Dahlia Assisted Living and Memory Care, LLC

Based on documentation review, record review, and interview, the manager failed to ensure that an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of two employees sampled. The deficient practice posed a potential 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… obtaining documentation of the individual’s freedom from infectious tuberculosis according to subsection (B)(1)….” 2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA) test is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E2’s personnel record revealed an employee hire date of November 30, 2025. The personnel record contained documentation of one negative TB skin test. A second TB skin test was not available for review. 4. In an interview, E1 acknowledged that E2 had documentation of only one TB test and that the TB test documentation was incomplete. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a service plan for residents receiving directed care services included strategies to ensure a resident’s personal safety; encouragement to eat meals and snacks; documentation of the resident’s weight, or from a medical practitioner stating that weighing the resident is contraindicated; and coordination of communications with the resident’s representative, family members, and, if applicable, other individuals identified in the resident’s service plan for two of two residents sampled. The deficient practice posed a risk if the resident's representative and other individuals identified were unable to participate in decisions concerning the assisted living services the resident was to receive. Findings include:   1. A review of R1’s medical record revealed a service plan dated December 3, 2025, which indicated R1 received directed care services. However, the service plan did not include strategies to ensure the resident’s personal safety. 2. A review of R2’s medical record revealed a service plan dated December 4, 2025, which indicated R2 received directed care services. However, the service plan did not include the following: -Strategies to ensure the resident’s personal safety; -Encouragement to eat meals and snacks; -Documentation of the resident’s weight, or from a medical practitioner stating that weighing the resident was contraindicated; and -Coordination of communications with the resident’s representative or family members. 3. In an interview, E1 acknowledged that service plans for residents receiving directed care services did not consistently include all required components. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure a food menu included any food substitutions no later than the morning of the day of meal service with a food substitution. Findings include: 1. Review of the facility's posted menu revealed a menu dated June 18th - June 24th. The Friday, June 23rd lunch menu stated: "Slow Roasted BBQ Ribs served with Sweet Potatoes and Sweet Corn, Apple Pie or choice of Ice Cream" 2. During an observation, the lunch meal served on Friday, June 23rd included the following: Fish, couscous, and salad. 3. During an interview, E1 acknowledged the lunch meal served on Friday, June 23rd was not the same as stated on the menu and the substitutions were not documented.