Jannah Assisted Living, LLC

Based on documentation review and interview the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident that covered job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers. Findings include: 1 . A review of facility documentation revealed a policy titled "Skills and Knowledge." However, the policy did not cover how skills and knowledge are verified or documented. 2 . In an interview, E1 acknowledged the facility did not have a policy which covered how skills and knowledge are verified and documented.

Based on observation, record review, and interview, the manager failed to ensure a caregiver's skill and knowledge were verified and documented before the caregiver provided physical health services, for one of two personnel members sampled. Findings include: 1 . While on-site, the Compliance Officer observed E2 providing physical health services to the residents at the facility. 2 . A review of E2's personnel record revealed a document titled "Caregiver skills and knowledge documentation." However, the document was not filled out completely indicating the caregiver's skills and knowledge were verified. 3 . In an interview, E1 acknowledged E2's skills and knowledge were not verified before providing services.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents sampled. 1 . In an interview, E1 reported all residents received medication administration services. 2 . R1's medical record review revealed a signed medication list dated January 7, 2025. The medication list included "Tamsulosin 0.4 MG once daily." 3 . Further review of R1's medical record revealed a medication administration record (MAR) sheet for March 2025. However, documentation of Tamsulosin being administered from March 1, 2025 to March 11, 2025 was not available for review at the time of inspection. 4 . In an interview, E1 acknowledged R1's medical record did not contain documentation of Tamsulosin being administered from March 1, 2025 to March 11, 2025

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a cabinet under the sink. The sink had a device that prevented it from being opened, but the device could be easily disengaged by the Compliance Officer. The drawers also had magnetic lock devices, however the locks were disengaged. Inside the cabinet were the following: -A bottle of "Windex"; -A bottle of "Spic and Span" all-purpose cleaner; -A can of "Bar Keeper's Friend" cleanser and polish; -A bottle of "Great Value" glass cleaner; and -A bottle of "Odoban" disinfectant. 2 . During an environmental inspection of the facility, the Compliance Officer observed a basket located in the unlocked laundry room. The basket contained a container of "Kirkland Signature Laundry Detergent." 3 . In an interview, E1 acknowledged toxins under the sink and in the laundry room were not locked and inaccessible to residents at the facility.