Terravella Assisted Living Care, LLC.

“Based on documentation review, record review, and interview, the health care institution’s chief administrative officer failed to implement tuberculosis infection control activities that annually assessed the health care institution’s risk of exposure to infectious tuberculosis, and annual training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed. Findings include: 1. A review of the facility’s annual TB facility risk assessment documentation revealed no completed documentation of a TB facility risk assessment. 2. A review of E1's and E2's personnel records revealed no documentation of annual training and education related to recognizing the signs and symptoms of tuberculosis. Based on E1's and E2's dates of hire, this documentation was required. 3. In an interview, E1 reported that E1 was unaware that a TB facility risk assessment was needed for the facility. 4. In an interview, E1 reported that E1 was unaware that annual training and education related to recognizing the signs and symptoms of tuberculosis were needed for each personnel. 5. In an exit interview, the findings were discussed with E1, and no additional information was provided. Technical assistance was provided regarding this rule during the compliance inspection conducted on August 23, 2023.”

“Based on record review, document review, and interview, the manager failed to ensure that each resident had a service plan that was established, documented, and implemented, and when updated, was signed and dated by the resident or the resident's representative, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a service plan dated December 12, 2025, which revealed R1 received personal care services. The service plan was signed and dated by the manager and by a nurse; however, not by the resident or the resident's representative. 2. A review of the facility's policies and procedures revealed a policy titled" Service Plan." This policy stated," 5. When initially developed and when updated, is signed and dated by: a. the resident or residents representative b. the manager c. If a review is required in subsection A.3.d, the nurse or medical practitioner who reviewed the service plan." 3. In an interview, E1 reported that they were aware that R1's most recent service plan was unsigned by the resident or representative. 5. In an exit interview with E1, the findings were reviewed, and no additional information was provided.”

“Based on record review, observation, documentation review, and interview, the manager failed to ensure that a resident's medical record contained a medication order for each medication that was administered to a resident, for two of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include:  1. A review of R1's medical record revealed a service plan that indicated R1 received medication administration services. 2. A review of R1’s medical record revealed an unsigned medication order sheet, which contained the following medications: Allopurinol 100 milligrams (mg) by mouth, one tablet twice daily; Atorvastatin 10 mg by mouth, one tablet every night; Azelastine 137 mcg/ inhaler (0.1%), one spray twice daily as needed; Donepezil 10 mg by mouth, one tablet every night; Finasteride 5 mg by mouth, one tablet once daily; and Metoprolol Succinate Er 25 mg by mouth one-half of a tablet twice daily. 3. A review of R1's March 2026 medication administration record revealed the following medications were being administered: Allopurinol 100 mg one tablet by mouth twice daily, at 8:00 am and 8:00 pm daily; Atorvastatin 10 mg one tablet by mouth, at 8:00 pm daily; Azelastine 1337 mcg inhaler, one spray nostril-both twice daily as needed, at 8:00 am and 8:00 pm daily; Donepezil 10 mg one tablet by mouth at bedtime, 8:00 pm daily; Finasteride 5 mg one tablet by mouth twice daily [sic], at 8:00 am; and Metoprolol Succinate extended release 25 mg one-half tablet by mouth twice daily at 8:00 am and 8:00 pm. 4. A review of R2's medical record revealed a service plan that disclosed R2 received medication administration services. 5. A review of R2’s medical record revealed an unsigned medication order sheet, which contained the following medications: Seroquel 50 mg by mouth, one tablet twice daily; and Omeprazole Dr 20 mg, one capsule by mouth once daily. 6. A review of R2's March 2026 medication administration record revealed the following medications were being administered: Omeprazole DR 20 mg capsule, one capsule by mouth daily at 8:00 am; and Seroquel 50 mg one tablet by mouth twice daily at 8:00 am and 8:00 pm. 7. A review of the facility's policies and procedures revealed a policy titled "Medication services." This policy stated," The resident's primary care provider shall: 1. Prescribe all medications, including all over-the-counter medications. O. Medication Administration Records All medications and treatments shall be recorded on the medication administration record (MAR) of each resident, which should include the name of the medication, strength, dosage, and route. " 8. The compliance officer observed R1's medication set, which included one Aller-tec Cetirizine Hydrochloride 10 mg tablet, one Allopurinol 100 mg tablet, one Finasteride 5 mg tablet, and one Metoprolol Succinate 25 mg tablet pre-filled in each morning slot for Tuesday through Saturday. 9. In an interview, E1 reported R1 was being administered one Aller-tec Cetirizine Hydrochloride 10 mg tablet once daily in the morning. E1 confirmed R1 did not have a signed order for this medication. E1 reports that E1 was unaware that this medication required a prescription. 10. In an exit interview, findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include:  1. A review of Department documentation revealed the facility was licensed to provide directed care services.  2. During an environmental tour of the facility, the Compliance Officers observed the following: The front door was equipped with an alert; however, the alert was turned off at the time of inspection; The back door was equipped with an alert; however, the alert was turned off at the time of inspection; and The exits from the facility were not monitored at the time of inspection. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided”

“Based on documentation review, record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record for one of two residents sampled. 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 the facility's policies and procedures revealed a policy titled "Medication services." This policy stated," The resident's primary care provider shall: 1. Prescribe all medications, including all over-the-counter medications. O. Medication Administration Records All medications and treatments shall be recorded on the medication administration record (MAR) of each resident, which should include the name of the medication, strength, dosage, and route. " 2. A review of R2's medical record revealed a service plan that disclosed R2 received medication administration services. 3. A review of R2’s medical record revealed an unsigned medication order sheet, which contained the following medication: Aspirin 81 mg, one tablet twice daily. 4. A review of R2's March 2026medication administration record revealed no documentation of Aspirin 81 mg, and whether it was being administered.  5. In an interview, E1 reported R2 received Aspirin 81 mg twice daily. E1 acknowledged R2's Aspirin was not being documented in the medication administration record, but was being administered. 6. In an exit interview, findings were reviewed with E1, and no additional information was provided.”