Quail Manor Assisted Living LLC

Based on record review, documentation review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution and annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of E1's personnel record revealed E1’s hire date of August 26, 2020. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 2. A review of E2's personnel record revealed E2’s hire date of September 13, 2021. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 3. A review of E3's personnel record revealed E3’s hire date of July 5, 2022. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 4. A review of E4's personnel record revealed E4’s hire date of August 1, 2018. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB. 5. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment. 6. In an interview, E4 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not conducted, nor was the employee's annual training. 7. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policy and procedures revealed a page titled "Policies and Procedures Manual Review Statement". However, the page was not signed. 2. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in R9-10-113, for one of three 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 R3's medical record revealed the following: No documentation of assessing risks of prior exposure to infectious tuberculosis No documentation of determining if the individual had signs or symptoms of tuberculosis Based on R3's admission date, this documentation was required. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included documentation of the resident’s weight or from a medical practitioner indicating that weighing the resident was contraindicated, for one of three residents sampled. Findings include: 1. A review of R3's medical record revealed a current written service plan dated October 25, 2025. However, R3’s service plan did not include R3’s weight or documentation from R3’s medical practitioner stating that weighing R3 was contraindicated. 2. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed that the facility provided medication administration services. 2. A review of facility policies and procedures revealed “Medication policies.” However, the medication policies and procedures were not reviewed, signed, and dated by a medical practitioner, registered nurse, or pharmacist. 3. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of three residents reviewed. The deficient practice posed a health and safety risk to the resident if a caregiver did not know whether a medication was administered. Findings include: 1. A review of R2's medical record revealed the following: a current written service plan dated September 22, 2025. This service plan indicated R2 received medication administration. Medication order dated December 22, 2025, for “Clonazepam ODT 0.5 mg - Take ¼ tab (12.5mg) PO 1x every other day.” 2. A review of R2's December 2025 Medical Administration Record (MAR) revealed “Clonazepam ODT 0.5 mg - Take ¼ tab (12.5mg) PO 1x every other day” was not signed off for December 23, 2025, December 25, 2025, December 27, 2025, and December 29, 2025. 3. In an interview, E1 reported that R2 was administered “Clonazepam ODT” in the evening. 4. A review of the facility’s policies and procedures revealed a policy titled “Medication Administration.” The policy stated, “Your documentation of medication administration must be done at the time that you give the medication.” 5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that a first-aid kit was maintained in the assisted living facility. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed that the facility's first aid kit had expired and contained only gauze. 2. In an interview, E4 acknowledged the expired first aid kit, and the need to restock it. 3. In an exit interview, findings were reviewed with E4, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed an unlocked hall closet that contained a bottle of “Equate 3% Hydrogen Peroxide” and a bottle of “Swan 70% Isopropyl Alcohol.” 2. During an environmental inspection of the facility, the Compliance Officers observed in R1’s bathroom, on the floor next to the toilet, a container of “Great Value Disinfecting Wipes,” and inside an unlocked cabinet, an aerosol can of “Glade Air Freshener.” 3. During an environmental inspection of the facility, the Compliance Officers observed in R3’s bathroom an aerosol can of “Glade Air Freshener.” 4. A review of the facility’s Environmental Standards policy revealed that the facility required poisonous or toxic materials to be stored in labeled containers and kept in locked areas that are inaccessible to residents. 5. During an interview, E4 acknowledged that toxic materials were not in a locked area. 6. During an exit interview, the findings were reviewed with E4, and no additional information was provided.