AMIGA 2 ASSISTED LIVING HOME LLC

INSP-0133643

POC

Date: 6/9/2025

Type: Complaint;Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-07-22

Summary:

The following deficiencies were found during the on-site compliance inspection and investigation of complaint 00124409 conducted on June 9, 2025.

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident’s date of occupancy, and 2. As specified in R9-10-113

Evidence/Findings:

Based on record review, documentation review, and interview, the manager failed to ensure that an employee and/or resident provided documentation of freedom from infectious Tuberculosis (TB) as specified in R9-10-113, for one of four sampled residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A record review of R3’s, medical records revealed that the resident was admitted into the facility in December, 2024. 2. A record review of R3’s medical record revealed that the resident was administered a TB test prior to admission, however, the results of the test were not read. 3. A review of the facility's Policies and Procedures revealed a policy titled, "Admissions: Resident Acceptance/Residency Agreement Procedures: #4" which stated, "within 7 days of acceptance, each resident shall provide evidence of being free from pulmonary Tuberculosis. A report of a negative Mantoux Tuberculin (TB) skin test recorded along with the resident's name, date of injection, date read, the serum lot number, expiration date and follow up date (if applicable)." 4. In an interview, E2 acknowledged that the TB requirements were not met for R3.

Permanent Solution:

Please see attached documents.

Person Responsible:

Robert Russell Samson

Deficiency #2

Rule/Regulation Violated:

R9-10-808.A.5.a. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident’s representative;

Evidence/Findings:

Based on record review and interview, the manager failed to ensure a written service plan was signed by the resident or the resident's representative. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R3's medical record revealed that the initial service plan dated December 2024, was not signed by the resident nor the resident's representative. 2. A review of R4's service plan revealed that the initial service plan dated May 2025, was not signed by the resident nor the resident's representative. 3. In an interview, E2 acknowledged that the facility failed to ensure R3's and R4's service plans were signed by the resident or the resident's representative.

Permanent Solution:

Please see attached documents.

Person Responsible:

Robert Russell Samson

AMIGA 2 ASSISTED LIVING HOME LLC

Facility Information

Inspection History

INSP-0133643

Summary:

Deficiencies Found: 2

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Permanent Solution:

Person Responsible:

INSP-0058997

Summary:

INSP-0058996

Summary: