Haven Adult Assisted Living Home INC

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 residents reviewed. 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. Review of R1's medical record revealed no documentation of assessing risk of prior exposure to infectious TB or determining if the R1 had signs or symptoms of TB. Based on R1's acceptance date, this documentation was required. 3. In an interview, E1, E2, and E3 acknowledged R1 did not provide documentation of assessing risk of prior exposure to infectious TB or determining if the R1 had signs or symptoms of TB.

Based on record review and interview, the manager failed to ensure a residency agreement included the date of occupancy, for two of two residents reviewed accepted by the assisted living facility on or after October 1, 2013. Findings include: 1. Review of R1's medical record revealed a residency agreement. However, this residency agreement did not include documentation of R1's date of occupancy. Based on R1's acceptance date, this documentation was required. 2. Review of R2's medical record revealed a residency agreement. However, this residency agreement did not include documentation of R2's date of occupancy. Based on R2's acceptance date, this documentation was required. 3. In an interview, E1, E2, and E3 acknowledged R1's and R2's residency agreements did not include the date of occupancy. 4. Technical assistance was provided on this Rule during the compliance inspection conducted September 27, 2022.

Based on record review, observation, and interview, the manager failed to ensure a resident medical record contained a medication order from a medical practitioner for each medication that was administered, for one of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed a current written service plan dated August 4, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed no documentation of signed medication orders or verbal medication orders for the following: Omeprazole 20mg Trazadone 150mg 3. Review of R1's medical record revealed an August 2023 medication administration record (MAR). This MAR stated the following: "Omeprazole 20mg 2 capsules (40mg) oral QD" and indicated two tabs were administered at 8am August 1st - present. "Trazodone 150mg 1 tablet oral QHS" and indicated one tab was administered at 8am August 1st - present. 4. During an observation of R1's medications, the following was observed: Omeprazole 20mg was observed and two tabs were observed prefilled in the "8am" slot of R1's medication organizer. Trazodone 150mg was observed and one tab was observed prefilled in the "8pm" slot of R1's medication organizer. 5. In an interview, E1 reported the medications were administered per the MAR. E1, E2, and E3 acknowledged R1's medical record did not contain a medication order from a medical practitioner for each medication that was administered.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated August 4, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed no documentation of signed medication orders or verbal medication orders for the following: Omeprazole 20mg Trazadone 150mg 3. Review of R1's medical record revealed a signed medication order dated August 2, 2023. This medication order stated "Baclofen 5mg 1 tab PO TID". 4. Review of R1's medical record revealed an August 2023 medication administration record (MAR). This MAR stated the following: "Omeprazole 20mg 2 capsules (40mg) oral QD" and indicated two tabs were administered at 8am August 1st - present. "Trazodone 150mg 1 tablet oral QHS" and indicated one tab was administered at 8am August 1st - present. "Baclofen 10mg 1 tablet oral TID" and indicated one tab was administered at 8am, 2pm, and 8pm August 9th - present. 5. During an observation of R1's medications, the following was observed: Omeprazole 20mg was observed and two tabs were observed prefilled in the "8am" slot of R1's medication organizer. Trazodone 150mg was observed and one tab was observed prefilled in the "8pm" slot of R1's medication organizer. Baclofen 10mg was observed and one tab was observed prefilled in the "8am," "2pm," and "8pm" slot of R1's medication organizer. 6. Review of R2's medical record revealed a current written service plan dated August 25, 2023. This service plan indicated R2 received medication administration. 7. Review of R2's medical record revealed a signed medication order dated February 14, 2023. This medication order stated "Megesterol Acetate 40mg/ml oral suspension take half of a ml (20mg) by mouth 2 times per day". 8. Review of R2's medical record revealed an August 2023 MAR. This MAR did not include documentation Megesterol Acetate was administered. 9. During an observation of R2's medications, Megesterol Acetate was not observed. 10. In an interview, E1 reported the medications were administered per the MAR. E1, E2, and E3 acknowledged R1's and R2's medications were not administered in compliance with the available medication orders. 11. This is a repeat deficiency from the compliance inspection conducted September 27, 2022.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated August 4, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a verbal medication order dated August 25, 2023. This verbal medication order stated "Wound care - Change daily/PRN for soilage, cleanse with wound cleanser, pat dry, apply Chamosyn cream to wound, cover with adhesive foam dressing". 3. Review of R1's medical record revealed an August 2023 medication administration record (MAR). This MAR did not include documentation the wound care was administered. 4. During an observation of R1's medications, wound cleanser and Chamosyn were observed. 5. In an interview, E1 reported the wound care was administered. E1, E2, and E3 acknowledged R1's medical record did not include documentation the medication was administered.

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB. 2. In an interview, E1, E2, and E3 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 3. Technical assistance was provided on this Rule during the compliance inspection conducted September 27, 2022.