Aaa Adult Care Home

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. 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. 2. In an interview, E1 acknowledged the health care institution had not documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Technical assistance was provided for this rule during the on-site compliance inspection completed on March 22, 2022 and the on-site compliance inspection conducted on March 21, 2023.

Based on documentation review, record review, observation, and interview, the manager failed to ensure that policies and procedures were implemented for inventorying controlled substances. Findings include: 1. A review of the facility's policies and procedures revealed a medication policy. The policy stated, "Controlled substances must be…documented with each time the medication is dispensed as ordered on the Resident’s MAR; and or Controlled substance document; and Controlled substances are monitored by the [E2] and accounted for by the manager every med fill 2 weeks." 2. A review of R1's medical record revealed a medication order dated December 2, 2024, for “Lorazepam 1 mg tab, take one tablet by mouth twice a day for anxiety.” 3. A review of R1's medical record revealed an accounting of R1’s Lorazepam on a controlled substance log, according to the facility’s policy, was not available for review. 4. In an interview, E1 and E2 acknowledged the facility's policies and procedures for inventorying controlled substances were not implemented.

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 directed care services dated March 10, 2023. However, at least three updated service plans completed no more than every three months later were not available for review. 2. A review of R2's medical record revealed a written service plan for personal care services dated January 18, 2022. However, at least four updated service plans completed no more than every six months later were not available for review. 3. In an interview, E1 acknowledged the provided service plans had not been updated as required.