BROOKDALE CENTRAL CHANDLER

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113, for two of ten 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. 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 E5 worked as a caregiver. The record documented a signs and symptoms screening. However, this documentation was not signed by a registered nurse, medical practitioner or local health department. Based on E5's hire date, this documentation was required.

4. A review E6's personnel record revealed E6 worked as a housekeeper. The record documented a signs and symptoms screening. However, this documentation was not signed by a registered nurse, medical practitioner or local health department. A review of E6's personnel record also revealed documentation of a negative TB skin test. However, a second negative TB skin test was administered eighteen days after E6's hire date. Based on E6's hire date, this documentation was required.

5. In an interview, E1 and E2 acknowledged E5's and E6's personnel records did not contain documentation of freedom from TB as specified in A.A.C. R9-10-113.

Based on interview, documentation review, and record review, for one resident receiving transportation to a dialysis clinic, the manager failed to ensure an evaluation of the resident was conducted before and after the transport, information from the resident's medical record was provided to a receiving health care institution, and documentation of if applicable, any communication with an individual at a receiving health care institution, the date and time of the transport and if applicable, the name of the caregiver accompanying the resident during a transport.

Findings include:

1. During an interview, E1 and E2 reported R8 was transported to a Dialysis clinic three times a week and the transportation arrangements were coordinated by the facility.

2. In documentation review, a facility policy titled, "Transfer/Transportation Policy," page 1, documented "...An evaluation of the resident will be conducted by the ALD/Nurse or designated staff and documented in the resident's medical record... The evaluation will consist of the level of assistance required by the resident for transport... The ALD/Nurse or designated staff member will explain and document the risks and benefits of the transport for the resident or resident's representative... Copies of Medical records including but not limited to the following will be provided to the receiving facility: The residents insurance information... A list of the resident's current medications... Resident's emergency contact information... All required documentation will be noted on the "Resident Transport Form."

3. In record review, R8's medical record did not include the required documentation of transport to the dialysis clinic.

4. During an interview, E1 acknowledged the facility did not implement the facility's transportation policy and procedures for R8's transportation to the dialysis clinic.

Based on interview and documentation review, for one resident reviewed, the manager failed to ensure a resident was treated with dignity, respect, and consideration.

Findings include:

1. During an interview, R5 (received personal care services) was interviewed based on a self report by the facility, to Adult Protective Services. During the interview, R5 reported feeling afraid of a caregiver, reported "can't lift me, I'm too heavy... we almost fall, doesn't have people skills, bluntly orders me to move... my bed is too high... thrown into bed, it sometimes hurt when ... empties catheter bag... pulls on it, caregiver seems confused about how to do it." R5 reported the caregivers do not use a transfer/gait belt during transfers. R5 reported this to "my table mate."

2. In documentation review, the facility provided documentation of an investigation of R5's allegations, which indicated inservice training would be provided for all staff.

3. During an interview, E1 and E2 acknowledged the findings of the interview with R5. E1 and E2 reported the caregivers, per the facility's policy and procedures, should use a transfer belt to transfer residents. E1 and E2 acknowledged the concerns, and indicated inservice education was scheduled to be provided in the near future.

Based on record review and interview, for two residents confined to a bed or chair and unable to ambulate, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a primary care provider (PCP) or medical practitioner (MP), upon acceptance or upon the onset of the condition, and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services. The deficient practice posed a safety risk to a resident, if a facility retained a resident without the required authorization.

Findings include:

1. In record review, R8's service plan (received personal care services), dated August 23, 2024, included documention R8 had a left leg amputation. R8's record did not include a written determination from a PCP or MP that stated the resident's needs could be met by the facility. Based on R8's acceptance date, the documentation was required to be in R8's medical record.

2. In record review, R10's record included a document titled ".... Provider Plan of Care," which indicated R10 had "left side hemiplegia." The record included a written determination, signed and dated March 29, 2024, which documented, R10 "is confined to a bed or a chair because of an inability to ambulate even with assistance." However, the medical record did not include a signed and dated written determination, every six months, that stated the resident's needs could continue to be met by the facility.

3. During an interview, E1 and E2 reported R8 and R10 were unable to walk even with assistance, and acknowledged a written determination from a PCP or MP was required every six months, stating the resident's needs could be met by the facility.

Based on observation and interview, for three resident bedrooms observed on the memory care unit, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services. The deficient practice posed a risk to the physical health and safety of a resident, if there was no means to alert employees of an emergency.

Findings include:

1. During an environmental inspection with E1, the Compliance Officers observed the resident's bedrooms, on the memory care unit, had a pull cord nurse call system in the rooms, attached to the walls, and in the resident bathrooms. Several rooms had non working alerts, including rooms 136B, 143A, and 152.

2. During an interview, E1 and E2 acknowledged the call system alerts were not working in several residential units.

Based on observation, and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a health and safety risk, if medications were accessible to residents.

