Ama Vida Care Home LLC

Based on documentation review, and interview the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before providing physical health services, for two of two caregivers sampled. The deficient practice posed a risk if employees were unable to meet the needs of residents. Findings include: 1. A review of E1's personnel record revealed E1 was hired as a caregiver in July, 2022. Further review revealed documentation of skills and knowledge training was not available for review. 2. A review of E2's personnel record revealed E2 was hired as an assistant caregiver in June, 2023. Further review revealed documentation of skills and knowledge training was not available for review. 3. A review of the facility's policies and procedures revealed a policy titled "Staffing, Hiring and Discipline," which stated the following: "Upon being hired by the facility the applicant must: "...Verification of qualifications, knowledge, and skills to perform the duties of the job hired for..." 4. In an interview, E1 acknowledged evidence of documentation of verification of E1's and E2's skills and knowledge was unavailable for review.

Based on interview and record review, the manager failed to ensure a resident had a written service plan, reviewed and updated at least once every three months for one of one residents sampled who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. In an interview E1 reported R1 received directed care services. 2. A review of R1's, medical record revealed a written service plan dated April 21, 2023. The service plan indicated R1 required "total care including feeding." Based on R1's date of admission, R1 required a reviewed and updated service plan. 3. In an interview, E1 acknowledged R1's service plan was not updated per R9-10-808.A.4.b.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which when initially developed and when updated, was signed and dated by the resident or resident's representative, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, dated April 21, 2023. The service plan included the signature of a registered nurse and the facility manager, however did not include the required signature of the resident or resident's representative. 2. In an interview, E1 acknowledged R1's service plan was not signed as required by the resident or resident's representative.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan and documented the services provided in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan indicating R1 required directed care and was to receive the following services: "Incontinent check every 2-3 hours." 2. A review of R1's medical record revealed a document titled "Activities of Daily Living," dated January 2024, used for documenting services provided and activities of daily living. The document included a section for documenting "Incontinence checks." The document included evidence of daily incontinence checks between 6 AM and 10 PM, however evidence of documentation the service was provided between 11 PM and 6 AM on any day during the month of January was unavailable for review. 3. A review of R2's medical record revealed a service plan indicating R2 received personal care and was to receive the following services: "Incontinent check every 2-3 hours." 4. A review of R2's medical record revealed a document titled "Activities of Daily Living," dated January 2024, used for documenting services provided and activities of daily living. The document included a section for documenting "Incontinence checks." The document included evidence of daily incontinence checks between 6 AM and 8 PM, however evidence of documentation the service was provided between 8 PM and 6 AM on January 4 through 31, 2024 was unavailable for review. 5. In an interview, E1 acknowledged R1 and R2 were not being provided the services as described in R1's or R2's service plan.

Based on record review and interview, the manager failed to ensure the service plan for a resident included the determination in R9-10-814(B)(2)(b)(iii), for one of five residents sampled who received directed care services. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: R9-10-814(B)(2)(b)(iii): 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...2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility:...b. The resident's primary care provider or other medical practitioner:...iii. 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... 1. In an interview, E2 reported R1 was non-ambulatory. 2. A review of R1's medical record revealed a document titled, "Service Plan" dated April 21, 2023. The document stated, R1 was "confined to bed or wheelchair." 3. Further review of R2's medical record revealed admission orders dated April 21, 2023. However, the medical record did not include the determination in R9-10-814(B)(2)(b)(iii). 4. In an interview, E1 acknowledged R1's medical record did not include evidence of documentation of the determination in R9-10-814(B)(2)(b)(iii) as required.