Aurora's Assisted Living, LLC

Based on observation, documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed E3 working at the facility at the time of the inspection. 2. Review of facility documentation revealed a policy and procedure titled "Fall Prevention and Recovery Training Responsible person: All employees and volunteers" that stated "Fall Prevention and Recovery Training is required upon hire and at least every 12 months thereafter." 3. Review of E3's personnel record revealed E3 worked as an assistant caregiver. The personnel record revealed no documentation of fall prevention and recovery training. 4. In an interview, E1 acknowledged E3 had not yet completed fall prevention and fall recovery training. E1 acknowledged E1 did not implement the health care institutions training program for fall prevention and fall recovery for E3.

Based on observation, record review, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregiver working each day, including the hours worked. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. The Compliance Officer observed E3 working at the facility at the time of the inspection. 2. Review of E3's personnel record revealed E3 had a hire date of January 2024 and worked as an assistant caregiver. 3. Review of the January 2024 and February 2024 personnel schedules revealed no hours worked for E3. A review of the facilities personnel schedules revealed no schedule for March 2024. 4. In an interview, E1 reported E1 was unaware assistant caregivers were documented on the schedule. E1 acknowledged documentation was not maintained of the assistant caregiver working each day, including the hours worked by E3. E1 acknowledged documentation was not maintained of the caregivers and assistant caregivers for the month of March 2024.

Based on observation, record review, and interview, the manager failed to ensure that a trained caregiver was present on the assisted living facility's premises when the manager was not present. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. The Compliance Officers observed E3 working alone at the facility with four residents at 9 a.m. on March 7, 2024. The Compliance Officers observed E1 return to the facility at approximately 9:11 a.m. 2. In record review, E3's record revealed E3 was an assistant caregiver. E3's personnel record did not include documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers. In addition, E3's record did not include documentation that showed an administrator's license, a nursing license, or employment as a caregiver prior to November 1, 1998. Therefore, E3 was not qualified to be left alone with the residents based on the lack of caregiver training. 3. In an interview, E1 reported E3 was an assisted caregiver. E1 acknowledged E3 was at the facility with four residents at the time of the inspection with no other staff present. E1 acknowledged neither a manager or caregiver was present at the facility when the Compliance Officer arrived.

Based on record review and interview, the manager failed to ensure an employee record included documentation of the starting date of employment, for one of three records reviewed. Findings include: 1. When the surveyor arrived, E3 was the only employee at the facility with four residents. 2. Review of facility records revealed E3 worked as an assistant caregiver. E3's personnel record revealed no documentation of a starting date of employment. 3. In an interview, E1 reported E3 began working at this facility as an assistant caregiver in January 2024. E1 acknowledged the manager failed to ensure an employee record included documentation of the starting date of employment.

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. Findings include: 1. Review of R2's medical record revealed a current written service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated February 22, 2024. This medication order stated "Discontinue medication: Abilify 10 mg oral one times a day for anxiety/agitation and depression. Abilify 15 mg oral one times a day for anxiety/agitation and depression." 3. Review of R2's medical record revealed a March 2024 medication administration record (MAR). This MAR stated the following: "Abilify 15 mg Take 1 tab QD" and indicated 1 tab was administered at 8am March 1, 2024 through March 5, 2024. 4. During an observation of R2's medications, Abilify 10 mg pill bottle was observed. A review R2's seven day mediset revealed one, 10 mg pill present in the am medi-set. A review of R2's medications revealed no Abilify 15 mg was available for review. 5. During an interview, E1 reviewed R2's medical record. E1 reported R2's daughter had provided the Abilify 10 mg pill bottle. E1 reported E1 did not realized the bottle did not have the correct dosage. E1 reported E1 completes medication administration with R2. E1 reported E1 administered Abilify 10 mg in the morning to R2 not 15 mg. E1 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 documented in the resident's medical record for two of two residents reviewed. Findings include: 1. A review of facility documentation revealed R1's Medication Administration Record (MAR) dated March 2024. The MAR stated "Levothyroxine 15 mg 1 tab |PO QD, Citalopram 20 mg 1 tab PO QD, BUDESOMIDE .5 MF inhale one time a day and Metformin 500 mg 1 tab PO QD." R1's MAR did not reveal documentation of the administration of the identified medications for March 6, 2024 and the morning of March 7, 2024. 2. A review of facility documentation revealed R2's MAR dated March 2024. The MAR stated "Pregabalin 50 mg 1 cap QHS, Sertiline 100 MG 1 tab QHS, Trazadone 100 mg 1 1/2 tab of 50 MG PO QHS, Abilify 15 mg 1 tab PO QD." R2's MAR did not reveal documentation of the administration of the identified medications for March 6, 2024 and the morning of March 7, 2024. 3. A review of R1 and R2's medications revealed the identified medications were available. 4. In an interview, E1 reported E1 administered the medication to R1 and R2. E1 acknowledged E1 did not document the administration of the medication in R1's and R2's medical record for the dates identified.

Based on observation, record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. The Compliance Officers observed R2 to have facial injury and bruising at the time of the inspection. 2. Review of R2's medical record revealed a document titled "Visit Note" from Faith Hospice indicating R2 had a fall event requiring their medical services on March 4, 2024. The document identified the following injuries; "1.5 cm @ R temple, .25 @ right upper lip, rug burn at R chin, .25 @ 2nd knuckle of R hand." However, documentation was not available that included the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future. 3. In an interview, E1 acknowledged R2 had a fall event that required medical services. E1 acknowledged R2's medical record did not include documentation of the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future. E1 completed the document on site during the inspection.