American Dream Home II, LLC

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident's date of occupancy, as stated in R9-10-113 for one of three residents sampled. 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 R1's medical record revealed there was no documentation of assessing risks of prior exposure to infectious TB or documentation of determining if R1 had signs or symptoms of TB. Based on R1's date of occupancy, this documentation was required. 3. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R3's medical record revealed a service plan dated and signed on November 5, 2025 that stated R3 received directed care services. 2. A review of R3's medical record revealed no documentation that stated whether R3 required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R3’s acceptance date, this documentation was required. 3. In an exit interview, the findings were reviewed with E4. E4 reported that R3 came from a previous assisted living licensee and was absorbed into their facility during a change of ownership. E4 reported the previous owner did not provide them with this required document, however, the facility failed to re-assess the resident.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for two of two residents sampled receiving directed care services. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of R1's medical record revealed a service plan for directed care dated January 30, 2026. This service plan did not include documentation of R1's weight. In addition, R1's record revealed no documentation of R1's weight or documentation from a medical practitioner stating that weighing R1 was contraindicated. 2. A review of R3's medical record revealed a service plan for directed care dated November 5, 2025. This service plan did not include documentation of R3's weight. In addition, R3's record revealed no documentation of R3's weight or documentation from a medical practitioner stating that weighing R3 was contraindicated. 3. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on record review and interview, the manager failed to ensure medication was administered to a resident 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 R1’s current service plan dated January 30, 2026. The service plan revealed R1 required medication administration. 2. A review of R1's medical record revealed a signed medication order dated December 22, 2025. The order prescribed Rexulti, 0.25mg 1 tablet in the morning and 1 tablet as needed once daily. 3. A review of R1’s Medication Administration Record (MAR) revealed no documentation that Rexulti, 0.25mg was administered to R1 during the month of February 2026. 4. In an exit interview, the findings were reviewed with E4, and E4 reported R1 had another order for Rexulti 0.5mg, which they were receiving every day and thought this second Rexulti (0.25mg) was only to be taken as needed. 5. This is a repeat deficiency from the inspection conducted on July 26, 2024.

Based on observation and interview, the manager failed to ensure that an evacuation path was conspicuously posted in each hallway of each floor of the assisted living facility. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a hallway nearest to the entrance inside of the facility that did not contain a posted evacuation path. 2. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a fall risk to ambulatory residents in the facility. Findings include: 1. During an environmental tour of the facility, the Compliance Officer (CO) observed a pile of unevenly arranged bricks as a part of a pathway in the backyard of the facility. 2. The CO observed ambulatory residents within the facility. 3. In an exit interview, the findings were reviewed with E4 and no additional information was provided.

Based on documentation review, record review, and interview, for one resident reviewed, the manager failed to ensure documentation of medication administration included the the name and signature of the individual administering medication. The deficient practice posed a health and safety risk to a resident if the facility did not properly document medication administration for a resident, and the Department was provided false and misleading information. Findings include: 1. In record review, R1's medication administration record (MAR), dated July, 2024, included documentation R1 received Glucosamine, Montelukast, Tamsulosin, and Temazapam medications daily in July. The MAR included documentation signed by E2 which indicated the medications were administered by E2 everyday on each shift. 2. R1's MAR included documentation R1 was administered Montelukast 10mg daily at 8:00am July 1 - 25, 2024. However, E2 reported [E2] did not administer the Montelukast medication for a couple of days on or around July 22 - 25, 2024. 3. During an interview, E2 reported [E2] withheld the medication; however, the MAR was signed inadvertently, with E1's initials, indicating the medication was administered. 4. In documentation review, a facility policy titled, "Medication Administration," page 114, documented, "3. For each employee authorized to administer medications; and will be placed on a list of medication approved caregiver. This list will be found in each file containing the current and filed "Medication Administration Records (MAR)... Immediately after giving medication document the administration on the ... MAR... Documentation that the medication was given will be recorded on the MAR by recording the medication giver's two-digit initials inside the square at the intersection of the date and the time for the given medication..." The facility did not have a list of medication approved caregivers. 5. During an interview, E1 reported E1 and E2 administered medication to residents. E1 said E2 prepared the medication for administration, while E1 administered the medication to the residents. E1 and E2 acknowledged R1's MAR did not include documentation of the name and signature of E1, who administered the medication to R1, and E1 signed the MAR for the administration of the Montelukast medication, when the medication was not administered to R1.

Based on documentation review and interview, the manager failed to ensure policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. In documentation review, the facility's medication policies and procedures for medication administration did not include documentation of review and approval by a medical practitioner, registered nurse, or pharmacist. 2. During an interview, E1 reported the policies were reviewed; however, acknowledged the policies did not include documentation of the review and approval by a medical practitioner, registered nurse, or pharmacist and acknowledged the requirements had not been met.

Based on documentation review, record review, and interview, for one resident reviewed, the manager failed to ensure medication was administered to a resident in compliance with a medication order. The deficient practice posed a health and safety risk to residents, if the facility did not administer medications in compliance with a medication order, and a resident did not receive the required medication. Findings include: 1. In documentation review, the Department received a report from O1 and O2; which documented the facility did not administer Montelukast medication to R1, in accordance with the medication orders. 2. In record review, R1's medical record included a medication order for Montelukast 10 mg (Singular), take 1 tab PO QD for allergies. R1's medication administration record included documentation R1 was administered the medication daily at 8:00am July 1 - 26, 2024. 3. During an interview, E2 reported [E2] did not administer the Montelukast medication to R1 for approximately two days between July 22 to July 25, 2024. E2 couldn't remember which days the medication was withheld, and reported the medication was not administered due to concerns for R1's health. E2 acknowledged not having a medication order to stop the medication. E1 and E2 acknowledged the medication was not administered to R1, as ordered; however, reported the facility was now aware a medication must be administered and/or discontinued in compliance with a medication order.