New Beginning Homes LLC

Based on record review and interview the licensee failed to ensure that a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. Findings include: 1 . A review of employee records revealed no evidence that E3 had completed the falls prevention and fall recovery training. 2 . In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on record review, document review and interview the licensee failed to ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that annually provided training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution and annually assessed the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1 . A review of employee records revealed that E3 did not complete the training for recognizing signs and symptoms of tuberculosis. 2 . A review of facility documents revealed no annual assessment for the risk of exposure to infectious tuberculosis. 3 . In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on document review, record review and interview the administrator failed to ensure that a policy and procedure for physical health services, habilitation services, and behavioral care are established, documented, and implemented to protect the health and safety of a resident that Included a method for obtaining an advocate for a resident, if necessary. Findings include: 1 . A review of facility document revealed the following policies and procedures: Behavior Management that covers the assessment, development of a behavior plan, if necessary, documentation and monitoring Member Funds that states New Beginnings will NOT act as the representative payee However, there was not a policy that covered a method for obtaining an advocate for a resident, if necessary. 2 . During a review of resident files, the Compliance Officer did reveal an application for a Public Fiduciary for R2. 3 . In an exit interview, the findings were reviewed with E1 and no further information provided.

Based on record review, document review and interview the licensee failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident's admission, and as specified in R9-10-113. Findings include: 1 . A review of resident files revealed that R1 and R2 did not have evidence of freedom from tuberculosis before or within seven calendar days after the resident's admission. 2 . A review of facility documents revealed a policy titled, Qualifications for Admission, with a section on Tuberculosis Screening that stated, "Before or within seven days after the Member's admission, the Member must provide documentation of freedom from infectious tuberculosis, as specified in R9-10-113.A.2.a-f." 3 . In an interview O1 reported that they recently learned that the residents were required to have a tuberculosis test before or within seven calendar days after the resident's admission. 4 . In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on documentation review and interview the administrator failed to ensure that an evacuation drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1 . A review of evacuation drills for employees revealed the following employee evacuation drills: September 26, 2025 at 4 pm for the 3 pm to 11 pm shift September 8, 2025 at 8:25 am for the 7 am to 3 pm shift September 26, 2025 at 9:00 am for the 7 am to 3 pm shift however, there was not an evacuation drill for employees that covered the 11 pm to 7 am shift for the past three months for the shift (11pm - 7 am) as indicated on the evacuation form used by the facility. 2 . In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on observation and interview the administrator failed to ensure that the premises and its structures were in a clean condition. Findings include: 1 . During a tour of the facility the Compliance Officer observed the following items to be in need of cleaning and or repair: The ceiling fans in three of the resident's rooms had accumulation of dust The caulk around the toilet in the master bedroom and a hall bathroom was cracked, missing and discolored. 2 . In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on record review and interview, the administrator failed to ensure that at the time of admission, a resident or the resident's representative received a written copy of the requirements in subsection (B) and the resident rights in subsection (C). Findings include: 1 . A review of R1's and R2's medical records revealed no documentation that R1 and R2 were provided a written copy of the requirements in subsection (B) and the resident rights in subsection (C). 2 . In an interview, E1 acknowledged there was no documentation that R1 and R2 were provided a written copy of the requirements in subsection (B) and the resident rights in subsection (C).

Based on record review and interview the administrator failed to ensure that a resident was treated with dignity, respect, and consideration. Findings include: 1 . A review of R1's service plan dated 9/8/2025 revealed that R1 is maximum assist with all activities of daily living. 2 . In an interview R1 reported that R1 was molested by E3 while E3 was assisting with changing R1's briefs. 3 . A review of facility documents revealed an incident report which showed that Adult Protective Services and the Support Coordinator were notified, of R1's reported incident, on October 20, 2025. 4 . In an interview, E1 acknowledged that there was an incident where a resident was not treated with dignity, respect, and consideration.