COMFORT ASSISTED LIVING HOME, LLC

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents reviewed. 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. Review of R1's medical record revealed no documentation of assessing risk of prior exposure to infectious TB or determining if the R1 had signs or symptoms of TB. Based on R1's acceptance date, this documentation was required.

3. In an interview, E1 acknowledged R1 did not provide documentation of assessing risk of prior exposure to infectious TB or determining if R1 had signs or symptoms of TB.

4. Technical assistance was provided on this Rule during the compliance inspection conducted October 7, 2022.

Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two residents reviewed accepted by the assisted living facility on or after October 1, 2013. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R1's medical record revealed no documentation stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1's acceptance date, this documentation was required.

2. In an interview, E1 acknowledged R1 did not provide documentation signed by a medical practitioner or a registered nurse stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.

3. This is a repeat deficiency from the compliance inspection conducted October 7, 2022.

Based on record review and interview, the manager failed to ensure the facility did not accept 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 medical practitioner, upon acceptance and every six months thereafter, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R1's medical record revealed a current written service plan for personal care services dated September 7, 2023. This service plan stated "Transfer assistance - 2 person".

2. Review of R1's medical record revealed no documentation indicating R1's medical practitioner examined R1 upon acceptance and every six months thereafter, signed and dated a determination stating R1's needs could be met by the facility, and reviewed the facility's scope of services.

3. In an interview, E1 reported R1 was unable to ambulate even with assistance since acceptance and acknowledged R1's medical practitioner did not provide a written determination upon acceptance and every six months thereafter.

4. This is a repeat deficiency from the compliance inspection conducted October 7, 2022.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and controlled 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. Review of the license issued by the Department revealed the facility was authorized to provide directed care services.

2. During an environmental inspection of the facility with E1, the Compliance Officer observed the door exiting to the backyard did not have a device that alerted employees to the egress of a resident to the outside area.

3. In an interview, E1 acknowledged there was a means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.

4. Technical assistance was provided on this Rule during the compliance inspection conducted October 7, 2022.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated September 7, 2023. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed a signed medication order dated September 12, 2023. This medication order stated "Gabapentin 300mg oral capsule - take one cap PO every 8 hours".

3. Review of R1's medical record revealed a September 2023 medication administration record (MAR). This MAR stated "Gabapentin 300mg PO BID" and indicated one tab was administered at 8pm and 5pm September 1st - present.

4. During an observation of R1's medications, Gabapentin 300mg was observed and one tab was observed prefilled in the "Morning" and "Evening" slot of R1's medication organizer.

5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R1's medication was not administered in compliance with the available medication order.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order and posed a risk as the medical record inaccurately indicated a medication was administered.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated September 7, 2023. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed signed medication order dated September 12, 2023. These medication orders stated the following:
"Calmoseptine 0.44%-20.6% topical ointment - apply topically at perineal area twice a day"
"Fenofibrate 54mg oral tablet - take one tab PO QHS"

3. Review of R1's medical record revealed a September 2023 medication administration record (MAR). This MAR stated the following:
Calmoseptine was not include on the MAR
"Fenofibrate 54mg 1 tab PO QHS" and indicated 1 tab was administered at 8am and 5pm September 1st - present

4. During an observation of R1's medications, the following was observed:
Calmoseptine was observed
Fenofibrate 54mg was observed and one tab was observed prefilled in the "Evening" slot of R1's medication organizer.

5. In an interview, E1 reported the medications were administered per the medication orders and acknowledged R1's medical record did not include accurate documentation the medications were administered.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication.

Findings include:

1. During an environmental inspection of the facility with E1, the Compliance Officer observed the medication cabinet that held seven residents' medications unlocked. The cabinet had a locking device that was broken.

2. During an observation, the caregivers were not accessing the medications at the time of arrival.

3. In an interview, E1 acknowledged medications were stored unlocked.

Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance.

Findings include:

1. Review of facility's documents revealed no policy and procedure that covered TB infection control activities.

2. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of July 2013. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB.

3. In an interview, E1 acknowledged E1 had not completed training and education related to recognizing the signs and symptoms of TB.

4. Technical assistance was provided on this Rule during the compliance inspection conducted October 7, 2022.

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff.

Findings include:

1. Review of facility's documents revealed no policy and procedure that covered TB infection control activities.

2. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB.

3. In an interview, E1 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted.

4. Technical assistance was provided on this Rule during the compliance inspection conducted October 7, 2022.