Amarsi Assisted Living

Based on observation, documentation, and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice violated a resident's rights. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed that the residents who resided in rooms 109, 111, 123, 122, 124, 125, 132, 137, 139, 143, 205, 206, 214, 215, 222, 224, 225, 232, 239, and 252 were infested with roaches. 2. In an interview, R2 reported that the facility has roaches and the roaches are in their rooms. 3. In an interview, R3 reported that the facility has roaches and the roaches are in their rooms. 4. During the environmental inspection of the facility, the Compliance Officers entered the room of R1. Upon entering, R1 started to cry and asked for help. R1 reported the facility had yet to give medication and had been waiting for a very long time for assistance from a caregiver. R1 reported that they had pushed their pendant for assistance, and no one had responded, and it had been a long period of time. 5. The Compliance Officers requested to see the pendant call alert system. Upon reviewing the pendant call alert system, it revealed that several residents had pushed their pendants, and the wait time was up to 68 minutes: Room 103 - wait time of 39 minutes, Room 124 - wait time of 68 minutes, Room 225 - wait time of 40 minutes, and Room 214 had a wait time of 26 minutes. 6. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided. This is a repeat citation from inspections conducted on June 3, 2025, and July 9, 2025 September 22, 2025.

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. Upon arriving at the facility, the Compliance Officers observed ambulatory residents at the facility. 2. During the environmental inspection of the facility, the Compliance Officers observed a medication cart in the dining room/kitchen common area, which contained medication for residents at the facility. The medication cabinet was unlocked at the time of inspection. 3. In an exit interview, the findings were reviewed with E1 and E2, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order for one of three residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a current written service plan dated July 22, 2025. This service plan indicated R1 received medication administration. 2. A review of R1’s October 2025 medication administration record (MAR) revealed “Gabapentin Tablet 600 mg. Give 1 tablet by mouth three times a day for neuropathy.” This medication was administered from October 1, 2025, to October 19, 2025. 3. A review of R1's medical record revealed a medication order dated October 2, 2025, for “Gabapentin Tablet 600 mg. Give 1 tablet by mouth three times a day for neuropathy.” 4. The Compliance Officer (CO) observed R1's medication bubble pack, stated, “Gabapentin Tablet 400 mg. Give 1 tablet by mouth every 6 hours.” The CO observed the following: The “Gabapentin 400 mg” for 6:00 am administration had nine bubbles popped. The “Gabapentin 400 mg” for 2:00 pm administration had 19 bubbles popped. The “Gabapentin 400 mg” for 10:00 pm administration had 18 bubbles popped. 5. In an interview, E3 reported that the “Gabapentin 400 mg” was administered to R1. 6. A review of R1’s October 2025 MAR revealed no documentation of “Pregabalin 75 mg.” However, a document titled “Controlled Drug Sign Out Log” revealed “Pregabalin 75 mg” was administered on September 19, 2025, at 7:00 pm; September 20, 2025, at 12:00 pm; September 26, 2025, at 8:25 pm; September 28, 2025, at 8:00 pm; October 7, 2025, at 8:00 am; and October 10, 2025, at 7:00 pm. 7. A review of R1’s medical record revealed a discontinued order for “Pregabalin 75 mg” dated September 19, 2025. 8. The CO observed R1's medication bubble pack, stated, “Pregabalin 75 mg Capsule. Take 1 capsule by mouth every 8 hours.” 9. In an interview, E3 reported that the “Pregabalin 75 mg” was administered after being discontinued. 10. In an exit interview, the findings were reviewed with E3 and E4, and no additional information was provided. 11. This is a repeat deficiency from the inspections conducted on March 28, 2023, November 13, 2023, September 2, 2025, and September 22, 2025.

