BROOKDALE CHANDLER REGIONAL

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of six residents sampled. The deficient practice posed a potential illness 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 R6's medical record did not include documentation of evidence of freedom from infectious TB for Compliance Officer review. Based on R6's acceptance date, this documentation was required.

3. In an interview, E1 acknowledged R6's medical record did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113.

Based on documentation review and interview, the manager failed to ensure there was the required documentation of the annual disaster plan review.

Findings included:

1. At the beginning of the compliance inspection E1 received a list of the required documents that would be reviewed during this inspection. Later in the compliance inspection, the compliance officer requested and was provided documentation of the annual disaster plan meeting that was dated June 22, 2023. The documentation did not include a critique of the disaster plan review, and if applicable, recommendations for improvement.

2. In an interview, E1 acknowledged the disaster plan meeting was lacking the required documentation.

Technical assistance was provided during the compliance inspection conducted on October 4-5, 2022.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted at least once every three months on each shift and documented.

Findings include:

1. During an interview, E1 and E2 reported the facility had three shifts: First shift from 6:00 AM to 2:00 PM, the second shift from 2:00 PM to 10:00 PM, and the third shift from 10:00 PM to 6:00 AM.

2. Based on the documentation provided, the facility had employee disaster drills during the past 12 months that were conducted on the second shift on December 29, 2022, May 8, 2023, and July 30, 2023.

3. In an interview, E1 acknowledged the required employee disaster drills were not conducted on the second shift every three months, as required. E1 confirmed the facility had three shifts.

Based on observation and interview, the manager failed to ensure the premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury which posed a safety risk.

Findings include:

1. During a facility tour of randomly selected residents' units, E1, E2, and the surveyor observed in R3's, R4's, and R5's units swinging closet doors near the entrance of the unit. The swinging closet doors may cause a resident or other individuals to suffer physical injury if leaned against.

2. In an interview, E1 acknowledged the swinging closet doors could cause the resident or other individual to suffer physical injury.

Technical assistance was provided during the compliance inspection conducted on October 4-5, 2022

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Based on observation and interview, the manager failed to ensure that soiled linens stored by the assisted living facility were stored in a closed container away from food storage, kitchen, and dining areas.

Findings included:

1. During a tour of the facility, E1 and the compliance officer observed E9 carrying an arm full of linen down a common resident hall. E9 then placed the linen in a pile on top of a clothes hamper in an employee service room. In an interview, E9 reported the linen was soiled.

2. In an interview, E1 acknowledged the facility was storing uncovered soiled linen.

Technical assistance was provided during the compliance inspection on October 4-5, 2022.