Jennina's Adult Care Home LLC.

“Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, before or within seven calendar days after the resident's date of occupancy, for one of two sampled residents. Findings include: A review of R1's medical record revealed baseline screening, to include an assessment of R1's risk of prior exposure to TB, and a determination if R1 had symptoms of TB, was not available for review. R1's medical record included a baseline screening form; however, the form had not been filled out, signed, or dated. R1's medical record included a negative TB skin test. Based on R1's date of occupancy, completed TB baseline screening was required. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a documented residency agreement included a resident's date of occupancy or expected date of occupancy, for one of two sampled residents. Findings include: A review of R1's medical record revealed a documented residency agreement. However, the residency agreement did not include R1's date of occupancy or expected date of occupancy. In an exit interview with E1, the finding was reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident had a complete service plan no later than 14 calendar days after the resident's date of acceptance, for one of two sampled residents. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: A review of R1's medical record revealed a service plan was not available for review. However, based on R1's date of acceptance, a service plan was required. In an exit interview with E1, the finding was reviewed and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that a resident's privacy was protected. The deficient practice violated a resident's rights.  Findings include: During an environmental inspection of the facility, in the hallway west of the living room, the Compliance Officer observed the microphone component of an audio-only monitoring device hanging from the wall. In an interview with R2, R2 repeatedly warned the Compliance Officer not to speak loudly because of the monitoring device. R2 reported being yelled at by E3 after saying something about E3's boyfriend to R2's roommate, which was private, but E3 had heard it over the monitoring device. R2 reported the caregiver, E1, doesn't use it, that it is only used by the owner, who has the speaker in the owner's private room. In an interview, E1 reported the monitoring device was in E3's private room, where E3's family and visitors spend time. In an interview, E3 reported the monitoring device is in E3's bedroom, so E3 can hear if a resident needs something at night when E3 is in E3's bedroom. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom used by a resident receiving personal care services. Findings include: During an environmental tour of the facility, the Compliance Officer observed two residents in the far northwestern bedroom. The Compliance Officer observed both residents were in bed. The Compliance Officer observed a bell, intercom, or other mechanical means to alert employees to a resident’s needs was not available or accessible in the bedroom. In an interview with R1 and R2, both residents said they did not have a bell, intercom, or other mechanical means to alert employees to their needs or emergencies. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure staff obtained certificates of completion of memory care services training within the first 30 days of hire, as specified in R9-10-126, for two of two sampled staff. R9-10-126(A) states: A. Memory care services training programs, approved by the Department according to R9-10-122, shall provide staff and contractors who complete the training, a certificate of completion that may be used to work at an assisted living facility that is licensed to provide directed care services with the following information: 1. The title of the certificate is clearly stated as, “Certificate of Completion”; 2. The name, address, email address, and telephone number of the individual completing the memory care services training; 3. Title of the training program; 4. Name of the training organization or provider; 5. Contact information for the training organization; 6. The date the individual successfully completed the memory care services training; 7. The address where the memory care services training and assessment was held; 8. The name of the memory care services trainer; 9. The number of hours completed; 10. The training topics covered; 11. A statement confirming the trainee’s successful completion of the training; 12. Signature of the trainer; and 13. Date of issuance. Findings include: A review of E2's personnel record revealed a memory care training certificate. However, the certificate did not include the address, email address, or the telephone number of the individual completing the memory care services training. The certificate included areas to document the required information, however, the certificate had been signed by the trainer and issued to E2 without including this information. A review of E3's personnel record revealed a memory care training certificate. However, the certificate did not include the address, email address, or the telephone number of the individual completing the memory care services training. The certificate included areas to document the required information, however, the certificate