Immaculate Heart of Mary Assisted Living Home LLC

Based on record review, documentation review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, and documented in the resident's medical record. Findings include: 1 . A review of R1's medication orders revealed an order dated, 9/2/2025, for naystatin 100,000 unit/gram topical powder on the skin twice a day; affected groin and groin region, however the facility did not have this medication and it was not a part of R1's medication administration record. 2 . In an exit interview the findings were reviewed with E3 and no further information was provided.

Based on record review and interview the manager failed to ensure that for each individual who is employed by the health care institution provided annual documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101. Findings include: 1 . A review of E2's personnel file revealed a Tuberculosis signs and symptoms form, however it was dated 8/1/2023. There was not a signs and symptoms form for the Compliance Officer to review for 2024. 2 . In an interview, E3 acknowledged that there was not a annual Tuberculosis signs and symptoms form for and employee for 2024.