CLASS ACT LOS ALAMOS MESA, LLC

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. When the Compliance Officer arrived, E3, E4, E5 and E6 were working at the facility. 2. Review of the posted personnel schedule dated January 2025 revealed E3 and E4 were documented as working the day shift from 6:00 am - 6:00 pm the day of the inspection. E5 and E6 were not listed on the schedule that day. 3. During an interview, E2 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked.

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for five of six employees reviewed. 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. A review of personnel records revealed E1, E2, E3, E4, and E6 had no documentation for assessing risks of prior exposure to infectious tuberculosis and for determining if the individual has signs or symptoms of tuberculosis. Based on E1, E2, E3, E4, and E6's hire dates, this documentation was required. 3. In an interview, E2 acknowledged the aforementioned documentation was not available at the time of the inspection.

Based on documentation review, observation, and interview, the manager failed to ensure a food menu included any food substitutions no later than the morning of the day of meal service with a food substitution. Findings include: 1. Review of the facility's posted menu revealed a menu dated January 5 - January 11. The Thursday, January 9th breakfast menu stated: "Cream of wheat, toast with jam, and cup of fruit" 2. During an observation, the breakfast meal served on Thursday, January 9 included the following: waffles, bananas, and an omelet. 3. During an interview, E2 acknowledged the breakfast meal served on Thursday, January 9 was not the same as stated on the menu and the substitutions were not documented.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of the resident's orientation to exits from the assisted living facility, for one of three sampled residents. The deficient practice posed a risk if a resident was unaware of the evacuation path to be used in an emergency. Findings include: 1. Review of R2's medical record revealed there was no documentation indicating R2 received orientation to the exits from the facility and the route to be used when evacuating the facility. Based on R2's date of acceptance, this documentation was required. 2. During an interview, E2 acknowledged there was no documentation to indicate R2 had received evacuation orientation to the exits from the facility within 24 hours after the residents' acceptance, nor anytime since.