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Based on record review and interview, the manager failed to ensure resident records contained evidence of freedom from infectious tuberculosis(TB) as specified in R9-10-113 for one of two residents sampled. The deficient practice posed a TB exposure 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 R2's medical record revealed no documentation of freedom from infectious TB. Based on R2's acceptance date, this documentation was required. 3. In an interview, E3 acknowledged R2's medical record did not contain evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113.

Based on interview and record reviewed, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future, for one of one resident reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. In an interview, E2 and E3 reported that R1 was transported to the hospital from the facility by emergency medical services in November 2023. 2. Review of R1's medical record revealed no documentation for the incident. 3. In an interview, E2 acknowledged R1's medical record did not include documentation showing the date and time of the incident; a description of the incident; the names of individuals who observed the incident; the action taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the incident from occurring in the future.

Based on documentation review and interview, the manager failed to establish and document a plan to an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided to residents, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Establishing a Quality Management Plan" (dated January 18, 2023). The policy and procedure stated "Policy: The manager shall ensure that a plan is established, documented, and implemented for an ongoing quality management plan that includes a method to identify, document and evaluate incidents. A method to collect data to evaluate services provided to residents. A method to evaluate the data collected to identify concern about the delivery of services related to resident care. Procedures: 1. Staff will be familiar with the report of UNUSUAL OCCURRENCE FORM or Incident Reports and able to utilize whenever an incident occurs. The form must be completely filled out leaving no area blank. If you are unsure what to put discuss it with the facility manager. The facility manager must be informed immediately following such an incident, once the patient's safety is secure. 2. The manager will review all incident reports, document, evaluate and identify the problem as to how such an incident happened and how to minimize or prevent the incident from happening again. 3. The report and the documentation of incident will be maintained for the period of 12 months after the date the report is done. These are internal documents and not meant to be shared with residents or their families...." However, the quality management progrom did not include a method to collect data to evaluate services provided to residents, a method to evaluate the data collected to identify a concern about the delivery of services related to resident care, a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care, and the frequency of submitting a documented report required in subsection (2) to the governing authority. 2. In an interview, E1 acknowledged the facility's quality management program had not been established and documented to include a method to collect data to evaluate services provided to residents, a method to evaluate the data collected to identify a concern about the delivery of services related to resident care, a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care, and the frequency of submitting a documented report required in subsection (2) to the governing authority.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, when updated, was signed and dated by the manager, for one of three residents sampled. The deficient practice posed a risk if the manager was unaware of the services to be provided to the resident at the facility, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R1's medical record revealed a written service plan dated May 7, 2023, for directed care services. However, the service plan was not signed and dated by the manager. 2. In an interview, E1 acknowledged R1's written service plan was not signed and dated by the manager.