Amira Care, LLC

Based on documentation review, observation, and interview, the licensee implemented a modification of the facility, without an approval or amended license issued by the Department. The deficient practice posed a risk as the Department was unable to assess and approve the modification, as the facility did not submit an updated floor plan. Findings include: 1. Review of Department documentation revealed a floor plan for AL13204. The document indicated AL13204 had eight bedrooms and the primary bedroom was one bedroom. Department documentation revealed no documentation the licensee submitted a request for approval for a modification to the physical plant, including the addition of one bedroom. 2. The Compliance Officers observed the primary bedroom was modified by splitting it into two separate bedrooms. 3. In an interview, E1 reported E1 did not notify the department of the modification of the primary bedroom. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for three of four residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1’s medical record revealed a service plan that indicated R1 received “Hair Care/ Shaving BID” and “Nail care Q W”. 2. Review of R1’s medical record revealed R1’s activities of daily living (ADL) for the month of July 2025 that did not include documentation of hair care, shaving, and nail care being completed. 3. Review of R7’s medical record revealed a service plan that indicated R7 received “Hair Care/ Shaving BID”. 4. Review of R7’s medical record revealed R7’s ADL for the month of July 2025 that did not include documentation of hair and shaving being completed. 5. Review of R8’s medical record revealed a service plan that indicated R8 received “Hair Care/ Shaving BID” and “Resident is checked every 3-4 hours at night and as needed during the day time”. 6. Review of R8’s medical record revealed R8’s ADL for the month of July 2025 that did not include documentation of hair, shaving, and night checks being completed. 7. In an interview, E1 reported R1, R7, and R8 received their activities of daily living; however the services provided were not documented. 8. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the health care institution failed to ensure that the facility documented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis for two of two employees reviewed. The deficient practice posed a potential illness risk to residents. Findings Include: 1. A review of E1's and E2’s personnel records revealed no documentation of tuberculosis training. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that policies and procedures were implemented that covered in-service education for two of two employee records reviewed. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of the facility's policy and procedure titled “Orientation and in-service training” revealed a policy statement that stated, “12 hours of continuing education completed in the previous 12 months will be required upon start of employment services.” 2. A review of E1's personnel record revealed a hire date of August 5, 2024. E1's personnel record did not include any previous continuing education completed prior to the start date for E1. 3. A review of E2’s personnel record revealed a hire date of September 25, 2024. E2's personnel record included documentation of two hours of continuing education in fall prevention and recovery completed prior to the start date for E2. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation, interview, and documentation review, the manager failed to ensure a resident's sleeping area was not used as a passageway to a common area or another sleeping area. The deficient practice posed a potential privacy rights violation to the resident. Findings include: 1. The Compliance Officers observed caregivers sleeping in the primary bathroom. The caregivers could only access the bathroom by entering R7's bedroom. 2. In an interview, E1 reported the caregivers’ room was in the primary bedroom's bathroom. 3. Review of Department records revealed the facility was originally licensed on September 20, 2024, therefore, an exception from the Department before October 1, 2013 would not apply.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings Include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed the following: flammable air freshener out in the hallway and bathrooms; and antifreeze/coolant in the unlocked garage. 2. During an environmental inspection of the facility with E2, the Compliance Officers also observed the following chemicals in an unlocked cabinet under the kitchen sink: LA's Totally Awesome All Purpose cleaner spray; Granite and Stone disinfectant spray; Comet cleaning powder; and Easy Off heavy duty degreaser spray. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that medication stored by the 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 residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed the following medications in common areas around the facility: Tetracyte first aid and antibiotic topical ointment; Watergel triple antibiotic ointment; Mupirocin prescription ointment; Bacitracin ointment; Medline antifungal ointment; Periguard ointment; Dynarex diaper rash ointment; Chamosyn ointment with manuka honey; and Aspercreme pain reliever ointment. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided