Bella Vista Assisted Living Home, LLC

Based on documentation review and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for E4. Findings include: 1. A documentation review of the facility's Policies and Procedures Manual revealed a policy titled, "Tuberculosis ("TB") Testing", which stated, "The TB test must be BOTH administered AND read prior to the individual being accepted as a resident, providing services to residents, or moving into the facility, as appropriate." 2. In an interview, E2 revealed that E4 did not have proof of a negative TB test or screening. 3. In an interview, E2 acknowledged that E4 did not provide documentation of freedom from infectious TB prior to providing services at or on the behalf of the assisted living facility.

Based on observation, record review and interview, the manager failed to ensure that a personnel record for each employee or volunteer was maintained throughout the individual’s period of providing services in or for the assisted living facility. The deficient practice posed a risk as required information for a personnel member could not be verified. Findings include: 1. Upon entry into the facility, the Compliance Officer was greeted by E4 who was the only employee at the facility. 2. A review of personnel records revealed that E4 did not have a record available for review. 3. In an interview, E2 revealed that E4 did not have a personnel record because the employee was temporarily covering for E3. 4. In an interview, E2 acknowledged a personnel record for E4 was not available.

Based on observation, documentation review, and interview, the manager failed to ensure a designated caregiver was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. Upon arrival at the facility, the Compliance Officer was greeted by E4, who was the only employee on-site. 2. A documentation review of the manager designation form listed E2 and E3 as authorized designated managers in the absence of E1. 3. In an interview, E2 revealed that E4 was not listed as a designated employee. E2 revealed that E4 was a temporary employee who was covering for E3. 4. In an interview, E2 acknowledged that no manager or designee was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises.

Based on record review, documentation review and interview, the manager failed to ensure the facility did not retain a resident who was confined to a bed or chair without meeting the requirements in R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition, for one of two residents sampled who were confined to a bed or chair because of an inability to ambulate even with assistance. 1. A review of R1's service plan revealed that the resident was receiving Directed Care services and was wheelchair bound. 2. A review of the “Certification for Non-Ambulatory Residents to Reside in the Group Home” form for R1 was completed by the resident's physician on October 22, 2022. 3. A review of the “Approval of Continued Residency” form for R1 was last completed by the physician on August 13, 2024. In parenthesis, the form reads, "Completed by Doctor ever six months' 3. In an interview, E2 acknowledged that the manager failed to ensure that a physician examined the resident at least once every six months throughout the duration of the resident's condition.

Based on record review and interview, the manager failed to ensure a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G), for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed residency agreements. The residency agreements stated "...Termination of the Residency Agreement & Additional Refund Policies A residency agreement may be terminated due to any of the following reasons: 1. The Home may terminate a resident's residency agreement without notice if: a. The resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in the assisted living facility, b. The resident's urgent medical or health needs require immediate transfer to another healthcare institution, or c. The resident's care and service needs exceed the services the facility is licensed to provide. 2. The Home may terminate a resident's residency agreement after providing fourteen (14) days written notice to a resident or the residents' representative for any of the following reasons: a. Documentation of failure to pay fees or charges, b. Documentation of the resident's non-compliance with the Residency Agreement or Internal Facility Requirements (House Rules)." However, documentation to indicate the policy and procedure for an assisted living facility to terminate residency, in compliance with A.A.C. R9-10-807(G) was not available for review. 2. In an interview, E1 acknowledged R1's and R2's residency agreements did not include the correct provisions for an assisted living facility to terminate residency.

Based on record review and interview, the manager failed to ensure a service plan included the requirements in R9-10-815.C.3.5., for one of two residents sampled; and the requirements in R9-10-815.C.1.3-5., for one of two residents sampled who received directed care services. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed a written service plan dated in June 2023. However, the service plan did not include cognitive stimulation and encouragement to eat meals and snacks. 2. Review of R2's (admitted in 2023) medical record revealed a written service plan dated in May 2023. However, the service plan did not include the following: -Skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; -Offering sufficient fluids to maintain hydration; -Cognitive stimulation and activities to maximize functioning; -Strategies to ensure a resident's personal safety; and -Encouragement to eat meals and snacks. 3. In an interview, E1 acknowledged R1's and R2's service plans did not include all requirements in R9-10-815.C.