EVERGREEN VILLAGE PRESCOTT

<p><span style="font-size: 14px;">Based on a record review and interview, </span><span style="font-size: 14px; color: black;">the manager failed to ensure a personnel record for each employee included current documentation of first aid (FA) training and cardiopulmonary resuscitation (CPR) training for one of six employee records reviewed.</span><strong style="font-size: 14px; color: black;"> </strong><span style="font-size: 14px; color: black;">The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.</span></p><p><span style="color: black; font-size: 14px;"> </span></p><p><br></p><p><span style="color: black; font-size: 14px;">Findings include:</span></p><p><span style="color: black; font-size: 14px;"> </span></p><p><br></p><p><span style="color: black; font-size: 14px;">1. A review of the personnel record for E4 revealed that E4's CPR and FA certification expired on July 11, 2025.</span></p><p><span style="color: black; font-size: 14px;"> </span></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); color: rgb(0, 0, 0); font-size: 14px;">2. A review of the personnel schedule dated "July 2025", revealed E4 worked the following days with an expired CPR and First certification: July 12 - July 14, 2025.</span></p><p><br></p><p><br></p><p><span style="color: black; font-size: 14px;">3. In an interview, E1 checked and verified that E4 did not have a current CPR/FA certification.</span></p><p><span style="color: black; font-size: 14px;"> </span></p><p><br></p><p><span style="background-color: rgb(255, 255, 255); font-size: 14px; color: rgb(0, 0, 0);">4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</span></p>

<p>Based on observation and interview, the manager failed to ensure that stored food was protected from potential contamination. The deficient practice posed a risk for potential contamination.</p><p> </p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. During an environmental inspection, the Compliance Officer observed the following foods were stored in a refrigerator uncovered: </p><p>-In the main refrigerator, there was a container that was labeled "meat sauce" that was uncovered. </p><p>-In a smaller refrigerator, there was a container that was labeled "diced onion" with a date of July 13, a container labeled "cheese", and a container labeled "diced chicken" that was uncovered.</p><p> </p><p><br></p><p>2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.</p>

Based on 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 six of seven employees 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. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used."

3. A review of E3's personnel record revealed a Mantoux skin test that was less than 12 months old. However, the required second Mantoux skin test for employees and a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. Based on E3's hire date, this documentation was required.

4. A review of E5's personnel record revealed a Mantoux skin test that was less than 12 months old. However, the required second Mantoux skin test for employees and a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. Based on E5's hire date, this documentation was required.

5. A review of E6's personnel record revealed a Mantoux skin test that was less than 12 months old. However, the required second Mantoux skin test for employees and a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. Based on E6's hire date, this documentation was required.

6. A review of E7's personnel record revealed a Mantoux skin test that was less than 12 months old. However, the required second Mantoux skin test for employees and a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. Based on E7's hire date, this documentation was required.

7. A review of E8's personnel record revealed no documentation of freedom from infectious tuberculosis and no documentation of a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. Based on E8's hire date, this documentation was required.

8. A review of E9's personnel record revealed a Mantoux skin test that was less than 12 months old. However, the required second Mantoux skin test for employees and a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. Based on E9's hire date, this documentation was required.

9. In an interview, E1 acknowledged E3's, E5's, E6's, E7's, E8's, and E9's personnel records did not contain documentation of freedom from infectious TB as specified in R9-10-113.

10. Technical assistance was provided on this rule during the on-site compliance inspection conducted on April 12, 2023.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of nine residents reviewed, which posed a health and safety risk to the resident if a caregiver did not know if a medication was administered.

Findings include:

1. A review of R4's medical record revealed a written service plan dated April 18, 2024. The service plan indicated R4 self-administered R4's medications.

2. A review of R4's medical record revealed an electronically signed order dated May 21, 2024 that stated, "Facility to manage pts medication."

3. A review of R4's medical record revealed an updated service plan dated May 21, 2024. The service plan indicated R4 now required medication administration by the facility.

4. A review of R4's medical record revealed a signed medication order dated March 1, 2021 for Aricept 5 milligrams (mg), one tablet every day.

5. A review of R4's MAR indicated the Aricept 5 mg was self-administered by R4 May 21, 2024-May 31, 2024 and June 1, 2024-June 11, 2024, which contradicted the medication order dated May 21, 2024 (for the facility to administer medications).

6. In an interview, E1 acknowledged Aricept 5 mg was not accurately documented in R4's MAR. E1 believed the Aricept was administered by the facility as ordered from May 21, 2024-June 11, 2024; however, the medication administration did not get accurately documented in R4's MAR.

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

Findings include:

1. A review of R1's medical record revealed a signed medication list dated February 9, 2023 that included the following medication and instructions:
-Humalog Mix 75/25 KwikPen Suspension 100 Unit/milliliter (ml). Inject as per sliding scale:
-70-130 = 0 units;
-131-150 = 2 units;
-151-240 = 4 units; and
-241-300 = 6 units, subcutaneously before meals.

-Glucose 4 gram tablet chew. Give 4 tablets orally every 15 minutes as needed for hypoglycemic episodes. Give 4 tablets by mouth if blood glucose is less than 70 and recheck in 15 minutes. If blood glucose is still less than 70 give 4 more tabs and recheck in 15 minutes. Repeat every 15 minutes until blood glucose is greater than 70 and contact 911 after 45 minutes of blood glucose less than 70.

2. A review of R1's medication administration record (MAR) revealed on March 22, 2023, R1's blood glucose level was recorded as 65.

3. Further review of R1's MAR revealed no evidence that R1 received the glucose 4 gram tablet chews as ordered if R1's blood glucose level measured below 70.

4. In an interview, E1 and E2 acknowledged R1 did not receive medication administration for the aforementioned medications in compliance with a medication order. E1 and E2 reported it does not appear that R1 received glucose tablets as ordered on March 22, 2023. E2 reported the glucose tablets may have been missed as the computer system does not prompt the medication technician to administer the glucose tablets if the blood glucose level falls under the desired level.