ROBSON RESERVE AT PEBBLECREEK

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for four of nine caregivers sampled. 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. 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 E5's personnel record revealed documentation that showed E5's second TB skin test was read 10 days after hire.

4. A review of E7's personnel record revealed documentation that showed E7's second TB skin test was read 14 days after hire.

5. A review of E8's personnel record revealed documentation that showed E8's second TB skin test was read 17 days after hire.

6. A review of E9's personnel record revealed documentation that showed E9's second TB skin test was read 22 days after hire.

7. In an interview, E1 acknowledged E5, E7, E8, and E9 were providing services at the facility and the personnel records did not contain evidence of freedom from infectious tuberculosis(TB) as specified in R9-10-113.

Based on observation, record review, and interview, the manager failed to ensure, before or at the time of acceptance by the assisted living facility, the resident or resident's representative was provided a copy of resident rights.

Findings include:

1. A review of R4's medical record revealed a document titled "Acknowledgement Form (Initial each line)," The document revealed the acknowledge receipt of Resident Rights signed by R4 six days after R4's documented date of admission. Based on R4's date of admission this was not provided before or at time of the acceptance by the assisted living facility.

2. A review of R6's medical record revealed a document titled "Acknowledgement Form (Initial each line)," The document revealed the acknowledge receipt of Resident Rights signed by R6 two days after R6's documented date of admission. Based on R6's date of admission this was not provided before or at time of the acceptance by the assisted living facility.

3. A review of R7's medical record revealed a document titled "Acknowledgement Form (Initial each line)," The document revealed the acknowledge receipt of Resident Rights signed by R7 six days after R7's documented date of admission. Based on R7's date of admission this was not provided before or at time of the acceptance by the assisted living facility.

4. In an interview, E1 reported the residents date of admission is the date the resident takes financial possession of the apartment however the date they move in may vary from this date of admission identified. E1 reviewed the dates identified medical records and acknowledged the records did not reflect before or at the time of acceptance by the assisted living facility, the resident or resident's representative was provided a copy of resident rights.

Based on record review, documentation review, and interview, for two of four residents reviewed, the manager failed to ensure the residents or representatives were provided a copy of the policy and procedure on health care directives at the time of acceptance.

Findings include:

1. A review of R4's medical record revealed a document titled "Acknowledgement Form (Initial each line)," The document revealed the acknowledge receipt of Health Care Directives signed by R4 six days after R4's documented date of admission. Based on R4's date of admission this was not provided before or at time of the acceptance by the assisted living facility.

2. A review of R6's medical record revealed a document titled "Acknowledgement Form (Initial each line)," The document revealed the acknowledge receipt of health care directives signed by R6 two days after R6's documented date of admission. Based on R6's date of admission this was not provided before or at time of the acceptance by the assisted living facility.

3. A review of R7's medical record revealed a document titled "Acknowledgement Form (Initial each line)," The document revealed the acknowledge receipt of health care directives signed by R7 six days after R7's documented date of admission. Based on R7's date of admission this was not provided before or at time of the acceptance by the assisted living facility.

4. In an interview, E1 reported the residents date of admission is the date the resident takes financial possession of the apartment however the date they move in may vary from this date of admission identified. E1 reviewed the dates identified medical records and acknowledged the records did not reflect before or at the time of acceptance by the assisted living facility, the resident or resident's representative was provided a copy of health care directives .

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area, which posed a health and safety risk for medications to be stored inappropriately.

Findings include:

1. During the facility tour with E2, the compliance officer observed an office identified as "Doctors Office." The office door was closed with a single key in the door lock. The unattended office door opened with the key. Inside the office was a refrigerator containing single dose vials of Tetanus and Diphtheria. The medication was unlocked and accessible to the residents.

2. In an interview, E2 acknowledged the doctor's office was unlocked and the medications were stored unlocked and accessible to residents.

3. In an interview, E1 acknowledged the manager failed to ensure medications stored by the facility were stored in a locked area, which posed a health and safety risk for medications to be stored inappropriately

Based on observation, documentation review and interview, the manager failed to ensure food was protected from potential contamination and was safe for human consumption.

Findings include:

1. The compliance officer and E2 observed the following stored in the kitchen freezer: a box of meat patties which was not sealed and open to contamination. The compliance officer and E2 observed in the kitchen refrigerator the following items stored unsealed and exposed to potential contamination; two trays of chocolate cake, one tray of chocolate and raspberry individual deserts, two trays of brown rice, one tray of pasta with cheese and sauce, four trays of shepherd pie, and one plastic container of diced potatoes in water.

2. In an interview, E2 acknowledged the identified food stored in the kitchen freezer and refrigerator was not protected from contamination.

3. In an interview, E1 and E3 reviewed the photos of the identified food. E1 acknowledged the manager failed to ensure food was protected from potential contamination and was safe for human consumption.

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 immediately notified the resident's primary care provider.

Findings include:

1. Review of R1's medical record revealed a document titled "Incident Report" dated March 28, 2023. This document indicated the time of incident was 2:36 pm and stated "...resident was found unresponsive....EMS was called at 2:36 pm..." This document indicated R1's primary care provider was not notified until March 29, 2023.

2. During an interview, E1 and E3 acknowledged R1's medical record revealed documention showing R1's primary care provider was not immediately notified when R1 had an incident resulting in needing medical services.

Based on record review and interview, the manager failed to ensure when an accident resulted in a resident needing medical services, the caregiver documented the names of individuals who observed the accident.

Findings include:

1. A review of R1's medical record revealed an incident report dated March 28, 2023. The incident report stated "...Resident was found on her bedroom floor at 2:36 pm by caregiver....it took 3 staff members to role R1 on R1's back...." The incident report did not identify the names of the individuals who observed the accident.

2. In an interview, E1 and E3 reviewed the identified medical record and acknowledged the record did not identify the names of the individuals who observed the accident. E1 reported E1 had believed the names of the caregivers were not to be included in the incident report. E1 acknowledged the manager failed to ensure when an accident resulted in a resident needing medical services, the caregiver documented the names of individuals who observed the accident.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. During the facility tour with E2, the compliance officer observed an office identified as "Doctors Office." The office door was closed with a single key in the door lock. The unattended office door opened with the key. Inside the office was the following toxic materials unlocked and accessible to residents: Bleach, Clorox Wipes, and Lysol Spray.

2. In an interview, E2 acknowledged the identified toxic materials were stored by the facility unlocked.

3. In an interview, E1 acknowledged the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents.

This is a repeat deficiency from the inspections conducted on October 23, 2020 and November 10, 2021.