had been signed by the trainer and issued to E3 without including this information In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: A review of the facility's policies and procedures revealed a medication policy. On the last page of the medication policy, the policy stated, "This medication policy and procedure had been reviewed and approved by:" However, the signature line had been left blank. A pink adhesive note on the policy stated, "[nurse] please sign," and a second orange adhesive note was placed as an arrow to the signature line. In an exit interview with E1, the finding was reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order for one of two sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: A review of R2's medical record revealed a list of medication orders from R2's hospice provider, dated March 9, 2026. This list included the following orders: "Clonazepam, 0.5 mg tablet, 0.25 mg oral BID"; "Doxepin 10 mg/ML oral, 5mg/0.5ml, oral at bedtime"; "Morphine ER 15 mg tablet, 15 mg, oral, twice a day - along with MSER 30mg for total of 45 mg BID"; "Morphine ER 30 mg tablet, 30 mg, oral, every 12 hours"; and "Tylenol Extra Strength 500 mg tablet, 1000 mg, oral BID." A review of R2's medical record revealed orders to discontinue R2's medications were not available for review. A review of R2's physical medications revealed multi-dose packages of Clonazepam, Morphine 15 milligram tablets, and Morphine 30 milligram tablets. A review of R2's medical record revealed a Medication Administration Record (MAR) dated March 2026. The MAR documented medication administered to R2 between March 1, 2026, and the date of the inspection, March 25, 2026, including medications administered every day in March 2026. However, the MAR also included the following: For the medication "Clonazepam tab 0.5 mg, PO 1/2 tab BID," the MAR documented R2 had received the medication at 8 AM and 5 PM between March 1, 2026, at 8 AM and March 17, 2026, at 8 AM. However, starting on March 17, 2026, at 5 PM, the MAR had a note written over the rows, preventing further documentation of administration, which read, "D/C from [hospice] sign with [another primary care provider] 3/17/26." No Clonazepam had been administered between 5 PM on March 17, 2026, and the date of the inspection, March 25, 2026; For the medication "Acetaminophen tab 500 mg, PO 2 tabs (1000mg) BID," the MAR documented R2 had received the medication at 8 AM and 5 PM between March 1, 2026, at 8 AM and March 17, 2026, at 8 AM. However, starting on March 17, 2026, at 5 PM, the MAR had a note written over the rows, preventing further documentation of administration, which read, "[R2] was refused to take it - [E3]." No Acetaminophen had been administered between 5 PM on March 17, 2026, and the date of the inspection, March 25, 2026; For the medication "Morphine sul ER 15 mg TAB PO 1 tab BID for pain," the MAR documented R2 had received the medication at 8 AM and 5 PM between March 1, 2026, at 8 AM and March 16, 2026, at 5 PM. However, starting on March 17, 2026, at 8 AM, the MAR had a note written over the rows, preventing further documentation of administration, which read, "[R2] was refused to take it - [E3]." No Morphine had been administered between 8 AM on March 17, 2026 and the date of the inspection, March 25, 2026; For the medication "Morphine sul ER 30 mg TAB, PO 1 tab BID," the MAR documented R2 had received the medication at 8 AM and 5 PM between March 1, 2026, at 8 AM and March 17, 2026, at 8 AM. However, starting on March 17, 2026, at 5 PM, the MAR had a note written over the rows, preventing further documentation of administration, which read, "[R2] was refused to take it - [E3]" No morphine had been administered between 5 PM on March 17, 2026, and the date of the inspection, March 25, 2026; and For the medication "Doxepin HCL 10 mg/ml PO 0.5 ml at bedtime, dilute w/120 ml of water," the MAR documented R2 had received the medication at 8 PM between March 1, 2026, at 8 AM and March 16, 2026 at 8 PM. However, starting on March 17, 2026, at 8 PM, the MAR had a note written over the rows, preventing further documentation of administration, which read, "D/C from [hospice] sign with [another primary care provider] 3/17/26." No Doxepin had been administered between 8 am on March 17, 2026, and the date of the inspection, March 25, 2026. In an interview with E1, E1 reported E1 did not realize those medications had not been discontinued and had seen E3's notes on the MAR and thought they were discontinued. E1 reported R2 asks for the pain medications frequently, even before the next dose is available to be given. In an interview with R2, R2 reported not being allowed by E3 to take pain medications, but due to their health problems, they were in chronic pain. R2 denied refusing medications. In an interview, E3 reported R2 had refused to take those specific medications. E3 acknowledged that no refusals had been documented, and blocking out the MAR by writing a note across the relevant rows is how discontinued orders are documented, not how refusals are documented. A review of R2's medical record revealed orders from the new doctor were not available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided. This is a repeat deficiency from the on-site compliance inspection conducted on November 17, 2023.”

“Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented for inventorying and dispensing controlled substances. Findings include: A review of the facility's policies and procedures, reviewed and approved January 10, 2025, revealed a medication policy, which stated, "...Controlled substances must be: 1. Logged in on a controlled substance document (Please see Controlled Substance Log) for the: a. Name of the medication; b. Strength of the medication and c. Quantity delivered; 2. Documented with each time the medication is dispensed as ordered on the: a. Resident's MAR; and/or b. Controlled substance document; and 3. Controlled substances are monitored by the _______________________ Name of Responsible Person (Manager, Nurse, etc) and accounted for by the ___________________ Individual (caregiver, Manager, etc) every ____________________ Time frame (shift, week, med-fill, etc.)." A review of R2's medical record revealed a list of medication orders from R2's hospice provider, dated March 9, 2026. This list included the following orders: "Clonazepam, 0.5 mg tablet, 0.25 mg oral BID"; "Morphine ER 15 mg tablet, 15 mg, oral, twice a day - along with MSER 30mg for a total of 45 mg BID"; and "Morphine ER 30 mg tablet, 30 mg, oral, every 12 hours." A review of R2's medical record revealed a Medication Administration Record (MAR), dated February 2026. The MAR indicated R2 had received administration of Clonazepam and Morphine during the month of February 2026. A review of R2's medical record revealed a MAR, dated March 2026. The MAR indicated R2 had received administration of Clonazepam and Morphine during the month of March 2026. A review of R2's medical record revealed a document titled "Individual Resident Controlled Substance Record," which was labeled, "[R2] meds: Morphine 30 mg tabs." However, the document was blank and did not include an inventory of R2's remaining Morphine each time it was administered as required by policy. A review of R2's medical record revealed a document titled "Individual Resident Controlled Substance Record," which was labeled, "[R2] meds: Morphine 15 mg tabs." However, the document was blank and did not include an inventory of R2's remaining Morphine each time it was administered as required by policy. A review of R2's medical record revealed a controlled substance record for R2's Clonazepam was not available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure a food menu was prepared at least one week in advance, included the foods to be served each day, and was conspicuously posted at least one calendar day before the first meal on the food menu was served. Findings include: During an environmental inspection of the facility, the Compliance Officer observed a menu was not posted in the facility. During the on-site inspection, the Compliance Officer requested to review the food menu; however, a menu was not available for review. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review, documentation review,, and interview, the chief administrative officer failed to implement tuberculosis control activities to include baseline screening for each individual employed by or admitted to the health care institution, annual training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by the health care institution, and annually assessing the health care institution's risk of exposure to infectious tuberculosis, for two of two sampled employees and one of two sampled residents. Findings include: 1. A review of E2's personnel record revealed E2's baseline screening was incomplete. E2's personnel record included a single skin test dated within a year prior to E2's date of hire. However, E2's record did not include documentation of assessing E2's risks of prior exposure to infectious tuberculosis or of determining if E2 had signs or symptoms of tuberculosis. Additionally, a second step skin test, dated within one year prior to E2's date of hire, was not available for review. 2. A review of E1's and E2's personnel records revealed documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. 3. A review of R1's medical record revealed incomplete documentation of baseline screening. R1's record included documentation of R1's freedom from infectious tuberculosis. However, R1's medical record did not include documentation of assessing R1's risks of prior exposure to infectious tuberculosis or of determining if R1 had signs or symptoms of tuberculosis. 4. A review of facility documentation revealed documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis was not available for review. 5. In an exit interview with E1, the findings were reviewed and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance inspection conducted on December 27, 2024.”

