House of Lydia LLC

Based on record review, documentation 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 E2. Findings include: 1. A record review of E2's personnel record revealed, the employee did not have a TB screening assessment form available for review. 2. A documentation review of the facility's Policies and Procedures manual titled, "Tuberculosis Screening", stated, "2.a. For each individual who is employed by the healthcare institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is and who is object to the requirements of this Section, baseline 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 ii. Obtain documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 3. In an interview, E1 acknowledged, the manager did not ensure E2 provided a TB screening assessment upon hire and annually prior to providing services at or on the behalf of the assisted living facility.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious Tuberculosis before or within seven calendar days after the resident's date of occupancy as specified in R9-10-113. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A record review of R1's medical records revealed, documentation of a TB screening and risk assessment form, was not available for review. Based on R1's date of admission, this document was required. 2. A documentation review of the facility's Policies and Procedures manual titled, "Tuberculosis Screening", stated, "2.a. For each individual who is employed by the healthcare institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is and who is object to the requirements of this Section, baseline 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 ii. Obtain documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)." 3. In an interview, E1 acknowledged the manager did not ensure R1 provided evidence of freedom from infectious Tuberculosis before or within seven calendars after the resident's date of occupancy as specified in R9-10-113.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident has a service plan that is established, documented, and implemented that: when initially developed and when updated, is signed and dated by: the resident or resident’s representative. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of the medical records for R1, revealed the resident received Directed Care services per the resident’s service plan. 2. A review of R1's medical records revealed, the resident's service plans dated May, 2025 and February, 2025, were not signed by the resident or resident's representative. 3. A documentation review of the facility's Policies and Procedures titled, "Admittance and Re-admittance of residents" stated, "16. If a potential resident is accepted for service, a Service Plan shall be developed with the potential resident/representative and a written Service Agreement shall be signed by the potential client/representative and the Manager." 4. In an interview, E1 acknowledged the manager did not obtain the signature of R1 or R1's representative on the service plans as required.

Based on record review, documentation review and interview, the manager retained a resident confined to a bed or chair without meeting the requirements in R9-10-814.B.2.a.b.i-iii., including documentation of the resident's or the resident's representative's request the resident remain in the facility; documentation to demonstrate the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility. The deficient practice posed a risk if the facility was unable to meet a resident's needs. 1. A record review of the “Approval For Continued Residency” form for R1, revealed, the form was last signed and dated by a medical professional on January 31, 2025. 2. A review of the facility's Policies and Procedures titled “Scope of Services/Predetermination form” stated, "The management will ensure that at the time of admission or earlier the resident or the resident representative is required to provide the documentation no older than 90 days for the resident's need of continuous or intermittent nursing services, restraints, or behavior care. Documentation provided has to be signed appropriately. The documentation will be maintained in the resident records." 3. In an interview, E1 acknowledged that the manager did not to obtain documentation to demonstrate the resident's primary care provider or other medical practitioner examined the resident at least once every six months throughout the duration of the resident's condition; reviewed the facility's scope of services; and signed and dated a determination stating the resident's needs were being met at the facility.

Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services includes documentation of the resident’s weight, or from a medical practitioner stating that weighing the resident is contraindicated. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A record review of R1's service plan revealed, the resident received Directed Care services. The service plan did not list R1's weight nor was there a statement from medical practitioner stating that weighing the resident was contraindicated. 2. In an interview, E1 acknowledged the manager did not ensure R1's service plan included the resident's weight or statement from a medical practitioner stating that weighing the resident is contraindicated.

Based on documentation review and interview, the manager failed to ensure that a disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A documentation review of the facility's Disaster plan revealed no date it was last reviewed. 2. A documentation review of the facility's Policies and Procedures titled, "Emergency and Safety Standards Policies and Procedures" stated, "The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months." 3. In an interview, E1 acknowledged the manager did not ensure the disaster plan was reviewed at least once every 12 months.