plan, dated January 20, 2024, for supervisory care services. The service plan stated, "Resident keeps medication in locked container in room," and "Mediation Requirements: Resident Requires: No Assistance." 2. A review of R1's medical record revealed a Medication Administration Record (MAR) dated May 2023. The MAR indicated R1 had been administered medications in May, 2024. 3. The Compliance Officer observed R1's medications were stored in a locked cabinet in the kitchen along with all other resident medications. 4. In an interview, E1 reported at each medication pass, they place R1's medication in a small cup and hand the cup to R1 to ensure R1 takes the medications as ordered. 5. In an interview, E1 and E2 acknowledged R1's service plan did not accurately state that R1 was receiving medication administration.

Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the water pressure was low and the hot water temperature measured at 85.6\'b0 F in a shared bathroom at the sink in the northwest hallway, and measured 83.5\'b0 F in the shower in the same bathroom. 2. During an environmental inspection of the facility, the Compliance Officer left the shower running in the shared bathroom in the northwest hallway for an additional ten minutes and rechecked the water temperature. The water temperature after running the shower for approximately 15 total minutes measured at 83.6\'b0 F in the shower. 3. During the onsite inspection, After E1 and E2 had arrived, some adjustment was made and E2 requested the Compliance Officer recheck the water temperature. Approximately half of an hour after the initial check, the water temperature in the shared bathroom in the northwest hallway measured 98\'b0 F in the shower. The Compliance Officer observed the water heater, which appeared to be functioning. 4. In an interview, E1 and E2 denied having made any significant adjustments to the supply of hot water. E1 reported having turned the heat setting dial on the water heater, however, E1 acknowledged this would not normally make a sudden change in the supply of hot water in the facility. E1 denied having adjusted any valves which would affect the supply of hot water. E1 and E2 acknowledged the water temperature was not maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents at the time of the environmental inspection.