Based on observation and interview, the manager failed to ensure the health, safety, or welfare of a resident. The deficient practice posed a health and safety risk to a resident. Findings include: 1. In an interview, R3 asked the Compliance Officers if R3 could speak about something bothering R3. R3 then reported that E9 had made unwanted sexual advances to R3. R3 reported that E9 pressured R3 to perform oral sex on E9. R3 report E9 would come into R3’s room and harass R3 to engage in sexual relations. R3 reported that E9 told R3 that if R3 would perform oral sex on E9, E9 would give R3 twenty dollars. R3 reported not liking E9 and not feeling safe at the facility due to E9 working at the facility. 2. In an interview with E5, who was hired as a housekeeper, E5 reported that the room R10 resided in was infested with roaches. 3. A review of documentation revealed E5 had a clipboard, which E5 had shown to the Compliance Officers, which stated “[R10 room number] roach inf.” 4. During the facility's environmental inspection, the Compliance Officers observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. 5. In an interview, the Compliance Officers discussed with E11 that the roach infestation is an ongoing issue with the facility. 6. During the environmental inspection of the facility, the Compliance Officer observed that R12’s residential unit had the door wide open and had a medication organizer that contained unknown medication pills 7. During the environmental inspection of the facility, the Compliance Officer observed in R12’s residential unit, a section of the flooring was missing, which could be a trip hazard for a resident or other individual. A bottle of laundry detergent “Xtra.” Also, medications which were unlocked were “DG Health Cold/Hot Roll On, 2.5 oz” 8. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided. This is a repeat citation from an inspection conducted on July 9, 2025.

Based on interview, documentation review, and observation, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice violated a resident's rights. Findings include: 1. In an interview with E5, who was hired as a housekeeper, E5 reported that the room R10 resided in was infested with roaches. 2. A review of documentation revealed E5 had a clipboard, which E5 had shown to the Compliance Officers, which stated “[R10 room number] roach inf.” 3. During the facility's environmental inspection, the Compliance Officer observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. The resident's bed had a dark brown stain on the mattress. 4. During the facility's environmental inspection, the Compliance Officer observed that R11’s residential unit had food, dirt, and cigarettes on the floor. The condition remains unsanitary and appears not to have been recently mopped or swept. The residents' bathroom toilet bowl contains standing water with visible discoloration and an unidentified object inside, and what looks to be blood and feces on the toilet seat. 5. In an interview, R3 asked the Compliance Officers if R3 could speak about something bothering R3. R3 then reported that E9 had made unwanted sexual advances to R3. R3 reported that E9 pressured R3 to perform oral sex on E9. R3 report E9 would come into R3’s room and harass R3 to engage in sexual relations. R3 reported that E9 told R3 that if R3 would perform oral sex on E9, E9 would give R3 twenty dollars. R3 reported not liking E9 and not feeling safe at the facility due to E9 working at the facility. 6. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided. This is a repeat citation from an inspection conducted on June 3, 2025, and July 9, 2025.

Based on documentation review, observation, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility are cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a potential illness risk to residents. Findings Include: 1. A review of the facility's policies and procedures revealed a policy titled "Housekeeping Services"—section 3. A states, "In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs". 2. During the facility's environmental inspection, the Compliance Officer observed that R2’s residential unit near the bed had loose debris and litter on the floor, including a red bag, an empty bottle, and discarded cigarette packaging. Electrical cords are also loosely spread across the floor, presenting a tripping hazard. 3. In an interview, R2 reported that housekeeping had not been to R2’s residential unit in over two and a half weeks. 4. During the facility's environmental inspection, the Compliance Officer observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. The resident's bed had a dark brown stain on the mattress. 5. During the facility's environmental inspection, the Compliance Officer observed that R11’s residential unit had food, dirt, and cigarettes on the floor. The condition remains unsanitary and appears not to have been recently mopped or swept. The residents' bathroom toilet bowl contains standing water with visible discoloration and an unidentified object inside, and what looks to be blood and feces on the toilet seat. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the inspection conducted on June 3, 2025, and July 9, 2025.

Based on observation, record review, and interview, the manager failed to ensure a written service plan included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for one of nine residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. During the environmental inspection, R2 was observed lying in bed with multiple erythematous, scaly, open, and scabbed lesions covering the arms, legs, and forehead, consistent with an active psoriasis flare. The affected areas appeared red, inflamed, and irritated, with several lesions showing signs of bleeding. The lesions varied in size, with larger patches on the left leg and upper arm presenting raw and open surfaces. Dried blood and crusting were visible in several areas, suggesting ongoing skin breakdown. R2 appeared alert but uncomfortable, and no visible dressings or topical treatments were observed on the affected areas at the time of inspection. 2. In an interview, R2 reported that the psoriasis flare began around the beginning of August 2025, and the doctor had prescribed medication at that time. However, R2 reported that staff did not apply the medication to all affected areas. 3. A record review of R2's medical record included a medication order, dated August 25, 2025, for "CALCITRIOL 3MCG OINTMENT Apply topically to affected area twice daily (Related Diagnoses: PSORIASIS, UNSPECIFIED" with a start date of August 01, 2025, and CLOTRIMAZOLE-BETAMETHASONE CREAM Apply topically to affected area on scalp and arms 4 times daily (Indications for use: Psoriasis)" with a start date of August 11, 2025. 4. A review of R2's service plan for personal care services, dated April 07, 2025, documented a diagnosis of "Psoriasis." A review of the service plan stated, "Skin Maintenance: Skin check completed during each shower of the week and changes reported to the Wellness Director or medical practitioner." However, although R2’s diagnosis of psoriasis was documented in the medical record, the service plan did not include a description of the condition, including its physical effects or related care needs. The lack of documentation describing R2’s psoriasis and the necessary skin maintenance services to address the condition indicates that the service plan was incomplete and did not accurately reflect the resident’s current medical and physical care needs. 5. In an interview, E11 acknowledged the residents' service plans did not include a description of the residents' medical or health problems, as required. This is a repeat deficiency from the inspection conducted on November 27, 2024.

