All Star Group LLC

Based on documentation review, record review, and interview, the administrator failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of three personnel sampled. The deficient practice posed a health and safety risk for residents. 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. A review of E1's ,E2's, and E3's personnel record revealed no documentation was available verifying completion of fall prevention and fall recovery training either initially on hire or ongoing. 3. In an interview, E4 acknowledged the health care institution did not develop and administer a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training.

Based on record review and interview, the administrator failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) before or within seven calendar days of admission and as specified in R9-10-113, for two of two residents sampled. 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 R1's, and R2's medical record revealed documentation of R1's, and R2's freedom from infectious TB was not available for review. 3. In an interview, E1 acknowledged R1, and R2 did not provide documentation of R1's and R2's freedom from infectious TB before or within seven calendar days after R1's and R2's admission.

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for three of three personnel sampled. The health care institution failed to establish, document, and implement TB infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. Findings include: 1. A review of E1’s, E2’s, and E3’s personnel record revealed no documentation E1, E2, or E3 completed training on recognizing the signs and symptoms of TB was available for review. 2. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available for review. 3. In an interview E4 reported they were unaware of the TB training and facility risk assessment requirement. E1 acknowledged training and education related to recognizing the signs and symptoms of TB was not provided annually to individuals employed by the healthcare institution. E1 acknowledged TB infection control activities including annually assessing the health care institutions risk of exposure to infections TB was not established, documented, and implemented.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. A review of the facility's policies and procedures revealed documentation of a review of the policies and procedures being conducted by the administrator was not available for review. 2. In an interview, E4 reported the policies and procedures were reviewed in 2024 although the review was not documented. E4 acknowledged that the facility's policies and procedures were not reviewed every three years.

Based on documentation review, record review, and interview, the administrator failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for two of three personnel 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 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 E1's personnel record revealed a hire date of May 2023. E1's personnel record included a negative PPD skin test from June 2024. However, no assessment of risks of prior exposure to infectious TB, determination of signs or symptoms of TB, or second PPD skin test was available for review. 4. A review of E2's personnel record revealed a hire date of June 2024. E2's personnel record revealed no documentation of assessing risks of prior exposure to infectious tuberculosis, determining if E2 had signs or symptoms of tuberculosis, and of the E2's's freedom from infectious tuberculosis was available for review. 5. In an interview, E4 acknowledged E1, and E2, did not provide evidence of freedom from infectious TB as specified in R9-10-113 on or before E1, and E2, began providing services at or on behalf of the nursing-supported group home.

Based on documentation review and interview, the administrator did not ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1 . A review of facility documentation revealed no documentation of a disaster drill for employees conducted was available for review. 2 . In an interview, E4 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the administrator did not ensure an evacuation drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1 . A review of facility documentation revealed the following evacuation drill were conducted: March 15, 2024 at 12:47PM; June 6, 2024 at 7:54PM; September 5, 2024 at 4:00PM; December 5, 2024 with no time documented; and March 6, 2025 at 12:00PM. However, no documentation of evacuation drills for employees conducted on each shift every three months was available for review. 2 . In an interview, E4 acknowledged an evacuation drill for employees was not conducted on each shift at least once every three months and documented.