Mountain Park Senior Living.

“Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of five personnel sampled. The deficient practice posed a potential illness 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 the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E4's personnel record revealed a hire date of June 2023. E4's personnel record included a negative TST within 12 months prior to hire, an assessment of risks of prior exposure to infectious TB, and a determination of signs or symptoms of TB. However, no second TST was available for review. 4. In an interview, E1 acknowledged E4 did not provide evidence of freedom from infectious TB as specified in R9-10-113.”

“Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of seven residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. A Review of R1's medical record revealed a current written service plan for directed care services from February 2025. The service plan stated the following services were needed: - Meal Consumption - Staff members will monitor resident's during meals and report to the nurse if there are any concerns. However, documentation was not available indicating meals or monitoring were provided.  1. A Review of R2's medical record revealed a current written service plan for directed care services from March 2025. The service plan stated the following services were needed: - Meal Consumption - Set-up - R2 is able to chew and swallow with no problems. However, documentation was not available indicating meal set-up was provided.  4. During an interview, E1 reported the residents are all receiving meals. E1 acknowledged R1's and R2's medical records did not include documentation of the services provided.”

“Based on record review and interview, the manager failed to ensure that if an assisted living facility provides medication administration, a medication administered to a resident is administered in compliance with a medication order. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a service plan from February 2025, reporting R1 was to receive Medication Administration services. 2. A review of R1's medical record revealed a document titled "State Reportable Form" The document reported R1 had been administered the following medication: Acetaminophen; Benefiber; Carbamazepine; Carvedilol; "DOK"; Lisinopril; Metformin; Omeprazole; Salonpas; Tab-a-vite; Tolterodine; and Valproic Acid. However, the form stated "which were not prescribed to the resident." 3. A review of R1's medical record revealed no medication orders for the aforementioned medications were available for review. 4. A review of R1's medical record revealed a medication administration record (MAR) documenting medications were held on the day of the incident per direction from R1's primary care physician. 5. During an interview E1 acknowledged medication administered to R1 was not in compliance with a medication order.”