Based on observation, record review, and interview, the manager failed to ensure a written service plan was updated no later than 14 days after a significant change in a resident's physical, cognitive, or functional condition, for one of one resident sampled who had a significant change in condition. The deficient practice posed a health and safety risk to the resident if the caregivers did not know what services the resident needed. Findings include: 1. During the environmental inspection, R2 was observed lying in bed with multiple erythematous, scaly, open, and scabbed lesions covering the arms, legs, and forehead, consistent with an active psoriasis flare. The affected areas appeared red, inflamed, and irritated, with several lesions showing signs of bleeding. The lesions varied in size, with larger patches on the left leg and upper arm presenting raw and open surfaces. Dried blood and crusting were visible in several areas, suggesting ongoing skin breakdown. R2 appeared alert but uncomfortable, and no visible dressings or topical treatments were observed on the affected areas at the time of inspection. 2. In an interview, R2 reported that the psoriasis flare began around the beginning of August, and the doctor had prescribed medication at that time. However, R2 reported that staff did not apply the medication to all affected areas. 3. A record review of R2's medical record included a medication order, dated August 25, 2025, for "CALCITRIOL 3MCG OINTMENT Apply topically to affected area twice daily (Related Diagnoses: PSORIASIS, UNSPECIFIED" with a start date of August 01, 2025, and CLOTRIMAZOLE-BETAMETHASONE CREAM Apply topically to affected area on scalp and arms 4 times daily (Indications for use: Psoriasis)" with a start date of August 11, 2025. 4. A review of R2's service plan for personal care services, dated April 07, 2025, documented, "Skin Maintenance: Skin check completed during each shower of the week and changes reported to the Wellness Director or medical practitioner." However, the service plan was not updated to indicate this significant change. 5. In an interview, E11 acknowledged R2's service plan was not updated after a significant change of condition. This is a repeat deficiency from the inspection conducted on October 2, 2023,

Based on observation, record review, and interview, for two of two residents sampled, who received opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record; an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident's health and safety if the facility did not appropriately assess and monitor opioid administration for a resident. Findings include: 1. During the environmental inspection, R4's medications were observed at the facility, and included "OXYCODONE HCL 20 MG TABLET.” 2. A record review of R4's medical record revealed a service plan for personal care and medication administration services. A review of R4's medication order revealed "OXYCODONE HCL 20 MG TABLET Take 1 tablet by mouth every 4 hours for chronic pain.” A review of R4's electronic medication administration record (eMAR) included documentation that R4 received the OXYCODONE HCL 20 MG medication daily from July 2025 to September 18, 2025. The medical record did not include documentation of an identification of the need for the opioid before the opioid was administered, nor did it include monitoring of the effect of the opioid administered. R4's medical record did not include documentation of an active malignancy or an end-of-life condition. 3. During the environmental inspection, R7's medications were observed at the facility, and included "TRAMADOL HCL 50 MG TABLET" medication. 4. A record review of R7's medical record revealed a service plan for personal care and medication administration services. A review of R7's medication order revealed "TRAMADOL HCL 50 MG TABLET Take 1/2 tablet by mouth three times daily (Indications for use: Pain)." A review of R7's eMAR included documentation that R7 received the TRAMADOL HCL 50 medication daily from August 2025 to September 18, 2025. The medical record did not include documentation of an identification of the need for the opioid before the opioid was administered, nor did it include monitoring of the effect of the opioid administered. R7's medical record did not include documentation of an active malignancy or an end-of-life condition. 5. In an interview, E11 reported that the facility implemented documentation of the resident’s need for the opioid before administration and the monitoring of its effect after administration, beginning on September 19, 2025, and acknowledged that before this date, the facility had not documented the resident’s need for the opioid before administration or the monitoring of the effect after administration. 6. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided. This is a repeat deficiency from the inspection conducted September 26, 2022, November 13, 2023,

