One On One Adult Care Home LLC.

“Based on documentation review, record review, and interview, the manager failed to ensure employees provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of three personnel sampled. The deficient practice posed a potential 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 the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel. The webpage states, "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing." 3. A review of E2's personnel record revealed one TB test, risk assessment, and signs and symptoms screening. 4. In an interview, E1 acknowledged that E2 did not have a second TB test.”

“Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of four residents sampled.   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 R1's medical record revealed no documentation of a risk assessment and signs or symptoms screening. Based on R1's date of acceptance, this documentation was required. 3. In an interview, E1 acknowledged R1 did not have a risk assessment, signs and symptoms screening.”

“Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record for two of two sampled residents. Findings include: 1. A review of R1's medical records revealed current service plans, showing medication administration. 2. A review of R1's medical records revealed signed medication orders showing levetiracetam(Keppra) 250 mg 1 tablet by mouth every 12 hours. 3. A review of R1's Medication Administration Records (MARs) dated August 2025, revealed no documentation showing Keppra being administered on August 1st and 2nd at 8 pm. 4. In an interview, E1 acknowledged R1's MAR did not show Keppra as being administered on August 1st and 2nd. However, E1 reported that medication was administered to R1.”