Anastasia Assisted Living Home, LLC

Based on documentation review and interview, the manager failed to ensure the health care institution developed a training program for all staff regarding fall prevention and fall recovery, including initial training and continued competency training. Findings include: 1. A review of facility documentation revealed a program or policy regarding when initial training and competency training is conducted for all staff members was not available for review at the time of inspection. 2. In an interview, E4 acknowledged documentation of a fall prevention and fall recovery program or policy regarding initial and competency training was not available for review.

Based on observation, documentation review, and interview, the manager failed to designate in writing a caregiver who is present on the assisted living facility's premises and accountable for the assisted living facility when the manager is not present on the assisted living facility premises. Findings include: 1 . When the Compliance Officer arrived at the facility at approximately 9:30 AM, the Compliance Officer observed only E2 and E3 working on the premises. 2 . A review of facility documentation revealed a "Delegation of Authority." However, E2 was not listed on the delegation. E3 signed the document, but was not listed as a designee, and is an assistant caregiver. 3 . In an interview, E4 acknowledged that there was no documented designee on site while the manager was not on site.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record for one of two residents sampled. Findings include: 1 . A review of R2's medical record revealed a service plan dated March 16, 2025. The service plan reported R2 was to receive two showers a week. However, a review of R2's Activities of Daily Living (ADL) sheet for the month of April 2025 revealed no documentation of a shower provided to R2 from April 10, 2025 to April 17, 2025. 2 . In an interview, E4 reported R2 had refused to take a shower multiple times; however, it was not documented on the ADL sheet. E4 acknowledged R2 had no documentation of showers being provided from April 10, 2025 to April 17, 2025.

Based on observation and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that provides access to an outside area that controls or alerts employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed an alert on the front door of the facility leading to the front yard. However, the alert was turned off, and the door had no control. 2 . During an environmental inspection of the facility, the Compliance Officer observed a door leading to the garage which provided access to the front yard and the back yard. However, the door had no control or alert. 3 . In an interview, E4 acknowledged the front door alert was turned off, and the garage door had no control or alert.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility are inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a magnetic key attached to the dishwasher next to a cabinet underneath the sink. The cabinet underneath the sink was locked with magnetic locks. The Compliance Officer detached the magnetic key from the dishwasher and was able to disengage the magnetic locks on the cabinet and access a bottle of "Cascade" dishwasher detergent. 2 . In an interview, E4 acknowledged the magnetic key was left in a space which allowed the magnetic lock to be disengaged, allowing the toxins to be accessible.

Based on record review and interview, the manager failed to ensure 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, unless the facility obtained a written determination from a medical practitioner, upon acceptance and every six months thereafter, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R1's medical record revealed a current written service plan dated March 20, 2023. This service plan stated "Full assistance of 1 caregiver" and "Wheelchair". 2. Review of R1's medical record revealed no documentation indicating R1's medical practitioner examined R1 upon acceptance and every six months thereafter, signed and dated a determination stating R1's needs could be met by the facility, and reviewed the facility's scope of services. 3. During an interview, E1 reported R1 was unable to ambulate even with assistance since acceptance and acknowledged R1's medical record did not include a written determination from R1's medical practitioner upon acceptance and every six months thereafter.

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 two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication, and the Department was provided false and misleading information. Findings include: 1. Review of R2's medical record revealed a current written service plan dated June 13, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated January 16, 2023. This medication order stated "Amlodipine 2.5mg tab, 1 tab po once a day". 3. Review of R2's medical record revealed a July 2023 medication administration record (MAR). This MAR stated the following: "Amlodipine 2.5mg tab, 1 tab po once a day" and indicated one tab was administered at 8am July 1st - 6th. 4. During an observation of R2's medications, Amlodipine 2.5mg was not observed. 5. During an interview, E1 reported the Amlodipine had been out since July 2nd and acknowledged R2's medication was not administered in compliance with the available medication order.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as the medical record inaccurately indicated a medication was administered, and the Department was provided false and misleading information. Findings include: 1. Review of R2's medical record revealed a current written service plan dated June 13, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated January 16, 2023. This medication order stated "Amlodipine 2.5mg tab, 1 tab po once a day". 3. Review of R2's medical record revealed a July 2023 medication administration record (MAR). This MAR stated the following: "Amlodipine 2.5mg tab, 1 tab po once a day" and indicated one tab was administered at 8am July 1st - 6th. 4. During an observation of R2's medications, Amlodipine 2.5mg was not observed. 5. During an interview, E1 reported the Amlodipine had been out since July 2nd and the caregiver initialed the MAR in error. 6. This is a repeat deficiency from the compliance inspection conducted July 5, 2022.