Good Nurses Assisted Living Facility

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R2's medical record revealed a current written service plan for directed care services dated August 2023. This service plan stated "Catheter care...caregiver to empty bag every 4-8 hours or more frequently". However, documentation was not available indicating this service was provided October 1st - present. 2. In an interview, E1 acknowledged R2's medical record did not include documentation of the above listed service and reported the service was provided as indicated in the service plan.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included documentation of the resident's weight or from a medical practitioner stating weighing the resident was contraindicated, for one of two residents sampled who received directed care services. Findings include: 1. A review of R2's medical record revealed a current service plan dated in August 2023 for directed care services. However, the service plan did not include documentation of R2's weight or documentation from a medical practitioner stating weighing R2 was contraindicated. 2. In an interview, E1 acknowledged R2's service plan did not include the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated.

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution established, 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 tuberculosis infection activities required in R9-10-113.A.2.a-f were not available for review. 2. A review of E1's, E2's, and E3's personnel records revealed documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis was not available for review. 3. 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. 4. In an interview, E1 reported the health care institution had not established, documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Technical assistance was provided on this Rule during the compliance inspection completed on October 12, 2022.