Am Home Assisted Living LLC

Based on record review and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E3’s personnel record did not include documentation of completed initial training on fall prevention and fall recovery. Based on E3's date of hire, this documentation was required. 2. In an interview, E1 acknowledged the facility failed to develop and administer a training program for all staff regarding fall prevention and fall recovery that included initial and continued competency training. Technical Assistance was provided regarding this regulation during the compliance inspection conducted on June 13, 2023.

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution, for two of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E2's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E2's date of hire, this documentation was required. 2. A review of E3's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E3's date of hire, this documentation was required. 3. In an interview, E1 acknowledged E2's and E3's personnel records did not include documentation of initial and annual training on recognizing the signs and symptoms of TB.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed the facility's disaster plan; however, no documentation of a review was available. 2. In an interview, E1 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.

Based on documentation review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program, which included the frequency of submitting a documented report required in subsection (2) to the governing authority. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled, “Quality Management.” The policy stated, “A summary Report form will be completed monthly which include [sic] numbers of errors in the documentation of medication, treatments, ADL’s, number of residents experiencing weight loss, number of residents with MRSA, C-diff, number of residents reporting loss of money, number of incidents requiring response of emergency services like fire departments, police or paramedics.” 2. A review of the facility’s quality management documentation revealed a report dated April 30, 2025. However, the ink on the documentation was wet and smeared when touched. 3. In an interview, E1 reported E1 backdated the facility’s documentation at the time of inspection. E1 acknowledged the report required in subsection (2) was not submitted to the governing authority at the frequency established by the facility’s policies and procedures.

Based on documentation review, observation, record review, and interview, the manager failed to ensure that an assistant caregiver's skills and knowledge were verified and documented before the caregiver provided health services for one of three personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Skills Assessment.” The policy stated, “The Manager of AM Home Assisted Living will assess caregiver’s skills before employment and validates skills during employment …” 2. While on-site for the compliance inspection, the Compliance Officer observed E3 at the facility, providing services to residents. 3. A review of E3’s personnel record did not include documentation of the verification of E3’s skills and knowledge. 4. In an interview, E1 acknowledged E3’s skills and knowledge were not verified before E3 provided physical health services. This is a repeat deficiency from the compliance inspection conducted on June 13, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 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)..." 2. A review of R1's (admitted 2021) medical record revealed a chest x-ray which indicated R1 did not have active TB at R1's time of admission. However, R1's medical record did not include documentation of R1's freedom from infectious TB according to R9-10-113. 3. In an interview, E1 acknowledged R1's medical record did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113.

Based on documentation review, record review, and interview, the manager failed to ensure that the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, except as provided in R9-10-814.B(2), for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814.B.2 states, “A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: The resident or resident’s representative requests that the resident be accepted by or remain in the assisted living facility; The resident’s primary care provider or other medical practitioner: Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident’s condition; Reviews the assisted living facility’s scope of services; and Signs and dates a determination stating that the resident’s needs can be met by the assisted living facility within the assisted living facility’s scope of services and, for retention of a resident, are being met by the assisted living facility…” 2. A review of R1’s medical record revealed a determination for continued residency signed by R1’s medical practitioner on July 14, 2023. However, documentation of additional determinations was not available for review. 3. In an interview, E1 acknowledged the facility failed to obtain documentation per R9-10-814(B)(2) to maintain R1 as a resident.

Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident’s weight or documentation from a medical practitioner indicating that weighing the resident was contraindicated, for two of two residents sampled. Findings include: 1. A review of R1’s medical record revealed a service plan update dated April 1, 2025 for directed care services. However, R1’s service plan did not include R1’s weight or documentation from R1’s medical practitioner stating that weighing R1 was contraindicated. 2. A review of R2’s medical record revealed a service plan update dated May 1, 2025 for directed care services. However, R2’s service plan did not include R2’s weight or documentation from R2’s medical practitioner stating that weighing R2 was contraindicated. 3. In an interview, E1 acknowledged that R1’s and R2’s medical records did not include the residents’ weight or documentation from a medical practitioner stating that weighing the residents was contraindicated.

Based on observation, record review and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for three of three caregivers reviewed. Findings include: 1. The Compliance Officer observed E1 and E3 assisting residents during the inspection. 2. A review of E1's personnel record revealed no documentation to indicate E1's skills and knowledge were verified before E1 provided physical health services at the facility. 3. A review of E3's personnel record revealed no documentation to indicate E3's skills and knowledge were verified before E3 provided physical health services at the facility. 4. In an interview, E1 acknowledged the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services.