Bring-healing-home Personal Care LLC

Based on documentation review, 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, for two of two residents sampled. The deficient practice posed a TB exposure risk to residents. 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) A review of R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 3) A review of R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 4) In an interview, E1 acknowledged R1's and R2's medical records did not include documentation of a risk assessment of prior exposure to infectious TB or a determination if they had signs or symptoms of TB.

Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication. Findings include: 1) During an environmental inspection of the facility with E1, the Compliance Officer observed a box labeled "Trulicty; 1.5 mg/once weekly" located in the door of the unlocked refrigerator. 2) In an interview, E1 acknowledged the medication was not locked as required.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1) A review of the facility's personnel schedule revealed there were two shifts. 2) A review of the facility's disaster drills revealed documentation of a disaster drill conducted during the day shift on November 1, 2024. However, no additional documentation of disaster drills was available for review. 3) In an interview, E1 acknowledged disaster drills were not conducted on each shift once every three months.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical records, for five of five residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R1's medical record revealed a service plan (dated in April 2023) for personal care services. The service plan stated the following services were to be provided to R1: -Bathing; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Ambulation. 2. A review of R1's medical record revealed an activities of daily living document for June 1-30, 2023. However, the following services were not documented as provided from June 10-13, 2023 -Bathing; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Ambulation. 3. A review of R2's medical record revealed a service plan (dated in April 2023) for directed care services. The service plan stated the following services were to be provided to R2: -Bathing; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Mobility. 4. A review of R2's medical record revealed an activities of daily living document for June 1-30, 2023. However, the following services were not documented as provided on June 10-13, 2023: -Bathing; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Mobility. 5. In a interview, E1 acknowledged services provided were not being documented in R1's and R2's medical records.

Based on record review and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner, for two of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R1's medication administration record (MAR) dated June 2023 revealed R1 received medication administration for the following medication: -Seroquel (Quetiapine) 50mg. However, a medication order for Seroquel (Quetiapine) 50mg was not available for review. 2. A review of R2's MAR dated June 2023 revealed R2 received medication administration for the following medication: -Loratidine 10mg. However, a medication order for Loratidine 10mg was not available for review. 3. In an interview, E1 acknowledged medication orders for medications administered to R1 and R2 were not in the medical records.