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The facility failed to ensure that one of three sampled residents was tested for tuberculosis upon admission. While immunization records and skin test dates were present, the actual results of the tests were not documented in the resident's record.

The facility failed to ensure that one of three sampled residents was tested for tuberculosis upon admission. While immunization records and skin test dates were present, the actual results of the tests were not documented in the resident's record.

The facility failed to notify the Division of Health Service Regulation that the evacuation capabilities of its residents had changed. Specifically, six residents required verbal prompting to exit the facility during a fire drill, which differs from the facility's licensed status for ambulatory residents.

The facility failed to notify the Division of Health Service Regulation (DHSR) that the evacuation capabilities of 6 residents had changed. During fire drills, residents required verbal prompting and staff assistance to exit the facility, which differs from the facility's licensed status for ambulatory residents.

The facility failed to ensure that one of three sampled staff members had documentation of a tuberculosis skin test being read for results. While a test was placed, there was no record of the reading or a subsequent test upon hire. The Administrator was responsible for ensuring all required TB testing was completed and documented in the personnel record.

The facility failed to ensure that one of three sampled staff members had documentation of being tested for tuberculosis disease in compliance with required control measures. Specifically, a medication aide had a single skin test on file but lacked the required second step of the two-step testing process.

The facility failed to ensure that one of three sampled residents was tested for tuberculosis disease in compliance with required control measures. Resident #2 had documentation of only one TB skin test upon admission, failing to meet the requirement for a two-step testing process.

The facility failed to ensure that one of two medication aides (Staff B) had completed the required 5, 10, or 15-hour training program or provided verification of previous employment as a medication aide. Specifically, there was no documentation for medication aide employment verification or the completion of the required 5/10 or 15-hour medication training.

The facility failed to ensure that one of two medication aides had completed the required 5/10 or 15-hour training program or provided verification of previous employment as a medication aide. Specifically, records for Staff B did not sufficiently demonstrate compliance with the state-mandated training and competency requirements.