Legend Ddd Services - Siesta

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for two of two residents 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 R1's and R2's medical record did not include documentation of evidence of freedom from infectious TB for Compliance Officer review. Based on R1's and R2's acceptance date, this documentation was required. 3. In an interview, E5 acknowledged R1's and R2's medical record did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113.

Based on record review and interview, the administrator did not ensure a resident's medical record contained documentation of physical health services, habilitation services, and behavioral care provided to the resident for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a current Person-Centered Service Plan (PCSP) from February 2025, which reported R1 would receive the following physical care services: - Mobility - Minimal level of support; - Bathing - Moderate level of support; - Dressing - Moderate level of support; - Grooming - Maximum level of support; - Eating - Minimal level of support; - Toileting - Moderate level of support; and - Continent of Bladder - Partial requiring support. 2. A review of R2's medical record revealed no documentation of physical health services provided was available for review. 3. During an interview E5 reported R2 had received all physical health services and staff are to complete a checklist daily to document care conducted. E1 and E5 acknowledged R2's medical record did not contain documentation of physical health services provided to R2.

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 . The Compliance Officer requested to review documentation of disaster drills conducted at 12:00PM. 2 . A review of facility documentation revealed no disaster drill documentation was available for review. 3 . In an interview, E5 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the administrator did not ensure an evacuation drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1 . In an interview E5 reported the facility operates with the following shifts: 7:00AM to 7:00PM; and 7:00PM to 7:00AM 2 . A review of facility documentation revealed the following evacuation drills conducted: July 31, 2023 at 3:30PM; November 27, 2024 at 4:53PM; December 30, 2024 at 8:00AM; and February 28, 2025 at 4:40PM. However, no documentation of evacuation drills conducted every three months on each shift was available for review. 3 . In an interview, E5 acknowledged an evacuation drill for employees was not conducted on each shift at least every three months.

Based on documentation review and interview, the administrator did not ensure an evacuation drill for residents was conducted at least once each year on each shift and documented. Findings include: 1 . In an interview E5 reported the facility operates with the following shifts: 7:00AM to 7:00PM; and 7:00PM to 7:00AM. 2 . A review of facility documentation revealed no evacuation drill documentation was available for review for a drill conducted between 7:00PM and 7:00AM. 3 . In an interview, E5 acknowledged an evacuation drill for residents was not conducted at least once each year on each shift and documented.