Comfort Gardens

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 record, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a service plan dated October 2024. The service plan revealed R2 required "Turning ...care staff turn R2 every 2hrs when in bed". 2. A review of R2's medical record revealed no documentation of turning services being provided. 3. In an interview E1 agreed turning was not being tracked on the form the facility uses to track the services provided. 4. In an interview, E1 acknowledged services provided to R2 had not documented. E1 reported turning was provided and R2 is very verbal and will let you know if R2 needs assistance.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a document titled, "Baseline TB Screening Tool for Assisted Living Resident/Employee". The form included a screening questions, when the skin test was placed on R1's right forearm, and was signed by a registered nurse. The form was signed as being read, however the result was not documented. 2. In an interview, E1 acknowledged R1's medical record did not include current evidence of freedom from TB.