Based on observation and interview, the manager failed to ensure the health, safety, or welfare of a resident. The deficient practice posed a health and safety risk to a resident. Findings include: 1. In an interview, R3 asked the Compliance Officers if R3 could speak about something bothering R3. R3 then reported that E9 had made unwanted sexual advances to R3. R3 reported that E9 pressured R3 to perform oral sex on E9. R3 report E9 would come into R3’s room and harass R3 to engage in sexual relations. R3 reported that E9 told R3 that if R3 would perform oral sex on E9, E9 would give R3 twenty dollars. R3 reported not liking E9 and not feeling safe at the facility due to E9 working at the facility. 2. In an interview with E5, who was hired as a housekeeper, E5 reported that the room R10 resided in was infested with roaches. 3. A review of documentation revealed E5 had a clipboard, which E5 had shown to the Compliance Officers, which stated “[R10 room number] roach inf.” 4. During the facility's environmental inspection, the Compliance Officers observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. 5. In an interview, the Compliance Officers discussed with E11 that the roach infestation is an ongoing issue with the facility. 6. During the environmental inspection of the facility, the Compliance Officers observed that R12’s residential unit had the door wide open and had a medication organizer that contained unknown medication pills. 7. During the environmental inspection of the facility, the Compliance Officers observed that in R12’s residential unit, a section of the flooring was missing, creating a potential trip hazard for residents or other individuals. Additionally, a bottle of laundry detergent labeled ‘Xtra’ and an unlocked medication, ‘DG Health Cold/Hot Roll-On, 2.5 oz,’ were observed in the room.” 8. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided. This is a repeat citation from an inspection conducted on July 9, 2025.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver had the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident. This deficient practice posed a health and safety risk to R2 due to unmet medical and skin care needs. Findings include: 1. During the environmental inspection, R2 was observed lying in bed with multiple erythematous, scaly, open, and scabbed lesions covering the arms, legs, and forehead, consistent with an active psoriasis flare. The affected areas appeared red, inflamed, and irritated, with several lesions showing signs of bleeding. The lesions varied in size, with larger patches on the left leg and upper arm presenting raw and open surfaces. Dried blood and crusting were visible in several areas, suggesting ongoing skin breakdown. R2 appeared alert but uncomfortable, and no visible dressings or topical treatments were observed on the affected areas at the time of inspection. 2. In an interview, R2 reported that the psoriasis flare began around the beginning of August 2025, and the doctor had prescribed medication at that time. However, R2 reported that staff did not apply the medication to all affected areas. 3. A record review of R2's medical record included a medication order, dated August 25, 2025, for "CALCITRIOL 3MCG OINTMENT Apply topically to affected area twice daily (Related Diagnoses: PSORIASIS, UNSPECIFIED" with a start date of August 01, 2025, and CLOTRIMAZOLE-BETAMETHASONE CREAM Apply topically to affected area on scalp and arms 4 times daily (Indications for use: Psoriasis)" with a start date of August 11, 2025. 4. A review of R2's service plan for personal care services, dated April 07, 2025, documented a diagnosis of "Psoriasis." A review of the service plan stated, "Skin Maintenance: Skin check completed during each shower of the week and changes reported to the Wellness Director or medical practitioner." 5. In an interview, the Compliance Officers reported that R2’s needs were not met, as the assigned staff did not demonstrate the necessary qualifications, skills, and knowledge to properly address and manage R2’s medical and skin care needs.

Based on record review and interview, the manager failed to ensure an employee provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for seven of ten employees reviewed. The deficient practice posed a TB exposure 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 the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E2's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E2 had signs or symptoms of TB done on or before the date of hire. Based on E2's hire date, this documentation was required. 4. A review of E3's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E3 had signs or symptoms of TB done on or before the date of hire. Based on E3's hire date, this documentation was required. 5. A review of E4's personnel records revealed a negative TB skin test that was less than 12 months old, however, no documentation of a second negative TB skin test was available for review. Also, a review of E4's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E4 had signs or symptoms of TB done on or before the date of hire. Based on E4's hire date, this documentation was required. 6. A review of E5's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E5 had signs or symptoms of TB done on or before the date of hire. Based on E5's hire date, this documentation was required. 7. A review of E6's personnel record revealed no documentation of a risk assessment of prior exposure to infectious TB, and a determination if E6 had signs or symptoms of TB done on or b

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility, which included the manager's signature and date signed, for two of nine residents sampled. Findings include: 1. A review of R1’s medical record revealed a residency agreement that included the manager’s signature and date; however, it was signed and dated three days later by the manager or designee. 2. A review of R4’s medical record revealed a residency agreement that included the manager’s signature and date; however, it was signed and dated fifteen days later by the manager or designee. 3. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided.

Based on interview, documentation review, and observation, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice violated a resident's rights. Findings include: 1. In an interview with E5, who was hired as a housekeeper, E5 reported that the room R10 resided in was infested with roaches. 2. A review of documentation revealed E5 had a clipboard, which E5 had shown to the Compliance Officers, which stated “[R10 room number] roach inf.” 3. During the facility's environmental inspection, the Compliance Officer observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. The resident's bed had a dark brown stain on the mattress. 4. During the facility's environmental inspection, the Compliance Officer observed that R11’s residential unit had food, dirt, and cigarettes on the floor. The condition remains unsanitary and appears not to have been recently mopped or swept. The residents' bathroom toilet bowl contains standing water with visible discoloration and an unidentified object inside, and what looks to be blood and feces on the toilet seat. 5. In an interview, R3 asked the Compliance Officers if R3 could speak about something bothering R3. R3 then reported that E9 had made unwanted sexual advances to R3. R3 reported that E9 pressured R3 to perform oral sex on E9. R3 report E9 would come into R3’s room and harass R3 to engage in sexual relations. R3 reported that E9 told R3 that if R3 would perform oral sex on E9, E9 would give R3 twenty dollars. R3 reported not liking E9 and not feeling safe at the facility due to E9 working at the facility. 6. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided. This is a repeat citation from an inspections conducted on June 3, 2025 and July 9, 2025.

Based on observation and interview, the facility maintains residents' medical records electronically, and the manager failed to ensure that safeguards existed to prevent unauthorized access. Findings include: 1. During an environmental inspection, the Compliance Officers observed a laptop left unattended on a medication cart in the common dining area with no staff present. The laptop was open to a list of resident records and was accessible without safeguards. The device was located in a shared area where residents, visitors, and other guests of the facility were present. 2. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided.

Based on observation, record review, and interview, for one of nine residents sampled, the manager failed to ensure the service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. The deficient practice posed a health and safety risk to residents if staff were unaware of the skin maintenance services needed by a resident. Findings include: 1. During the environmental inspection, R2 was observed lying in bed with multiple erythematous, scaly, open, and scabbed lesions covering the arms, legs, and forehead, consistent with an active psoriasis flare. The affected areas appeared red, inflamed, and irritated, with several lesions showing signs of bleeding. The lesions varied in size, with larger patches on the left leg and upper arm presenting raw and open surfaces. Dried blood and crusting were visible in several areas, suggesting ongoing skin breakdown. R2 appeared alert but uncomfortable, and no visible dressings or topical treatments were observed on the affected areas at the time of inspection. 2. In an interview, R2 reported that the psoriasis flare began around the beginning of August, and the doctor had prescribed medication at that time. However, R2 reported that staff did not apply the medication to all affected areas. 3. A record review of R2's medical record included a medication order, dated August 25, 2025, for "CALCITRIOL 3MCG OINTMENT Apply topically to affected area twice daily (Related Diagnoses: PSORIASIS, UNSPECIFIED" with a start date of August 01, 2025, and CLOTRIMAZOLE-BETAMETHASONE CREAM Apply topically to affected area on scalp and arms 4 times daily (Indications for use: Psoriasis)" with a start date of August 11, 2025. 4. A review of R2's service plan for personal care services, dated April 07, 2025, documented, "Skin Maintenance: Skin check completed during each shower of the week and changes reported to the Wellness Director or medical practitioner." 5. In an interview, E11 acknowledged that R2’s service plan did not include documentation of the skin maintenance services provided to prevent and treat bruises, injuries, pressure sores, and infections, nor did it include services specific to treating R2’s psoriasis.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for one of nine residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R4's record revealed a current service plan for personal care services dated June 2025. This service plan indicated R4 received medication administration. A review of R4's signed medication orders revealed "CLONIDINE HCL 0.2 MG TABLET Take 1 tablet by mouth every 8 hours. Hold for SBP less than 100. (Related Diagnoses: ESSENTIAL (PRIMARY) HYPERTENSION (I10)." 2. A review of R4's electronic medication administration record (eMAR) revealed that "CLONIDINE HCL 0.2 MG TABLET Take 1 tablet by mouth every 8 hours. Hold for SBP less than 100. " was administered September 15, 2025, to present. However, R4’s MAR did not include documentation of the resident’s systolic blood pressure (SBP) reading before each administration of the medication. 3. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided. This is a repeat deficiency from the inspections conducted on March 28, 2023, November 13, 2023, and September 2, 2025.

