Legend Ddd Services - Elwood Nsgh

Based on documentation review, record review, and interview, the administrator did not ensure a personnel member's skills and knowledge was verified and documented before the personnel member provided physical health services, habilitation services, or behavioral care for three of five personnel sampled. Findings include: 1. A review of facility documentation revealed a personnel schedule for September, 2025. The personnel schedule revealed E2, E4, and E5 were scheduled to work throughout September 2025. 2. A review of E2's, E4's, and E5's personnel record revealed documentation of E2's, E4's, and E5's skills and knowledge was not available for review. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, record review, and interview, the administrator failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for four of five personnel sampled. The deficient practice posed a potential illness 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. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E2's personnel record revealed a hire date of April 2025. E2's personnel record revealed no documentation of assessing risks of prior exposure to infectious tuberculosis, determining if E2 had signs or symptoms of tuberculosis, and of the E2's's freedom from infectious tuberculosis was available for review. 4. A review of E3's personnel record revealed a hire date of June 2025. E3's personnel record included one negative PPD skin test, an assessment of risks of prior exposure to infectious TB, and a determination of signs or symptoms of TB. However, a second PPD skin test was not available for review. 5. A review of E4's personnel record revealed a hire date of August 2025. E4's personnel record revealed no documentation of assessing risks of prior exposure to infectious tuberculosis, determining if E4 had signs or symptoms of tuberculosis, and of the E4's's freedom from infectious tuberculosis was available for review. 6. A review of E5's personnel record revealed a hire date of June 2025. E5's personnel record revealed no documentation of assessing risks of prior exposure to infectious tuberculosis, determining if E5 had signs or symptoms of tuberculosis, and of the E5's

Based on record review and interview, the administrator did not ensure that a medication administered to a resident was documented in the resident’s medical record for one of two residents sampled. Findings include: 1. A review of R1’s medical record revealed a document titled “Physician’s Orders” from May 2025. A review of the orders revealed signed medication orders for the following medications: - Calcium Carbonate S/F, A/F, NA/F, 500milligram (MG)/5milliliter (ML) Oral Susp – 10ML via G-Tube every day – 8:00PM; Chloral Hydrate 100MG/ML – Take 7.5ML every night via G-Tube – 8:00PM; Clobazam 2.5MG/1ML Oral Susp – 6MLs via G-Tube twice daily – 8:00AM and 8:00PM; Clonidine 0.1MG Tablet – 1 tab via G-Tube at bedtime – 8:00PM; Lamotrigine 150MG Tablet – 1 tab via G-Tube twice daily – 8:00AM and 8:00PM; Levocarnitine 100MG/1ML solution – 5MLs via G-Tube twice daily – 8:00AM and 8:00PM; Omeprazole-Sodium Bicarbonate Outer 40-1680MG Packet – Mix packet contents with 30ML of water, stir well and give via G-Tube twice daily – 8:00AM and 8:00PM; Senna 8.8MG/5ML Syrup – 15 MLs via G-Tube twice daily – 8:00AM and 8:00PM; Sucralfate 1gram (GM)/10ML Oral Susp – Shake liquid 10MLs via G-Tube twice daily – 8:00AM and 8:00PM; and Topiramate F/C 200MG Tablet – 1 tab via G-Tube twice daily – 8:00AM and 8:00PM. 2. A review of R1’s medical record revealed a Medication Administration Record (MAR) from September 2025. A review of the MAR revealed the aforementioned medications were not documented as administered at 8:00PM on the following dates: September 7, 2025; and September 18, 2025. 3 . In an exit interview, E1 reported the medications were administered per physician’s orders. The findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the administrator did not ensure a disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of the facility’s documentation revealed documentation of the facility’s disaster plan being reviewed was not available for compliance officer review. 2. In an interview, E1 reported E1 was not aware the disaster plan was required to be reviewed annually. E1 acknowledged the disaster plan was not reviewed at least once every 12 months.

Based on documentation review and interview, the administrator did not ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1 . A review of facility documentation revealed no documentation of disaster drills for employees having been conducted was available for review. 2 . In an interview, E4 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.