“Based on record review and interview, the manager failed to ensure the manager provided current documentation of first aid training. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. A review of E2's personnel record revealed documentation of first aid training was not available for review. E2's personnel record contained a current "Basic Life Support" (BLS) card that included only Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) training and did not include a First Aid certification. 2. During the on-site inspection, the Compliance Officer spoke with E2 telephonically. E2 reported E2 had taken a class that included both CPR and first aid training, and had been told the BLS card was documentation of First Aid training certification. E2 said they were attempting to contact the CPR instructor who had issued the BLS card to E2 to see if they could confirm E2 had taken a first aid course and issue the correct certification. However, no additional documentation was provided during the on-site inspection. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a resident had a service plan which accurately included the amount, type, and frequency of assisted living services being provided to the resident, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan, dated November 7, 2025, for personal care services. The service plan required provision of the following service, "Diabetes: Blood Glucose Monitoring. Check blood sugars: weekly." 2. A review of R1's medical record revealed documentation of weekly blood sugar checks was not available for review. 3. In an interview, E1 reported E1 contacted R1's doctor, who said checking R1's blood sugar was not necessary. E1 reported R1 does not have orders for a blood glucose monitor or regular blood sugar monitoring. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a caregiver and an assistant caregiver provided evidence of freedom from infectious tuberculosis, (TB) on or before the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of two personnel sampled. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. R9-10-113.B.1.b states, "For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: If the individual had a history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, compliance with subsection (A)(2)(b)." 3. R9-10-113.A.2.b states, "If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: Referring the individual for assessment or treatment; and annually obtaining documentation of the individual ' s freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101." 4. A review of E2's personnel record revealed E2 had been hired in September of 2023. E2's personnel record included a screening questionnaire including a negative chest X-ray and a statement that positive skin test result had occurred, "years ago." The screening form also indicated E2 had been treated for a latent TB infection. However, documentation of a positive test result and documentation of an annual TB screening were not available for review. 5. In an interview, E1 acknowledged the personnel record provided for E2 had not included documentation of evidence of freedom from infectious TB as required by R9-10-113.”

“Based on observation and interview, the manager failed to ensure a swimming pool enclosure's gate was locked when the swimming pool was not in use. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed no residents or staff were in the backyard at the time of the inspection, and observed the swimming pool was not in use. However, the Compliance Officer observed the swimming pool gate had been left open and unlocked. 2. In an interview, E1 acknowledged the swimming pool was not locked when the swimming pool was not in use.”

“Based on 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, for one of two personnel records sampled. Findings include: 1. A review of E2's personnel record revealed documentation of fall prevention and fall recovery training was not available for review. 2. In an interview, E1 acknowledged documentation of fall prevention and fall recovery training for E2 had not been provided for review.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan, reviewed and updated at least once every six months, for one of one residents sampled who received personal care services; and at least once every three months for one of one residents sampled who received directed care services. Findings include: 1. A review of R1's medical record revealed a written service plan for personal care services dated February 24, 2023. However, a service plan completed no more than six months later was not available for review. 2. A review of R3's medical record revealed a written service plan for directed care services dated May 18, 2023. However, a service plan completed no more than three months later was not available for review. 3. In an interview, E1 acknowledged the provided service plans had not been updated as required.”

“Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed each resident had a service plan describing the services which would be provided by the facility staff to each resident. 2. A review of each resident's medical record revealed an untitled document which listed the services provided to each resident and included boxes for caregivers to mark when services were provided. However, for both R1 and R2, documentation of services provided in September 2023 and May 2023 were not available for review. 3. In an interview, E1 the documentation of services provided to R1 and R2 in May 2023 and September 2023 had not been provided for review. E1 reported they had been misfiled and could not be located during the on-site inspection.”

“Based on observation, record review and interview, the manager failed to ensure a service plan for a resident receiving directed care services included the determination in subsection (B)(2)(b)(iii), for one resident who was confined to a bed because of the inability to ambulate even with assistance. . Findings include: 1. A review of R2's medical record revealed a form titled, "Determination for Admission", signed by a medical practitioner on October 26, 2022, which stated R2 was, "confined to a chair or bed and is unable to ambulate without assistance." 2. A review of R2's medical record record revealed a form titled, "Determination for Residency to continue in the facility," signed by a medical practitioner on October 26, 2022, which stated, "I have reviewed the facility's Scope of Services and have determined that the resident's needs for the above conditions can be met by this assisted living facility and I authorize this Resident to remain in the facility." The form included sections for the resident to request to remain in the facility and to indicate if the resident was confined to a bed or chair or if the resident had a pressure sore, however, the form had not been filled out and did not indicate which discharge requirement was being waived by the medical practitioner. 3. A review of R2's medical record revealed a service plan, dated May 18, 2023, for directed care services. The service plan stated R2 was, "Bed Bound," and under transfer assistance stated, "not out of bed at this time." 4. A review of R2's medical record revealed completed determinations dated October 2022, April 2023, and October 2023, signed by a medical practitioner every six months while R2 was not ambulatory, were not available for review. 5. In an interview, E1 reported R2 does not get out of bed at all and refuses to even attempt to ambulate. E1 acknowledged the required determinations had not been provided for review.”

“Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a health and safety risk to residents who could leave the facility without alerting employees. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During a facility tour, the Compliance Officer observed a door located in the kitchen leading to the back yard of the facility. The door was equipped with a door alarm; however, the alarm did not sound when the door was opened. The surveyors observed the property was fenced and the side gates were locked. 3. In an interview, E1 acknowledged a means of exiting the facility to an outside area allowing a resident to be at least 30 feet away from the facility did not control or alert employees of the egress of a resident from the facility. E1 reported the door alarm was turned off because E1 goes in and out of that door frequently during the day. This is a repeat deficiency from the previous on-site compliance inspections conducted on December 20, 2021 and January 12, 2023 .”

“Based on observation, record review, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents sampled. Findings include: 1. At approximately 9:40 AM, the Compliance Officer observed R1 sitting at the kitchen table eating breakfast. The Compliance Officer observed R1 had a souffle cup of medications and was taking medications while eating. 2. A review of R1's medical record revealed a service plan, updated February 24, 2023, for personal care services including medication administration. 3. A review of R1's medical record revealed a signed list of medication orders, which required the daily administration of multiple medications. 4. A review of R1's medical record revealed a Medication Administration Records (MARs) dated November 2023. The MAR documented morning medications were dispensed at 7 AM on each day in November 2023, including November 17, 2023, the day of the on-site inspection. However, the MAR was misleading, as R1 had been observed to have not yet had medications at 9:40 AM on November 17, 2023, more than one hour after the scheduled time, and was not being provided medication administration, due to the caregiver failing to observe R1 take the medications at 7 AM as had been documented. 5. A review of R2's medical record revealed a service plan, updated May 18, 2023, for directed care services including medication administration. 6. A review of R2's medical record revealed an order, dated July 20, 2023, for "metformin 500 mg tablet, take 1 tablet twice a day by oral route. 7. A review of R2's medical record revealed an order, dated October 26, 2022, for "Senexon-S 8.6 mg- 50 mg tablet, take 1 tablet twice a day by oral route." 8. A review of R2's medical record revealed an order for Omeprazole was not available. However, E1 contacted a pharmacy, who immediately faxed an order, dated May 18, 2023 for, "Omeprazole 20 MG Capsule, delayed release, take 1 capsule every day by oral route." 9. A review of R2's medical record revealed a Medication Administration Records (MARs) dated November 2023. The MAR included the following: - The MAR documented, "Metformin 850 mg tab PO 1 tab BID," had been administered to R2 on each day in November instead of the 500 milligrams ordered; - The MAR documented, "Docusate Sodium 50 mg, PO 1 tab BID," had been administered to R2 on each day in November instead of Senexon-S; and - The MAR did not document the administration of Omeprazole to R2 during the month of November 2023. 10. The Compliance Officer observed a box containing R2's medications included the following multi-dose packages: - A package of "Metformin 500 MG Tablets," last filled on July 20, 2023, with 28 of 60 doses remaining; - A package of "Stimulant 8.6-50MG tablets," last filled on February 28, 2023, with 8 of 60 doses remaining; and - A package of "Omeprazole 20 MG Capsules," last filled on November 9, 2023, with 29 of 30 doses remaining. 11. In an interview, E1 acknowledged R1 and R2 had not been administered medications in compliance with a medication order.”

“Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. During the on-site inspection, the Compliance Officer requested documentation of the annual review of the facility's disaster plan. However, documentation of an annual review of the facility's disaster plan was not provided for review. 2. In an interview, E1 acknowledged a current disaster plan review had not been provided to the Compliance Officer upon request.”