Findings include:

1. During an environmental inspection with E1, the Compliance Officers (CO) observed medications were stored in bedrooms on the memory care unit:
- Room 136A had a tube of Diclofenac Gel 1%
- Room 137 A-B had a bottle of Miconazorb Powder AF 2%, a tube of Hemorrhoidal cream and Sunscreen with Menthol 44% and Zinc Oxide 20%.

2. During an interview, E1 reported the residents who resided in the memory care unit received medication administration and the medicated creams were required to be stored by the facility in a locked manner.

Based on documentation review and interview the manager failed to ensure that an evacuation drill for employees and residents included all individuals on the premises.

Findings include:

1. A review of the facility documentation revealed an evacuation drill with residents and employees that was conducted on April 25, 2024. However, no documentation was provided to indicate that all the individuals on the premises had participated in the drill.

2. A review of the facility documentation revealed an evacuation drill with residents and employees that was conducted on September 05, 2024. However, no documentation to indicate that all the individuals on the premises had participated in the drill.

3. In an interview, E1 acknowledged that the evacuation drill did not include the names of all individuals who participated in the drill and a list of residents whose medical record contains documentation that evacuation from the assisted living facility would cause harm to the resident.

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 if toxic materials were accessible.

Findings include:

1. During an environmental inspection with E1, the Compliance Officers observed a housekeeping cart in a hallway by resident rooms. The cart was unlocked and had cleaning supplies, to include, but not limited to: ECOLAB Bio-enzymatic odor eliminator, Alcohol, Glass Cleaner, Disinfecting Acid Bathroom Cleaner, and Peroxide Multi Surface Disinfectant and Cleaner.

2. During an interview, E1 acknowledged the toxic materials were not stored in a locked manner, and inaccessible to residents.

Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was maintained in working order. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. During an environmental inspection with E1, the Compliance Officers (CO) observed the Memory Care Unit had a pull cord nurse call system in resident rooms. However, the CO's observed the call system was not working in the following rooms: 136B, 143A, and 152.

2. During an interview, E1 acknowledged the call system was not maintained in working order.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures for administering an opioid that covered how, when, and by whom a patient's need for opioid administration is assessed; how, when, and by whom a patient receiving an opioid is monitored; and how, when, and by whom the actions taken according to subsections (F)(1)(c) and (d) are documented. The deficient practice posed a safety risk to residents if the opioid rules were not understood and implemented by staff administering medications.

Findings include:

1. In documentation review, the facility did not establish, and document policies and procedures for administering an opioid that covered how, when, and by whom a patient's need for opioid administration is assessed; how, when, and by whom a patient receiving an opioid is monitored; and how, when, and by whom the actions taken according to subsections (F)(1)(c) and (d) are documented.

2. During an interview, E1 acknowledged the facility did not have policies and procedures which included documentation of the procedures required in R9-10-120.F.1.a-e.

Based on record review, documentation review, and interview, for one resident reviewed, who received opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record; an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident's health and safety if the facility did not appropriately assess and monitor opioid administration for a resident.

Findings include:

1. In observation, R3's medications were observed at the facility, and included Morphine medication.

2. In record review, R3's medical record (received directed care and medication administration services) included a medication order for "Morphine Sulf ER 15 mg tablet, take 1 tablet by mouth three times daily." R3's record included documentation R3 received the Morphine medication daily from January 24, through February 3, 2025. The record did not include documentation of an identification of the need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. R3's record did not include documentation of an active malignancy or an end of life condition.

3. During an interview, E1 and E2 acknowledged the facility did not document an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered.

Based on documentation review and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of facility documentation revealed a training program for all staff regarding fall prevention and fall recovery was not available for review.

2. In an interview, E1 acknowledged documentation of a training program for all staff regarding fall prevention and fall recovery was not available for review.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.

Findings include:

1. A review of facility documentation revealed a policy titled "Managing an Aggressive Resident." The policy stated "Clinical Approaches... The resident should be reassessed and the service plan updated as needed."

2. A review of R2's medical record revealed documentation of an assessment conducted on August 28, 2024 after an incident where R2 displayed sudden, intense or out control behavior by pushing R1 causing them to fall was not available for review.

3. In an interview. E1 acknowledged the facility had not followed their policy and procedure and reassessed R2 after R2 displayed sudden, intense or out control behavior.

Based on record review and interview, the manager failed to provide to the emergency responder a written document that included all required documentation, for one of two residents sampled.

Findings include:

1. A review of R2's medical record revealed a progress report dated July 5, 2024. The progress report revealed R2 had an accident, emergency, or injury, the facility contacted an emergency responder, and R2 was taken to the hospital. However, the documented information provided to the emergency responder did not include the following:
-The reason or reasons the emergency responder was requested on behalf of R2;
-The name, address and telephone number of the resident's current pharmacy;
-The point-of-contact information for the assisted living home, including the cell phone number and email address; and
-A copy of R2's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living home to plan for R2's discharge.

2. In an interview, E1 reported E1 was not familiar with the entire statute. E1 had not yet updated the facility documentation to include the required information.