Based on documentation review, observation, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility are cleaned and, if applicable, disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a potential illness risk to residents. Findings Include: 1. A review of the facility's policies and procedures revealed a policy titled "Housekeeping Services"—section 3. A states, "In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs". 2. During the facility's environmental inspection, the Compliance Officer observed that R2’s residential unit near the bed had loose debris and litter on the floor, including a red bag, an empty bottle, and discarded cigarette packaging. Electrical cords are also loosely spread across the floor, presenting a tripping hazard. 3. In an interview, R2 reported that housekeeping had not been to R2’s residential unit in over two and a half weeks. 4. A review of R2’s service plan stated” Housekeeping and Laundry Services Weekly and PRN.” A review of the activities of daily living (ADL) sheet dated September 2025 revealed "Intervention / Task HOUSEKEEPING: Pick up trash and check apartment daily to prevent clutter, make bed if needed. Time Qshift (0600-1400) (1400-2200) (1400-2200)." However, the room did not appear to be clean. 5. During the facility's environmental inspection, the Compliance Officer observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. The resident's bed had a dark brown stain on the mattress. 6. During the facility's environmental inspection, the Compliance Officer observed that R11’s residential unit had food, dirt, and cigarettes on the floor. The condition remains unsanitary and appears not to have been recently mopped or swept. The residents' bathroom toilet bowl contains standing water with visible discoloration and an unidentified object inside, and what looks to be blood and feces on the toilet seat. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from the complaint investigation conducted on April 23, 2025, June 3, 2025, and July 9, 2025.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed that R12’s residential unit had the door wide open and had a medication organizer that contained unknown medication pills 2. During the environmental inspection of the facility, the Compliance Officer observed in R12’s residential unit, a section of the flooring was missing, which could be a trip hazard for a resident or other individual. A bottle of laundry detergent “Xtra.” Also, medications which were unlocked were “DG Health Cold/Hot Roll On, 2.5 oz” 3. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided. This is a repeat deficiency from the inspection conducted on July 10, 2023, July 24, 2023 and January 30, 2025.

Based on observation and interview, the manager failed to ensure a pest control program was implemented and effective. The deficient practice posed a potential risk to infection control by exposing residents to unsanitary conditions due to cockroach infestation that could lead to the spread of pathogens and compromise resident health and safety. Findings include: 1. In an interview with E5, who was hired as a housekeeper, E5 reported that the room R10 resided in was infested with roaches. 2. A review of documentation revealed E5 had a clipboard, which E5 had shown to the Compliance Officers, which stated “[R10 room number] roach inf.” 3. During the facility's environmental inspection, the Compliance Officers observed that upon opening the door to R10’s, roaches started falling from the top of the door frame onto the floor of the residential unit. There were also roaches on the counters, the walls, and in the resident's bed. 4. In an interview, the Compliance Officers discussed with E11 that the roach infestation is an ongoing issue with the facility. 5. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided

Based on observation, record review, and interview, the manager failed to ensure that each sleeping area had clean linen for the resident. The deficient practice posed a risk to the health and safety of residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed that R2's bed sheet was draped over the headboard of R2’s bed. The bed sheet was stained, which looked like a brown substance. 2. A review of R2’s service plan stated” Housekeeping and Laundry Services Weekly and PRN.” 3. In an interview, R2 reported that housekeeping had not gone to R2’s resident unit for over two and a half weeks. 4. During the environmental inspection of the facility, the Compliance Officers observed that R10's bed had no bed sheet, and the bed was stained, which looked like a brown stain. 5. During the environmental inspection of the facility, the Compliance Officers observed that R11's bed had no bed sheet, and the bed was stained, which looked like a brown stain. 6. In an exit interview, the findings were reviewed with E10, E11, and E12, and no additional information was provided.