Sun Garden Care Home

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents reviewed. 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. Review of R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R1 did not provide documentation of freedom from infectious TB as specified in R9-10-113. 4. Technical assistance was provided on this Rule during the compliance inspection conducted September 6, 2022.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of two residents reviewed accepted by the assisted living facility on or after October 1, 2013. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R1's medical record revealed no documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1's acceptance date, this documentation was required. 2. Review of R2's medical record revealed no documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R1 and R2 did not provide documentation signed by a medical practitioner or a registered nurse stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated July 6, 2023. This service plan stated "Incontinent Both, Change every two hours/PRN". However, documentation was not available indicating this service was provided October 5th - present. 2. In an interview, E1 acknowledged R1's medical record did not include documentation of incontinent care and reported the service was provided as indicated in the service plan.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as the medical record inaccurately indicated a medication was administered and a medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated July 6, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated August 31, 2023. These medication orders stated the following: "Furosemide 20mg take 1 tab PO MWF" "Omeprazole Cap 20mg take 1 cap PO daily" "Senna Plus tab 8.6-50mg take 3 tabs PO twice daily" 3. Review of R1's medical record revealed an October 2023 medication administration record (MAR). This MAR stated the following: "Furosemide 20mg daily 1 tab PO" and indicated one tab was administered at 8am October 1st - present. Omeprazole was not documentation on the MAR. Senna Plus was not documented on the MAR. 4. During an observation of R1's medications, the following was observed: Furosemide 20mg was observed and one tab was observed prefilled in the "Morn" slot of R1's medication organizer on Monday, Wednesday, and Friday. Omeprazole 20mg was observed and one tab was observed prefilled in the "Morn" slot of R1's medication organizer. Senna Plus 8.6/50mg was observed and three tabs were observed prefilled in the "Morn" and "Bed" slot of R1's medication organizer. 5. In an interview, E1 reported the medications were administered per the medication orders and acknowledged R1's medical record did not accurately documentation the medications were administered.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented 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. Review of R2's medical record revealed a document titled "Report of Unusual Occurrence" dated October 27, 2023. This document stated "Pt was walking out of the bathroom got dizzie, sat on walker, stated is not feeling good...called 911, Pt was taken to Hospital..." However, the documentation did not include any action taken to prevent the incident from occurring in the future. 2. In an interview, E1 acknowledged R2's medical record did not include documentation of any action taken to prevent the incident from occurring in the future.

Based on documentation review, record review, and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities as specified in R9-10-113. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance and posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility documentation revealed no policy and procedure that covered TB infection control activities. 2. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of November 17, 2008. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of May 1, 2016. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 4. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of August 22, 2022. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 5. Review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB. 6. In an interview, E1 acknowledged the facility had not established, documented, and implemented a TB infection control program as specified in R9-10-113. 7. Technical assistance was provided on this Rule during the compliance inspection conducted September 6, 2022.